Every finding on record at Allendale Nursing and Rehabilitation Community

This citation pertains to intake #3006042Based on interview and record review, the facility failed to have safeguards and systems in place to ensure the proper storage, dispensing, administering, and reconciliation of controlled substances for 1 resident (Resident #3), reviewed for pharmacy services.Findings:Resident #3 (R3) Review of an admission Record revealed R3 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: traumatic brain injury (TBI).Review of R3's Order Summary dated 2/23/26-4/20/26 revealed he was to receive one 10mg methylphenidate (improves cognitive function following a TBI) tablet in the morning and one 5mg methylphenidate tablet at 3:00 PM.Review of the 4/14/26 and 4/15/26 staffing schedule revealed the following nurses provided care for R3:On 4/14/26 Agency Registered Nurse (RN) J worked 1st shift.On 4/14/26 Agency RN K worked 2nd shift.On 4/14/26 RN L worked 3rd shift.On 4/15/26 Licensed Practical Nurse (LPN) M worked 1st shift.The licensed nurses listed above all had background checks that indicated they were eligible to work, and all had valid nursing licenses that were in good standing with Michigan's board of nursingReview of R3's Controlled Substance Proof of Use form utilized from 4/6/26-4/20/26 and R3's April Medication Administration Record (MAR) revealed that on the morning of 4/14/26 RN J dispensed and administered the methylphenidate 10mg as ordered. On the morning of 4/15/26 LPN M dispensed and administered the methylphenidate 10mg as ordered (No other doses of the methylphenidate 10mg should have been dispensed/administered between the morning of 4/14/26 and 4/15/26). R3's Controlled Substance Proof of Use form revealed that between the morning of 4/14/26 and 4/15/26, there were 2 entries which documented the removal of a total of 2 10mg tablets of methylphenidate. The entries included an illegible date and an illegible nurse's signature with a time of 9:00 AM and 10:00AM on 2 separate lines. There was no documentation that the medication had been removed in error and disposed of with a secondary nurse's witness signature.Review of R3's Electronic Medical Record revealed no documentation that the 2 doses of methylphenidate had been administered, there were no one time orders for the administration of the methylphenidate, and there was no rationale/documentation related to the dispensing of the 2 doses of the methylphenidate.Review of the April Medication Administration Record for all residents residing in the facility at that time revealed no documentation that any other resident was prescribed methylphenidate (verification that R3's methylphenidate was not accidentally administered to another resident with the same medication and dose.)Review of the Facility Reported Incident (FRI) submitted on 4/21/26 revealed that be, On 4/21/2026 the Director of Nursing noted: A medication error was completed; however, two doses of Methylphenidate remain unaccounted for and were signed out with an unidentifiable signature.The Administrator was notified of a potential misappropriation of medication for (R3) after a routine audit was conducted and two methylphenidate 10mg tablets were unaccounted for. After conducting staff interviews to determine who's handwriting it was, we were unable to identify the nurse who wrote the medications down on the controlled substance proof of use sheet. Root Cause Analysis: The investigation determined that the discrepancies involving two unaccounted for methylphenidate 10 mg tablets were not the result of a confirmed medication diversion, intentional misappropriation, or deliberate misplacement. The controlled substance proof of use sheet contained entries that could not be matched to the MAR. The handwriting and signatures on the proof of use sheet could not be identified. All assigned nurses denied documenting or administering medications outside of their assigned responsibilities and denied sharing or leaving medication cart keys unattended. There were no gaps in medication administration in the MAR for (R3), receiving all prescribed doses of the medication.Review of RN J's Staff Interview completed via telephone and dated 4/23/26 (signed 4/24/26) revealed RN J was assigned to (R3) on 4/14/2026. She administered both doses of methylphenidate 10mg and 5mg that day. He has an AM dose and a dose scheduled at 3:00 PM. I gave my keys to (RN K) (as verified via photo) and completed our counts (counting off the number of controlled substances available for each resident). I did not give my keys to anyone else during the shift, I do not do things like that. I do not recognize the handwriting on the proof of use sheet under the name.Review of RN K's Staff Interview completed via telephone and dated 4/23/26 (signed 4/24/26) revealed, I was assigned to (R3) second shift on 4/14/2026. I do not know who's handwriting that is on the controlled substance proof of use sheet. I did not leave my keys anywhere to my knowledge and I was having trouble when I first got to my shift with my (computer system) login. I followed what was on the MAR.Review of RN L's Staff Interview dated 4/23/26 (signed 4/24/226) revealed, I did not notice the signatures on the sheet, although this medication is not one that I typically pass as it is due on first and second shift. I am not sure of who's handwriting that would be, I do not recognize it. I was assigned to (R3) on third shift.Review of LPN M's Staff Interview dated 4/23/26 (signed 4/24/226) revealed, I do not know who's name this is on the controlled proof of use sheet. I did not notice that it showed that the medication was administered three times that day. That is really strange. I was assigned to (R3) on 4/15/2026.During an interview on 6/29/2026 at 9:01 AM, the Nursing Home Administrator (NHA) reported that during a routine audit on Controlled Substance Proof of Use forms (on 4/21/26 per the FRI summary), 2 tablets of R3's methylphenidate 10mg tabs were discovered as dispensed outside of the practitioner's order. The management team and facility staff were unable to determine who dispensed R3's methylphenidate between 4/14/26 and 4/15/26 due to the illegible signature and dates. The NHA reported that based on the Controlled Substance Proof of Use forms, the MAR, and the witness statements, the result of the investigation was inconclusive. The NHA further reported that based on the timeline of events the management team deemed RN K responsible for the following reasons, 1.) she was the only licensed nurse caring for R3 during the time the methylphenidate went missing that had access to the medication cart, 2.) she may have left the medication cart and narcotic lock box keys accessible to other staff/visitors/residents, and/or 3.) she may have had the keys on her person but left the medication cart and narcotic lock box unlocked. Ultimately, the management team felt that she had not followed professional standards of nursing practice and placed her on the do not return list from the contracted agency.The NHA and the Director of Nursing (DON) confirmed that the facility's pharmaceutical services system would be reviewed to prevent any incident such as this from reoccurring. The NHA reported that a review of the process for accurate reconciliation and accounting for all controlled substances, prompt identification of loss or potential diversion of controlled substances, and proper storage of controlled substances to prevent unauthorized access and/or removal of the medications would be completed.The DON reported she would be increasing the monitoring of medication carts (to ensure they were properly locked without availability to the keys), resident MAR's (to ensure accurate documentation of the administration of controlled medications), as well as frequent audits/reconciliation of the Controlled Substance Proof of Use forms (to ensure controlled substances were not diverted, dispensed outside of the ordered times, and/or in excessive doses). The DON reported that the licensed nurses would be immediately educated on properly storing, dispensing, administering, documenting on, and disposing of controlled substances.Unable to contact RN K during onsite survey.Review of the facility policy, Controlled Substances Standards of Practice last reviewed January 2025 revealed, .The Proof-of-Use sheet will be placed in the medication cart Controlled Substance Tracking Binder (narcotic count book) which will be reviewed when change of ownership of the narcotic keys is made, shift to shift or change in assignment.Distribution and Record Keeping in Facility-Nurses removing controlled substance from the narcotic storage require documentation on the Proof-of-Use Sheet the amount removed using a full last name signature. Nurse documentation of inventory balance on Proof-of-Use sheet MUST be made as soon as the controlled substance is removed from the package/cart. Avoid waiting until the end of med pass or end of shift. Once the nurse completes the administration, then the nurse is to document on the MAR (Medication Administration Record) paper record or E (electronic)-MAR electronic record. If PRN (as needed) medication is administered, additional documentation regarding reason, result, time and initials are required. Note: If documentation is not provided on MAR or E-MAR, medication will be considered not given. MAR or E-MAR is record of administration NOT the proof-of use sheet.Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, Guidelines for Safe Opioid (Narcotic) Administration and Control:Store all narcotics in a locked, secure cabinet or container (e.g., computerized, locked cabinets are preferred).Maintain a running count of opioids by counting them whenever dispensing them. If you find a discrepancy, correct it and report it immediately.Use a special inventory record each time an opioid is dispensed. Records are often kept electronically and provide an accurate ongoing count of narcotics used, wasted, and remaining.Use the record to document the patient's name, date, time of medication administration, name of medication, and dosage. If the agency keeps a paper record, the nurse dispensing the medication signs the record.A second nurse witnesses disposal of the unused part if a nurse gives only part of a dose of a controlled substance .If paper records are kept, both nurses sign their names on the form .As a nurse, you are responsible for following all legal regulations when administering controlled substances (medications with potential for abuse). Controlled substances must be properly stored to prevent diversion. Violations of the Controlled Substances Act may result in fines, imprisonment, and loss of license.[NAME] RN, MSN, PhD, FAAN, [NAME] A.; [NAME] RN, MSN, EdD, FAAN, [NAME] G.; Stockert RN, BSN, MS, PhD, [NAME] A.; Hall RN, BSN, MS, PhD, CNE, [NAME]. Fundamentals of Nursing - E-Book . Elsevier. Kindle Edition.

This citation pertains to intakes # 2801558 and 2807946Based on interview and record review, the facility failed to provide care following professional standards of practice and facility policy to prevent the development and/or worsening of pressure injuries for 3 of 5 residents (Resident #100, #42, and #41) reviewed for pressure injury prevention and management, resulting in a stage IV sacral decubitus ulcer with exposed bone and presumed osteomyelitis for R100.Findings:Resident #100 (R100)Review of an admission Record revealed R100 was a [AGE] year-old female, originally admitted to the facility on [DATE] and readmitted following a hospitalization from 6/12/25-6/26/25, with pertinent diagnoses which included: frontal brain mass resection, urinary incontinence, cognitive communication deficit, and need for assistance with personal care. Further review of the admission Record revealed R100's spouse was Emergency Contact #1.Review of R100's SLUMS Evaluation (St. Louis University Mental Status Exam to determine mental status) dated 6/5/25 completed by Speech Language Pathologist (SLP) N revealed, .Examination for detecting mild cognitive impairment and dementia is more sensitive than the Mini-Mental Status Examination. A score from 1-20 for a person with a high school education indicates dementia. R100 scored a 10.Review of a Minimum Data Set (MDS) assessment for R100, with a reference date of 7/2/25 revealed a Brief Interview for Mental Status (BIMS) score of 11, out of a total possible score of 15, which indicated R100 was moderately cognitively impaired. Review of R100's Care Plan dated 06/10/2025 revealed, Cognitive Loss / Dementia-Resident has impaired cognition that fluctuates.Review of R100's Electronic Medical Record (EMR) revealed R100 was hospitalized from [DATE]-[DATE] following a craniotomy with the surgical excision of a large meningioma (brain tumor). Upon return to the facility, R100 required the use of an enteral feeding tube for nutrition and hydration supplementation but was also able to consume food and liquids orally.During an interview on 03/25/2026 at 10:17 AM, Family Member (FM) I reported that she and R100's spouse had not been notified of R100's pressure injury at the time of the care conference on 7/9/25. FM I reported that the care conference was to discuss all areas of concern and treatment plans and goals with family involvement, and she would have expected to be notified of a pressure injury at that time. FM I reported that the family and R100's spouse were completely unaware of the pressure injury or the severity of her wound until 7/30/25 when R100's spouse was at the facility during the time wound care was being completed stating we didn't know through that whole timeframe! FM I reported that she requested a meeting with management based on R100's spouse's observation from 7/30/25 and on 8/4/25 she was notified of the severity of the wound but had been told the wound was getting better. FM I reported that the director had told her that upon R100's return from the hospital a stage 1 pressure injury was identified and blamed the hospital. She was then told that it was a stage 3 pressure injury by 7/11/25. FM I reported that throughout her readmission on [DATE] until the meeting on 8/4/25 nobody said anything about treating it (the pressure injury) and stated, I don't know when it went to a stage 4. FM I reported that they were unaware of the severity of the wound until R100 was sent to the emergency department on 8/6/25 where they were told the pressure injury and infection that went into the bone. FM I reported R100 was in extreme pain and reported she did not recover from the pressure injury and infection, and her cause of death was from a stage 4 sacral ulcer.Review of R100's Care Plan with an approach start date 6/27/25 revealed, Category: ADLs Functional Status/Rehabilitation Potential Resident needs assistance with ADLs and care r/t: recent hospitalization, weakness, debility, overall functional decline. Bed mobility: 2PA (2 person assistance). R100 was independent for bed mobility prior to readmission.Review of R100's Care Plan dated 6/2/25 revealed, Category: Urinary Incontinence Resident is occasionally incontinent of bladder. Apply moisture barrier to skin PRN (as needed). R100's care plan did not reflect she was incontinent of bowels.Review of R100's Order Summary dated 6/26/25 revealed, Apply skin protectant after each incontinent episode / toileting assistance / brief change.Review of R100's Care Plan dated 06/02/2025 revealed, 06/05/2025 Category: Nutritional Status .*7/10/25: Significant weight loss at 30 days (prior to Corpak) .Approach Start Date: 06/05/2025 Observe labs.Review of R100's Laboratory Results dated 6/11/25 revealed R100's Albumin was 3.6 (Reference Range 3.5-5.7) and her protein was 6.4 (Reference Range 6-8.3). Review of R100's Critical admission Assessment dated 6/26/25 revealed Skin: Check all that apply-reddened.sutures to craniotomy site.Review of R100's Skin Body Assessment dated 6/26/25 written by Registered Nurse (RN) O revealed, left temporal hs bump and discoloration (sic). Head has 49 stitches and open to air. Left hand has bruising. Left wrist and left forearm have bruising. Left antecubital area has bruising. left outer and inner upper arm has bruising. Laft (sic) anterior shoulder have bruising. left thigh inside has bruising. Right hand and right antecubital area have bruising. Lower abdominal has multiple bruising. There was no documentation regarding a pressure injury to R100's buttocks.Review of R100's Progress Note written by Assistant Director of Nursing (ADON) B revealed, incontinent of bowel and bladder, A&O2-3 (A&O x4 refers to a person's level of orientation to four aspects: person, place, time and situation/circumstances. A&O x 2 can indicate confusion regarding time or situation).bilateral buttock red but blanchable. indicating no pressure injury. (Per the National Pressure Injury Advisory Panel, a Stage 1 Pressure Injury is non-blanchable erythema (redness) of intact skin.)Review of R100's Skin Body Assessment dated 6/26/25 written by RN O revealed the document was modified on 8/3/25 by ADON B to include .Stage one to buttock.Review of R100's EMR revealed no documentation that R100's spouse/emergency contact or provider were notified of the stage 1 pressure injury or that R100's care plan was updated to reflect the pressure injury with interventions to heal and/or prevent the worsening of the pressure injury or with R100's change of bowel control to incontinence.During an interview on 03/25/2026 at 3:22 PM with Regional Nurse Consultant (RNC) A present, Assistant Director of Nursing (ADON) B reported that due to the time that had lapsed she could not recall why she had modified Registered Nurse (RN) 0's Skin Body Assessment dated 6/26/25 but believed it was prompted from RN O's admission assessment upon her return from the hospital. RNC A and ADON B reported R100's husband was not notified of the pressure injury on 6/26/25 because R100 was her own person and did not have an activated power of attorney or responsible party.Review of the facility policy Notification of Change dated 7/2017 revealed, .9. The resident's legal representative or interested family member is notified of a significant change in the residents condition unless the resident has specified otherwise.Review of R100's physician Progress Note dated 6/27/25 revealed no documentation of a stage 1 pressure injury.Review of R100's dietary Progress Note dated 6/27/25 revealed, .Skin observation 6/26/25 indicates sutures to craniotomy. Score of 7 on mini nutrition screen indicating malnutrition, no interventions requested at this time. Continue to monitor weights/skin with po (oral) intake and adjust nutritional POC (plan of care) as needed. Confirming there was no pressure injury documented upon R100's readmission and therefore no supplements were initiated.During an interview on 3/26/26 at 10:06 AM, Registered Dietician (RD) K reported that had she been notified of R100's pressure injury identified on 6/26/25 she would have initiated the supplement pro heal to promote wound healing. RD K reported that she used the skin assessments completed upon a resident's return to determine their needs. RD K reported that she reviewed weekly wound and skin assessments to determine ongoing needs for the residents and their healing/nutritional requirements. Once a wound advances to a stage 3, additional supplements would be added as a standard of practice.Review of R100's physician Progress Note dated 6/30/25 revealed she was being seen for Debility and decreased mobility status post hospitalization. There was no documentation regarding a pressure injury to her buttocks.Review of R100's Skin Body Assessment dated 7/1/25 revealed Areas of Skin Impairment. left temporal has discolortation (sic) and head has stutures (sic), Open to air, and have some bruisese (sic) all over body. There was no reference to a pressure injury on R100's buttocks.Review of R100's Braden Scale For Prediction Of Pressure Sore Risk dated 7/1/25 revealed a score of 12 indicating R100 was at high risk for the development of pressure injuries. R100 had previously scored a 17 identifying her as at risk on 6/2/25.Review of R100's physician Progress Note dated 7/2/25 revealed, .she is dependent for rolling side-to-side x 3 repetitions. Indicating she was unable to independently offload pressure by rolling/repositioning.Review of R100's Care Plan revealed there were no new interventions initiated following the change of her pressure injury risk from at risk to high risk and her dependence on staff for repositioning/rolling side-to-side.Review of R100's Skin Body Assessment dated 7/8/25 revealed Areas of Skin Impairment.Open area to left buttock with purple area around it. Management aware and APM (alternating pressure mattress) mattress has already been ordered.Review of R100's Progress Note dated 7/8/25 revealed, .Skin assessment completed.Review of R100's EMR revealed no documentation that R100's spouse/emergency contact or provider were notified of the open area to left buttock or that a treatment order was initiated to prevent the worsening of the wound. On 7/9/25 an APM was delivered.Review of R100's Care Conference notes dated 7/9/25 revealed R100's spouse and multiple other family members were present as well as ADON B. Care conference held today with resident, family and IDT (interdisciplinary) team. Resident and family wondering about how dc (discharge) home will look, educated right now resident needs 24hr care, goal is for resident to become independent with transfers to a wheelchair. Home care and private duty options educated to family. Rationale for resident remaining in this facility. SAR (subacute rehab) with plans to return home with spouse. There was no documentation that R100's spouse and family members were notified of her pressure injury or that the pressure injury treatment plan was discussed.Review of R100's Skin Integrity Event Report dated 7/10/25 at 11:06 AM revealed, Date and time of discovery 07/09/2025 04:00 PM-In House Acquired.Stage 2. The wound measured 3 (cm) x 3 (cm) with no depth measured. Resident's condition prior to discovery of pressure injury-Recent Change in Condition.Date/Time the last skin assessment was conducted 07/08/2025 09:00 PM- Resident noted to have an open area to coccyx. Area was discovered on routine skin assessment.Was an order received for treatment? Yes-Name of family member/resident representative notified. self, spouse 07/09/2025 04:00 PM (indicating the facility staff was to notify R100's spouse of a newly identified pressure injury).MD and resident notified of the open area.Review of R100's Determination of Unavoidable Pressure Wound dated 7/10/25 revealed, Was an at risk assessment completed on admission? Yes, date completed: - 06/02/2025 (Confirming an At Risk Assessment was not completed upon her readmission following a craniotomy and a 2 week hospitalization).Was an initial preventative plan of care implemented? Yes, date completed-06/02/2025 (Confirming R100's Care Plan was not updated to reflect the newly identified bowel incontinence or a positioning/turn schedule initiated upon her readmission on [DATE]).Were nutritional interventions implemented and routinely evaluated? Yes. If Yes, explain. (no documentation) ( No supplement was initiated following the dieticians assessment on 6/27/25.)Was preventative care, including turning and repositioning, pressure reducing/relieving devices and goal to keep resident's skin clean and dry implemented? (R100's Care Plan did not include a turning/repositioning/offloading schedule, the Roho Cushion, or APM prior to 7/10/25).Does the resident have two or more primary risk factors? Chronic bowel incontinence.Did resident develop malnutrition and/or dehydration despite interventions to alleviate? No (6/27/25 the Registered Dietician documented Score of 7 on mini nutrition screen indicating malnutrition, no interventions requested at this time.).The physician has documented unavoidable pressure wound based on the resident's medical condition. Yes (R100's EMR did not reflect the physician's determination R100's pressure injury was unavoidable.)Review of R100's Order Summary dated 7/10/25 revealed, Cleanse area with soap and water, apply thin layer of triad cream to wound bed. Reapply twice daily.Review of R100's Treatment Administration Record revealed the wound treatment was completed on 7/10/25 between 7PM-11PM. (Approximately 24 hours after the identification of the wound).During an interview on 03/25/2026 at 3:22 PM RNC A and ADON B reported the reason there was a lapse from the initial identification of R100's pressure injury and the initiation of treatment was because previous Director of Nursing (PDON) L abruptly quit her position without notice while ADON B was on vacation. The concern was acted upon when ADON B returned.Review of R100's Wound Consultant Note dated 7/11/25 revealed, (R100) is seen today for a wound to her sacrum present for less than a week. Staff notes area did start to break down last week-treating with triad paste. She does verbalize some tenderness to the area.She does require staff assistance with mobility. The wound measured 4 (cm) x 3 (cm) x 0.2 (cm) and was determined be a Stage 3 pressure injury. A mechanical debridement (removal of dead tissue from wound bed). An order to start Medihoney gel to wound bed on sacrum.Cover with silicone bordered foam dressing every other day was initiated.Review of R100's EMR revealed no documentation that R100's spouse/emergency contact was notified of the worsening of the pressure injury, the debridement, or the treatment order change. R100's Care Plan was not updated to reflect the deterioration of the wound and no new interventions were implemented to promote the healing of and/or prevent the worsening of the pressure injury.Review of R100's Dietary Assessment dated 7/14/25 revealed, Skin observation 7/8/25 indicates open area to left buttock, request Pro Heal 30ml (100 kcal, 15 grams pro, ea) QD (everyday) be added. Review of R100's EMR revealed Pro Heal was ordered 7/14/25.Review of R100's Laboratory Results dated 7/16/25 revealed R100's Albumin was 2.4 and her protein was 5.1 (now below normal limits). R100's WBC (white blood cell-indicative of infection) was 10.6 (Reference Range 4-11). A handwritten date of 7/18/25 was reflected on the report indicating the provider reviewed the results.Review of R100's EMR revealed no documentation of any new treatments, medications, or interventions for R100's abnormal labs.Review of R100's Wound Consultant Note dated 7/18/25 revealed R100's sacrum wound was deteriorating and now measured 5.2 x 5 x 2.8 and required a sharp debridement. (use of scalpels, scissors, or forceps to remove dead tissue from wound bed). An order to start Dakin's solution 0.125% moistened gauze into wound bed.twice daily.Review of R100's Wound Management Note dated 7/18/25 revealed the wound was stable which contradicted the wound providers assessment.Review of R100's EMR revealed no documentation that R100's spouse/emergency contact was notified of the deteriorating pressure injury or the debridement. R100's Care Plan was not updated to reflect the deterioration of the wound and no new interventions were implemented to promote the healing of and/or prevent the worsening of the pressure injury.Review of R100's Progress Note dated 7/19/25 revealed, Resident returned from Hospital.resident was diagnosed with PNA (pneumonia) and hospital prescribed Ceftin 500mg x2 day for 5 days and Doxycycline 100mg x2 day for 5 days (antibiotics).DON notified of residents return and new diagnosis of PNA and ABX (antibiotics) order.Review of R100's Wound Consultant Note dated 7/25/25 revealed, She was sent out to the ED (emergency department) last week for pneumonia.Recent pneumonia may affect mobility. R100's sacrum wound was deteriorating and now measured 7.4 x 7 x 3.4, had a mild odor, and required a sharp debridement. Continue Dakin's solution 0.125% moistened gauze into wound bed .Twice daily. RD (registered dietician) to ensure nutritional intake is ideal for wound healing including increase protein intake.Review of R100's EMR revealed no documentation that R100's spouse/emergency contact was notified of the deteriorating pressure injury or the debridement. R100's Care Plan was not updated to reflect the deterioration of the wound and new diagnosis of pneumonia and no new interventions were implemented to promote the healing of and/or prevent the worsening of the pressure injury. There was no documentation that the dietician was notified of the worsening of R100's wound.Review of R100's Order Summary dated 7/25/25 revealed, Cleanse area with NS/wound cleanser. Apply Dakin's solution 0.125% moistened gauze into wound bed. Cover with bordered dressing. Every shift.Review of R100's Medication/Treatment Administration Record revealed that from 7/25/25-8/2/25 the Dakins 0.125% treatment was completed 3 times a day and not 2 times a day as recommended.During an interview on 03/25/2026 at 3:22 PM, ADON B reported that the wound consultant ordered the Dakin's treatment himself. ADON B reported that the wound treatment may have been inputted into the system incorrectly but the error was on his end.Review of R100's EMR revealed no documentation of the treatment order discrepancy or communication to the wound provider for a clarification order.Review of R100's Order Summary revealed the enteral feeding was held/discontinued on 7/30/25.Review of R100's Dietary Assessment dated 8/1/25 revealed, .Wound report indicates stage III to coccyx, stable 7/18/25.Considering NG (nasogastric) tube feeding on hold and average po intake, request med pass 120ml.TID (three times a day) and mighty shake.QD (daily) be added also increase pro heal.from QD (daily) to BID (twice a day). The assessment did not include a review of her abnormal laboratory studies (worsening of protein and albumin) and did not accurately reflect the state of R100's deteriorating pressure injury.Review of R100's Wound Consultant Note dated 8/1/25 revealed, Her appetite has been poor. Currently working on increasing PO (oral) intake. They have placed her tube feeding on hold. R100's sacrum wound was deteriorating and was now a stage 4 pressure injury. The wound measured 6.5 x 8.3 x 4 and had undermining with exposed fascia (connective tissue). The periwound (surrounding) was noted to have excoriation (skin damage) and rubor (redness caused by inflammation). A sharp debridement was performed and it was recommended to continue Dakin's solution 0.125% moistened gauze into wound bed .Twice daily.Review of R100's Order Summary revealed Coccyx: Cleanse area with NS/wound cleanser. Apply Dakin's solution 0.125% moistened gauze into wound bed. Cover with bordered dressing. Every shift. Twice A Day which was implemented on 8/3/25. (Previous order of Sakin's solution 0.125% three times a day ongoing until 8/3/25.)Review of R100's EMR revealed no documentation that R100's spouse/emergency contact was notified of the deteriorating pressure injury or the debridement. R100's Care Plan was not updated to reflect the deterioration of the wound and no new interventions were implemented to promote the healing of and/or prevent the worsening of the pressure injury.Review of R100's Laboratory Results resulted on 8/1/25 at 8:28 PM revealed R100's Albumin was 2.0 and her protein was 4.9 (continuing to trend down). R100's WBC was 14.8 (indicating an infection). A handwritten date of 8/4/25 was reflected in the report indicating the provider reviewed the results.Review of R100's Care Conference dated 8/4/25 revealed it was a family requested care conference. Care Conferencce (sic) held with residents daughter in law to discuss residents progress with wounds, therapy and to determine if there is a time frame that resident is expected to go home. information on wound statues, interventions, intake status and corpak given to (FM I). all questions were answered to the best of our ability and (FM I) verbalized understanding.Review of R100's Order Summary dated 8/4/25 revealed the osmolyte enteral tube feeding was restarted. (Approximately 3 days following R100's low protein and albumin levels).Review of R100's Dietary Assessment dated 8/5/25 revealed, .Wound report is indicating stage IV to coccyx stable as of 7/18/25.Agree with restarting tube feeding as po intake of meals has not improved with significance/ not meeting her elevated nutritional needs, unknown current weight status and coccyx wound has changed from stage III to IV. Suggest continuing with current po supplements as ordered.Review of R100's Practitioner Progress Note dated 8/6/25 revealed, .This morning the patient is seen lying in bed. She states that she did not sleep well last night because of her sacral pain. There is an order for her to be turned every 2 hours but she claims they are not doing it.Review of R100's Progress Note dated 8/6/25 revealed, (R100) was working with therapy, she was unable to sit on the EOB (edge of bed) less than 5 minutes without feeling lightheadedness and dizziness. Resident stated that it started yesterday and today it's worse. Pulse elevated, WBCs 14. NP (Nurse Practitioner) notified, order received to send resident to the ED for evaluation and treatment.Review of R100's Hospital Record dated 8/6/25 revealed, .There is a significant 10 x 10 centimeter stage IV decubitus ulcer along her sacrum. Foul-smelling purulent (oozing pus) drainage noted coming from the wound. Wound does extend down to the sacral bone. There is surrounding erythema.Principal Problem: Decubitus ulcer of sacral region, stage 4 Active Problems: Unspecified severe protein-calorie malnutrition-Acutely worsening stage IV sacral decubitus ulcer after extended stay at a nursing facility. Large defect- 9 x 11.4 x 3.2 cm wound Slough mixed with pale granulation tissue and centrally exposed bone. Presumed osteomyelitis .She has since been bed-bound. She was discharged from the hospital to a rehab, there her sacral wound acutely worsened and is now admitted for worsening sacral wound. Stage IV sacral decubitus ulcer with exposed bone, per definition this is osteomyelitis .her husband states the ulcer is growing in size and depth. There has also been a foul odor coming from the area last week . Photographs of R100's wounds were obtained by the hospital staff for reference of the severity of the wound.Review of R100's Death Certificate revealed the date of death was 8/30/25. The cause of death was listed as follows: Sacral Ulcer Stage 4 due to or as a consequence of malnutrition. Malnutrition due to or as a consequence of dysphagia. Dysphagia due to or as a consequence of Benign neoplasm of cerebral meninges. Review of the facility policy Advance Directive Planning last reviewed 1/2025 revealed, To give the residents the opportunity to discuss their goals for care.The resident and/or responsible party is informed of the scheduled time of the care planning discussion as far in advance as is practicable by face-to-face visit, written or telecommunication notification. The problems, goals and interventions are discussed and documented during the care planning session and documented in the medical record of the resident. During care conference the IDT will review resident's preference and determine if any changes are requested by the resident or resident representative, in compliance with state requirements.Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, For patients experiencing acute or chronic illnesses, diseases, or trauma, patients' family members and surrogate decision makers become active partners in decision making and care .When possible, patients and family caregivers want to participate in shared decision making about treatment options and ongoing symptom management. Incorporating a patient's and family's cultural beliefs, values, and communication patterns is essential to provide individualized patient/family-centered care. When developing a plan of care, consider all resources available to patients. The family plays a key role .Engaging the family or designated surrogate is a fundamental skill of patient-centered care [NAME] RN, MSN, PhD, FAAN, [NAME] A.; [NAME] RN, MSN, EdD, FAAN, [NAME] G.; Stockert RN, BSN, MS, PhD, [NAME] A.; Hall RN, BSN, MS, PhD, CNE, [NAME]. Fundamentals of Nursing - E-Book . Elsevier. Kindle Edition.Resident #42 (R42)Review of an admission Record revealed R42 was an [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: pressure injuries and osteomyelitis (infection in the bone).Review of the Physician Communication book (located at the nurses station) revealed a handwritten entry dated 3/15/26 for R42, 3cm x 3cm of skin breakdown to (right) buttock. Zinc cream treatment ordered.Review of R42's Progress Note dated 03/15/2026 revealed, .Wound care provided per orders. 3cm x 3cm reddened area noted to right buttock. Noted in (provider group) book. Treatment order placed.Review of R42's Wound Clinic Note dated 3/17/26 revealed, .The date acquired was 3/15/2026. The wound is currently classified as a Category/Stage II wound with etiology of Pressure Ulcer and is located on the Right Gluteus. The wound measures 1cm length x 1.5cm width x 0.1cm depth .comfort foam border dressing change frequency; 3 times weekly-Tues, Thur, Sat .Review of R42's Order Summary revealed the following entries:3/15/26: Area of breakdown to right buttock. Apply zinc cream after each incontinence care. Monitor for signs/symptoms of infection Q (every) shift until healed3/18/26: Right Buttock: Cleanse with soap and water, apply silicone bordered dressing to open area. Change three times weekly.3/19/26: Cleanse open area to right buttock with normal saline. Pat dry. Apply border gauze daily and PRN (as needed) until healed. The frequency of the order was ordered for every shift (3 times a day).Review of R42's Treatment Administration Record revealed the following concurrent treatments:From 3/15/26 through 3/25/26 the order to apply zinc cream was completed every shift (3 times a day) with the exception of 1st shift on 3/24/26. The treatment was an ongoing order.From 3/18/26 through 3/24/26 the order for dressing changes to be completed on Monday, Wednesday, and Friday was completed on 3/18/26, 3/20/26, 3/23/26 and 3/25/26. The treatment was an ongoing order.From 3/19/26 until 3/23/26 the order that was to be completed daily was completed on: 3/19/26 on the afternoon and evening shift3/20/26 on the morning, afternoon, and evening shift3/21/26 on the morning and evening shift3/22/26 on the morning and evening shift3/23/26 the order was discontinued.Confirming the wound clinic's order for 3 times a week wound care/treatment was not followed as ordered.Review of R42's Electronic Medical Record revealed no documentation related to the treatment order implemented on 3/19/26 or a rationale for initiating an additional treatment.During an interview on 03/26/2026 at 12:06 PM, Assistant Director of Nursing (ADON) B reported that the additional order for wound care was due to the nurse working on 3/19/26 erroneously believing there was no order for R42's wound care thus obtaining an order from the facility provider.On 03/25/2026 at 1:08 PM, Nursing Home Administrator (NHA) provided documentation confirming the additional order from 3/19/26 was not discontinued until 3/23/26.Review of R42's Order Summary dated 2/19/26 revealed, Skin Assessment Weekly.Review of R42's weekly Skin Body Assessments for the month of March 2026 revealed the only assessment that was completed was on 3/23/26 (last skin assessment was completed on 2/27/26).Review of R42's Electronic Medical Record revealed no documentation for missed/late weekly skin assessments.Resident #41 (R41)Review of an admission Record revealed R41 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: Parkinson's disease, protein-calorie malnutrition, and muscle weakness. Further review of the admission Record revealed R41 was hospitalized from [DATE]-[DATE].Review of R41's Order Summary dated 2/23/26 revealed, Skin Assessment Weekly.Review of R41's Care Plan dated 2/23/26 revealed, Skin Integrity-(R41) is at risk for impaired skin integrity related to: recent hospitalization with overall decline from baseline, decreased mobility, advanced age, presence of pressure ulcers currently, fragile skin, advanced age, incontinence. Complete skin inspection weekly and as needed.Review of R41's weekly Skin Body Assessments beginning on 2/23/26 revealed:A skin assessment was completed on 2/23/26. There was no skin assessment completed on 3/2/26. An assessment was not completed again until 3/5/26 (10 days).There was no weekly skin assessment completed on 3/12/26 or 3/19/26. R41's skin assessment was not completed until 3/23/26 (18 days).Review of R41's Electronic Medical Record revealed no documentation for missed/late weekly skin assessments.During an interview on 03/25/2026 at 1:16 PM, RNC A reported that ADON B was in charge of the wound management program and weekly wound meetings were to be held to monitor and track the progress of resident wounds. RNC A reported that weekly skin assessments were to be completed by the licensed nurses and the Certified Nursing Assistant (CNA) shower sheets were not to be utilized in place of the weekly skin assessments. RNC A reported that the licensed nurses would sign off on the CNA shower sheets but that was not a replacement for the licensed nurse assessment of resident skin. RNC A confirmed that weekly skin assessments had not been completed as directed by the facility policy.Review of the facility policy Pressure Injury Prevention and Care last revised 01/2025 revealed, This policy is intended to supplement the clinical staff's knowledge and provide a resource to guide on wound prevention and management procedures. The procedures and information contained herein are not intended to replace a licensed nurse's clinical judgment and experience and may not pertain to each individualized pressure injury occurrence.Purpose: To promote and facilitate pressure injury prevention and implement appropriate interventions and treatment of pressure injuries to promote and facilitate resolution of pressure injuries.Procedure:Nurses will complete the Skin Body Assessment Observation upon admission/readmission, then weekly and as needed.5. Interventions will be implemented, and care planned to prevent pressure injury development or to promote pressure injury resolution. Examples of interventions based on individualized resident needs may include the following. This list is not all-inclusive, nor does

Based on observation, interview, and record review the facility failed to implement ordered safety precautions for two (Resident #43 and Resident #41) of three residents reviewed for accidents, resulting in Resident #43 eating meals unsupervised, choking and aspirating, and requiring emergency medical attention and hospitalization. Findings: Resident #43 (R43)Review of a Face Sheet revealed R43 was a [AGE] year-old female, last readmitted to the facility on [DATE] following hospitalization for a stroke that caused dominant (right sided) facial, arm, and leg weakness and paralysis. R43 depended on staff to meet all of her daily needs. Review of a Speech Language Therapy Evaluation for R43, completed 02/02/26, recommended 1:1 staff assistance for safety during all meals due to reduced oral motor skills and overt signs and symptoms of aspiration.Review of a Therapy Communication form dated 02/04/26, revealed the following safety recommendations for R43: please provide 1:1 assist with all feeding due to intermittent physical assist needed, aspiration risk, and decreased sensation on right side of resident's face. Required for safety.During an observation on 02/10/2026 at 9:11 AM, R43 sat up in bed and ate breakfast without staff supervision. During an observation on 02/10/26 at 1:09 PM, R43 sat up in bed eating lunch without staff supervision and the call light was out of reach and out of sight. During an observation on 02/10/26 at 1:29 PM, R43's lunch tray, that sat on the collection cart near the bistro, contained a half-eaten portion of goulash, a completely consumed piece of chocolate cake, and untouched carrots (R3's meal ticket lists carrots as a dislike). During an interview on 02/10/26 at 1:30 PM, Certified Nurse Aide (CENA) E reported removing the lunch tray from R43's room when she realized that staff were not in there to supervise the meal. CENA E also stated that R43 indicated that she was having chest pain and CENA E notified Licensed Practical Nurse (LPN) F of this concern. During an interview on 02/10/26 at 1:31 PM, LPN F completed preparation for R43's medication pass and when asked if LPN F was aware that R43 had reported to CENA E that she was having chest pain, LPN F stated yes and that's pretty normal for her (R43). During an observation on 02/10/26 at 1:32 PM, LPN F, CENA D and this surveyor entered R43's room. R43 was crying, indicated that yes she was having chest pain, was red in the face, and appeared anxious. LPN F attempted to obtain a blood pressure and oral temperature from R43, and the resident could not tolerate the cuff inflating. During an observation on 02/10/26 at 1:39 PM, LPN F administered R43's medications crushed in pudding. R43 began to choke and cough and vomited unchewed elbow noodles and dice sized tomatoes from the goulash and dark brown liquid. LPN F commented that she thought R43 had aspirated and will need a chest x-ray. LPN F did not auscultate (listen to) R43's lung sounds.During an interview on 02/10/26 at 1:45 PM, CENA D stated that she had brought R43's lunch tray to the room and placed it on the over-bed table. When asked why she did not stay with R43 once the meal tray was placed in front of her, CENA D indicated that she was helping another resident finish their meal and was going to return to R43 once she had finished assisting the other resident. CENA D acknowledged knowing that R43 required 1:1 assistance with all meals.During an interview on 02/10/26 at 4:45 PM, Registered Nurse P stated she had assessed R43 and found abnormal lung sounds as well as elevated blood pressure, pulse and respirations. RN P prepared to send R43 to the emergency department.Review of a Hospitalist Progress Note dated 02/11/26 reflected.(R43) patient presenting with severe sepsis and mild hypoxia (low blood oxygen level) after questionable aspiration event at her subacute rehab facility.updated CXR (chest x-ray) this morning shows LLL (left lower lobe of the lungs) airspace disease, possible aspiration.Resident #41 (R41) Review of a Face Sheet revealed R41 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses of Parkinson's disease, cognitive communication deficit, and muscle weakness. During an observation on 02/10/26 at 9:00 AM, R41 sat in a chair eating breakfast. R41 drank hot coffee from a cup without a lid and did not have a clothing protector on. Review of a meal ticket that sat on the breakfast tray indicated that R41 should have a lid with all hot liquids and a clothing protector on. Review of a quarterly Hot Food/Liquid assessment dated [DATE] revealed that as a safety care plan intervention, R41 was to have a cup with a lid for hot liquids to reduce the risk of burns. The previously completed quarterly Hot Food/Liquid assessment dated [DATE] and not completed timely every 4 months, revealed the safety interventions of R41's use of a cup with lid and clothing protector over lap and chest.

Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include:During an observation beginning on 2/9/2026 at 8:30 AM, the door to the kitchen at the facility was observed open from a dining room. No staff were present in the kitchen at this time. Hair nets were not present at the entrance of the kitchen above a handwashing sink. Dirty dishes and scraps of food were noted on a two-shelf cart and on a dining room table outside the kitchen. During the initial kitchen tour starting on 2/9/2026 the following were observed:The microwave oven was opened and dried food debris were noted within the microwave and on the inside of the microwave door. According to the 2022 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Nonfood-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. -A 4-quart container with an unknown soup with large drops of condensation noted on the clear lid of the container (indication of the food being covered while still hot) was noted without a label or a date to indicate what the food is and when the food was stored and when it should be discarded. -A turkey sandwich wrapped in plastic was found without a label or a date. -A large bag of iceburg lettuce was open to air (not sealed or closed) on the bottom shelf of the reach in cooler, without a label or a date indicating when the produce was opened and when it needed to be discarded. -A package of lunch meat that had been opened was not labeled or dated.-A large pan of pasta with red sauce was noted on the bottom shelf of the reach in cooler, covered in clear plastic wrap. The pasta had portions removed and indicated the food had been served and was left over from a previous meal. The pan of food did not have a label or a date on it.-A large bag of pepperoni was observed to have been opened, no label or date were observed on the packaging.-A container of sour cream was observed in the reach in cooler and had expired on 2/7/2026.-Frozen ground beef patties were open to air in plastic bag not closed, within the reach in freezer. No label or date was noted on the packaging. -5 large bags of dry cereal were observed opened and without a label or date on them in the dry storage area. During an observation on 2/9/2026 at 8:50 AM of the reach in refrigerator in the main dining room serving area, the following were noted:-A full tray of fruit cups was noted uncovered and without a label or date. According to [NAME] G, the fruit cups had not been prepared that morning and she was not sure when they had been placed in the refrigerator. -A plastic grocery bag containing a plastic storage container with unknown food was stored in the refrigerator without a label or date on the plastic bag or contents. [NAME] G said the bag must be resident or staff food. A sign on the outside of the refrigerator indicated that no resident or staff food or drinks were to be stored in that refrigerator.-Applesauce portioned into plastic containers were covered with plastic wrap, no label or date were noted on the apple sauce. During an interview on 2/9/2026 at 9:00 AM, Food Service Director (FSD) H reported the food observed in the 4-quart container was a minestrone soup from the week before. FSD H said he did not have cooling logs for the soup or the large pan of pasta, which had been served two days prior. FSD H indicated the foods should be covered or closed, labeled and dated according to policy. FSD H also reported the facility tries not to prepare excess quantity of food to avoid having leftovers and indicated the facility does NOT implement cooling procedures. Review of a facility policy Food Production Guideline revised 1/2025 reflected Safe and sanitary handling of food will be employed during food production. 6. Leftovers must be dated, labeled, covered and immediately refrigerated or frozen for later use. If refrigerated, they will be used within 48 hours and/or follow State Food Code guidelines by use by date. 7. Food prepared in advance must be covered, dated and refrigerated. This excludes foods portioned just before service. Review of a facility policy Storage procedures revised 1/2025 reflected Food shall be properly stored to preserve flavor, nutritive value, and appearance. 5. Opened packages are to be stored in closed containers, labeled, with open date and use by date clearly visible. 6. Dry bulk foods are to be stored in plastic containers with tight covers, or bins which are easily sanitized. The container should be clearly labeled. 9. Food waste should be properly disposed. a. A garbage disposal provides a means of waste elimination. B. Garbage cans with liners and tight-fitting lids are available. These cans are cleaned on a regular basis.4. Hot foods to be refrigerated are to be placed in shallow pans to permit rapid cooling. Follow cooling HACCP (Hazard Analysis Critical Control Point) guidelines. 11. Leftovers are refrigerated immediately and used within 5-7 days with a use-by date clearly marked. Staff will follow Food Code Requirements for storage and dating. 12. All foods in the freezer are to be wrapped in moisture proof wrapping or placed in suitable containers, to prevent freezer burn. They are to be labeled and dated with use-by dates clearly marked. Refer to Food Storage guideline chart. According to the 2022 FDA Food Code section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TOEAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. (B) Except as specified in (E) -(G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety . On 02/10/2026 at 9:45AM, observed in the kitchen at the stainless-steel dirty side table of the dishwasher set up, foam used for caulking felt spongy and can absorb water. The foam was an expanding foam used to close the gap between the wall and the table. On 02/10/2026 at 10:10AM, the clean dish side of the dishwasher set up had gaps in caulking at the back of the table allowing openings in the caulk that cannot be easily cleaned. According to the 2022 FDA Food Code section 6-101.11 Surface Characteristics. (A) Except as specified in ¶ (B) of this section, materials for indoor floor, wall, and ceiling surfaces under conditions of normal use shall be: (1) SMOOTH, durable, and EASILY CLEANABLE for areas where FOOD ESTABLISHMENT operations are conducted; (2) Closely woven and EASILY CLEANABLE carpet for carpeted areas; and (3) Nonabsorbent for areas subject to moisture such as FOOD preparation areas, walk-in refrigerators, WAREWASHING areas, toilet rooms, mobile FOOD ESTABLISHMENT SERVICING AREAS, and areas subject to flushing or spray cleaning methods. On 02/10/2026 at 9:49AM, observed food debris, crumbs, dried greens, and a twist tie, at the back of the bakers table, behind a peanut butter jar and spice containers. On 02/10/2026 at 10:08AM, observed food crumbs in the dry basin of the steam well in the kitchen. During this observation, Foodservice Director (FD) R said the dietary staff plate and serve food out of the Bistro serving area and primarily use the kitchen for food preparation and cleaning only, at this time. According to the 2022 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. On 02/09/2026 at 10:15AM, condensation was observed in several of the double walled water pass cups that had been washed and were sitting in cup racks drying. The condensation was in the space between the double walls of the cups. At time of the observation, FD R was asked if this was regularly occurring and if the condensation evaporated after air drying was complete, FD R was unsure if the condensation evaporated after drying but did not see the condensation as unusual for these water pass cups. On 02/10/2026 at 1:20PM, FD R brought a double walled water cup to the conference room. FD R had run the unused water cup, that was brought out of backstock on 02/10/2026, through the dishwasher and there was no condensation accumulated between the walls. FD R was unable to determine when the water cups began to accumulate condensation since it does not appear to be immediate. On 02/10/2026 at 1:25PM, double walled water pass cups, washed during the AM shift, were observed with retained liquid from condensation between the double walls. Review of manufacturer's site indicates the double walled water cups are not intended to be washed in a commercial dishwasher. Rated only for washing on top rack of dishwasher. According to the 2022 FDA Food Code section 4-101.11 Characteristics. Materials that are used in the construction of UTENSILS and FOOD-CONTACT SURFACES of EQUIPMENT may not allow the migration of deleterious substances or impart colors, odors, or tastes to FOOD and under normal use conditions shall be: P (A) Safe; P (B) Durable, CORROSION-RESISTANT, and nonabsorbent; (C) Sufficient in weight and thickness to withstand repeated WAREWASHING; (D) Finished to have a SMOOTH, EASILY CLEANABLE surface; and (E) Resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition.

Based on observation, interview, and record review, the facility failed to secure three of four medication carts and properly store a medication pass supplement. Findings:During an observation on 02/09/26 at 8:47 AM the 200-hall low side medication cart sat unlocked and unattended by nursing staff. A glargine insulin pen for resident #42 was not dated and was opened. Six loose unidentified pills were found in the bottom of the second drawer. Registered Nurse (RN) B returned to the cart at 8:56 AM. During an observation on 2/10/2026 at 6:10 AM, the main 100 Hall medication cart and the split 100 Hall medication cart were observed unlocked and unattended by a licensed nurse. During an interview on 2/20/2026 at 6:20 AM, Registered Nurse (RN) J reported that she was responsible for both medication carts and knew that they should have been locked when unattended. During an observation on 2/10/2026 at 6:30 AM, RN J prepared a dose of an as needed narcotic medication for a resident. Upon completion of the medication preparation, RN J closed the drawer to the medication cart and proceeded to the resident room for administration of the medication. RN J did not lock the medication cart prior to leaving the cart unattended while administering the medication. During an observation of the 100 Hall medication storage room on 2/10/2026 at 6:45 AM, RN J unlocked the medication refrigerator in the medication storage room. An open container of a medication pass supplement was observed on the top shelf of the medication refrigerator. Review of the facility policy Maintenance of Medication Storage Areas dated 4/2020 reflected Cart security is maintained during entire med pass. The policy also specified, Med Room . 2. Opened food/juice must be covered and dated when put into a refrigerator must be used in 48 hours or per manufacturer's recommendation. Food/fluids are to be stored in a separate refrigerator from medications.

Based on observation, interview, and record review, the facility failed to utilize enhanced barrier precautions for 2 residents (R13 and R27), perform appropriate hand hygiene during care for one resident (R27), and provide a cleanable wheelchair for one resident (R20), of 3 residents reviewed for infection control.Findings include:Resident #13 (R13) Review of a Face Sheet revealed R13 admitted to the facility on [DATE] with pertinent diagnoses of pressure ulcers. During an observation and an interview on 2/9/26 at 11:48 AM, Licensed Practical Nurse (LPN) C was in R13's room providing dressing changes to his pressure ulcers. Outside the room there was a sign posted for staff to use Enhanced Barrier Precautions (EBP) when providing care. The EBP included the use of a gown and gloves. LPN C was observed with no gown on. When LPN C was done with R13's dressing change, a Certified Nursing Assistant (CNA) entered the room without a gown on to assist R13 with incontinence care. When LPN C was completed with his dressing change, LPN C reported he should have donned with a gown for wound care and the CNA who entered the room for incontinence care should have donned with the appropriate PPE (persona protective equipment) as well. During an interview on 2/11/26 at 1:22 PM, the Director of Nursing (DON) reported staff get educated all the time on infection control practices and the staff should have known to wear the appropriate PPE in rooms that require EBP. Resident #20 (R20) During an observation on 2/9/26 at 12:39 PM, R20 was observed sitting in his wheelchair and the arms of the wheelchair had the vinyl covering torn and tattered exposing the underlying fabric that is not cleanable. In an interview on 2/11/26 at 1:22 PM, the Director of Nursing (DON) reported she briefly heard about R20's wheelchair arms being replaced a couple weeks ago. The DON reported that R20 had OCD (obsessive compulsive disorder) and does like to pick at things. The DON verified the arms on the wheelchair are not a cleanable surface and reported the facility already has new wheelchair arms on order. R27Review of a Minimum Data Set (MDS) comprehensive assessment dated [DATE] reflected R27 admitted to the facility on [DATE] with diagnoses that included a history of stoke. R27 was cognitively intact as evidenced by a Brief Interview for Mental Status assessment score of 13/15 and required supervision and touching assistance for toileting hygiene and bathing. During an observation on 2/9/2026 at 10:45 AM, a sign outside R27's room indicated that R27 and the roommate were both in Enhanced Barrier Precautions. During an observation on 2/9/2026 at 10:55 AM, Certified Nurse Aide (CNA) N entered the room with washcloths and towels, donned gloves and proceeded to prepare a basin of water to give R27 a bed bath. CNA N did not don a gown for the procedure. CNA N applied a shower cap, removed the top sheet from R27, unfastened R27's brief and proceeded to provide incontinence care, washing the perinium. CNA N wiped over the shaft of R27's penis but did not clean under the penis or scrotum. CNA N did not change soiled gloves before removing R27's nasal cannula (supplemental oxygen) and t-shirt. CNA N then got warmer water in the wash basin, changing gloves at this time but did not perform hand hygiene before doing so. R27 was noted to have a wound on his chest covered with a bandage dated 2/6/26. CNA N proceeded with the bed bath, moving to R27's feet. R27 had a large area of eschar on his left heel, a small open area noted inside the wound. CNA N did not change gloves or perform hand hygiene before removing R27's shower cap and running her soiled, gloved hands through R27's hair. CNA N then obtained a comb from R27's personal items and combed R27's hair. CNA N applied a clean brief to R27, gathered the supplies and soiled linens with soiled gloves, touching personal items and bed controls then left the room to get help with completing a bed linen change. During an observation on 2/9/2026 at 11:20 AM, CNA N and CNA O entered R27's room. Neither CNA donned a gown despite R27 requiring Enhanced Barrier Precautions. CNA N and CNA O turned and repositioned R27, removing soiled linens and applying clean linens. During an interview on 2/11/2026 at 11:00 AM, the Director of Nursing (DON)/Infection Preventionist (IP) reported it was her expectation that staff perform appropriate hand hygiene and glove use and implement Enhanced Barrier Precautions (EBP) for residents who require it. Review of a facility policy Enhanced Barrier Precautions last reviewed 1/2025 reflected It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. The policy specified that staff don appropriate Personal Protective Equipment (PPE) (gown, gloves and face protection in the event a splash is anticipated) when performing high-contact care activities. High contact care activities include dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, direct care or use of central lines, catheters, feeding tubes, tracheostomy/ventilator tubes etc. and wound care. Review of a facility policy Hand Washing/Hand Hygiene last reviewed 1/2025 reflected Practicing Hand Hygiene is a simple effective way to prevent infections by preventing the spread of germs. The policy specified that hand hygiene should be performed After removing gloves or other personal protective equipment.

Based on observation and interview, the facility failed to maintain general cleanliness and repair of the facility, resulting in an increased potential for contamination and a possible decrease in satisfaction of living for residents. Findings Include:On 02/09/26 at 12:40PM, the following was observed in the spa shower room across from room [ROOM NUMBER]: (a) a bag of soiled linens laid on the floor, (b) fecal matter was smeared on the blue shower chair, and (c) fecal matter sat on one of the shower chair legs.On 02/10/2026 at 2:25PM, observed particle board shelving in the janitor closet next to the housekeeping office had peeling laminate, swelling of particleboard and a mold-like in appearance growth on the exposed particleboard. At time of observation Maintenance Director (MD) S indicated he was unaware of shelving damage. On 02/10/2026 at 2:26PM, observed the mop sink had a large gap between the mop sink and the wall, allowing water to splash out of the mop sink and then run down the wall and accumulate on the floor.On 02/10/2026 at 3:00PM, observed in the shower room on 100 hall, the shower surround had peeling and chipping paint on tiles. During this observation, MD S stated the facility is in the beginning work order process of renovating the shower room to include removal and replacement of tile. On 02/10/2026 at 3:15PM, observed in shower room on the west hallway, paint peeling in strips from the painted tiling in the shower area.

Based on observation, interview, and record review, the facility failed to follow physician ordered parameters for one resident (Resident #42) and failed to follow professional standards and facility policy for narcotic accounting for one resident (Resident #50) of four residents reviewed. Findings:Resident #42 (R42) Review of a Face Sheet revealed R42 was a [AGE] year-old male, last readmitted to the facility on [DATE], with pertinent diagnoses of orthostatic hypotension (low blood pressure when changing position), diabetes, high blood pressure, muscle weakness and lack of coordination. Review of an Emar (electronic medication administration record) reflected an order for R42 to take Midodrine 10 mg (milligrams) three times daily with ordered parameters of: hold medication if systolic blood pressure (top number) is greater than 130. Further review of the Emar dated February 2026 reflected that the medication Midodrine was given outside physician ordered parameters on (a) 2/6/26 at 8:00 AM BP (blood pressure) was 145/68, (b) 2/6/26 at Noon BP was140/65, (c) 2/2/26 at 5:00 PM BP was 140/64, and (d) 2/7/26 at 5:00 PM BP was 157/70. Review of an Emar reflected an order for R42 to take Midodrine 10 mg (milligrams) three times daily with ordered parameters of: hold medication if systolic blood pressure (top number) is greater than 120 (these parameters ordered from 12/23/25 to 1/5/26). Additional parameters ordered starting 01/05/26 of: hold medication if systolic blood pressure is greater than 130. Further review of the Emar dated January 2026 reflected that the medication Midodrine was given outside physician ordered parameters on (a) 1/1/26 at Noon BP was 128/64, (b) 1/1/26 at 5:00 PM BP was 128/64, (c) 1/4/26 at 5:00 PM BP was 161/70, (d) 1/8/26 at Noon BP was 134/70, (e) 1/13/26 at Noon BP was 147/64, (f) 1/25/26 at Noon BP was 136/78, (g) 1/26/26 at 8:00 AM BP was 150/66, (h) 1/26/26 at Noon BP was 152/70, and (i) 1/30/26 at 8:00 AM BP was 138/60. During an interview on 2/12/26 at 9:42 AM, the Director of Nursing indicated that the accepted standard of practice was for all nurses to follow physician ordered medication parameters. During an observation on 2/10/2026 at 6:46 AM, during a shift change narcotic count with Registered Nurse (RN) M and RN J , RN J was observed documenting the removal of two doses of Morphine Sulf (Sulfate) 20mg (milligrams)/ml (milliliter) soln (solution) 100 mg/5ml Give 0.25ml (5mg) PO (orally)/SL (sublingual, under the tongue) every 3HR (3hours) as needed for moderate/severe pain, trouble breathing, agitation, or restlessness for Resident 50 (R50). RN J said that when she pulled a dose at midnight and again at 6:00 AM for R50, she did not verify the quantity of narcotic in the container or document the removal of doses on the Controlled Substances Proof of Use form according to policy. Review of the Controlled Substance Proof of Use form for R50 reflected Every dose must be accounted for on this form. If dose is contaminated, lost, broken, or refused enter the information under comments. The bottom of the form indicated Important: The nurse who signs this record must also sign the separate medication administration record for each dose given. Review of a facility policy Medication Administration Procedures dated 4/2020, reflects D. Charting . 2. Sign out narcotics when removed from narc (narcotic) box and then after administration.

Based on observation and record review, the facility failed to provide routine hand hygiene for two (Resident #43 and Resident #2) of three residents reviewed. Findings: Resident #43 (R43)Review of a Face Sheet revealed R43 was a [AGE] year-old female, last readmitted to the facility on [DATE], with pertinent diagnoses of a recent stroke that caused right sided facial, arm, and leg weakness and paralysis and difficulty speaking. R43 was dependent on a staff person for all hygiene and activities of daily living. During an observation on 02/09/26 at 10:07 AM, R43's fingernails had a thick brownish substance under them. During an observation on 02/10/26 at 9:11 AM, R43's fingernails had the thick brownish substance still under them. Resident #2 (R2)Review of a Face Sheet revealed R2 was a [AGE] year-old male, last admitted to the facility on [DATE], with pertinent diagnoses of a stroke that caused difficulty speaking and right sided weakness and paralysis. R2 depended on staff for his personal care and hygiene. During an observation on 02/11/26 at 3:25 PM, a dark substance coated R2's fingernails. R2 was asked if staff clean his hands prior to each meal and R2 responded no.

Based on observation, interview, and record review, the facility failed to ensure safe and proper positioning was maintained for one (Resident #43) of three residents reviewed for quality of care. Findings:Resident #43 (R43) Review of a Face Sheet revealed R43 was a [AGE] year-old female, last admitted back to the facility on [DATE], with pertinent diagnoses of a stroke that caused right sided facial, arm, and leg weakness and paralysis. R43 required assistance from two staff persons to move and reposition in the bed. During an observation on 02/09/26 at 10:07 AM, Licensed Practical Nurse (LPN) F entered R43's room and raised the head of the bed (HOB) to administer medications. R43 slid down in the bed when the HOB was raised. LPN F did not check R43's position in the bed before leaving the room. During the same observation, R43's feet pressed against the footboard. During an observation and interview on 02/09/26 at 10:56 AM, R43's feet pressed against the footboard. R43 stated no she could not move her legs and feet and yes her feet hurt when pushed up against the footboard. During an observation on 02/10/26 at 9:11 AM, R43 laid in bed with the HOB elevated. R43's right foot pressed against the footboard and the black electrical cord for the mattress laid between the footboard and R43's left foot. R43 stated yes her feet hurt in that position.

Based on interview and record review, the facility failed to implement antibiotic use protocols for two (Resident #43 and Resident #19) of four residents reviewed for antibiotic stewardship. Findings:R19Review of a Face Sheet reflected R19 admitted to the facility with diagnoses that included vascular dementia and chronic kidney disease. Review of a Resident Progress Note dated 10/3/2025 reflected R19 was sent to the hospital at the request of family for eye redness and cough with phlegm. Review of a Resident Progress Note dated 10/3/2025 at 9:11 PM reflected R19 returned from the hospital with an order for Keflex (an antibiotic) for a urinary tract infection and an antibiotic ointment for eyes. Another progress note documented minutes later reflected the facility provider changed the antibiotic order to Doxycycline 100 mg (milligrams) BID (twice a day) for 5 days. Review of Resident Progress Notes from 10/01/2025 – 10/06/2025 did not reflect any indication of signs or symptoms of a urinary tract infection. Review of a Medical Decision Making note in the hospital record dated 10/03/2025 reflected R19 denies any urinary symptoms. Review of a hospital records from R19's visit to the Emergency Department (ED) on 10/03/2025 reflected a urinalysis was completed and a culture was obtained and reported 10/6/2026 which indicated R19 tested positive for greater than 100,000 CFU/mL Enterococcus faecalis (a bacteria). However, the reported indicated A positive urine culture alone is not indicative of infection; diagnosis and treatment of a urinary tract infection REQUIRES (emphasis included in record) urinary symptoms (i.e. dysuria, urgency, fever) unless patients are pregnant or undergoing urologic procedures. During an interview on 2/12/2026 at 9:59 AM, the Director of Nursing (DON) reported she was responsible for the Infection Control Program at the facility. The DON reported R19 met McGeer's Criteria (standardized surveillance definitions used to identify, monitor, and report infections in long-term care facilities. They define specific clinical signs, symptoms, and laboratory findings for common infections to distinguish true infections from colonization.) as evidenced by a fever and urgency/frequency of urination. Review of an Infection Control Check List (antibiotics) for the month of October 2025 reflected R19 was ordered Doxycycline to start on 10/3/2025 and end on 10/10/2025 (despite the order noted in the progress note indicating the antibiotic was to be given for 5 days, not 7). The form indicated R19 met McGeer's Criteria as evidenced by YES noted in the row on the checklist pertaining to McGeer's. Review of Vital Signs temperature log for the month of October 2025 did not reflect R19 ever had a fever. During the interview on 2/12/2026 at 9:59 AM, the DON said that R19 had urinary urgency and frequency at baseline (meaning this was normal for R19) and could not explain how she determined R19 ever had a fever. The DON could not explain why the antibiotic was discontinued three days after initiation if R19 did meet McGeer's criteria. Review of a Resident Progress Note dated 10/6/2025 reflected (name of hospital) called, they have the results back from (R19's) urine culture and they would like the ABT (antibiotic) discontinued. (R19) has not had any urinary infection symptoms and is afebrile (without a fever). Call to DPOA (Durable Power of Attorney). Resident #43 (R43) Review of a Face Sheet revealed R43 was a [AGE] year-old female, last admitted back to the facility on [DATE], with pertinent diagnoses of urinary tract infection and a stroke that caused right sided facial, arm, and leg weakness and paralysis. Review of Progress Notes revealed R43 was sent to the emergency room on [DATE] and was treated for a UTI (urinary tract infection) with a C&S (culture and sensitivity) pending. R43 returned back to the facility with an order for the antibiotic Cefuroxime (Cefin) 500 mg (milligrams) one tab twice daily for 5 days. R43 received the first dose of Ceftin on 01/29/26. Review of a Lab Report for R43 dated 01/29/26 revealed no bacterial growth on the culture. During an interview on 02/12/26 at 9:00 AM, the ICP (Infection Control Preventionist) indicated that the completed C&S was not obtained and reviewed by the facility on 01/29/26 and if it had been, the antibiotic that R43 was prescribed would have been discontinued due to no indication for its use. Review of the facility policy Antibiotic Stewardship Program revealed .The program includes antibiotic use protocols and a system to monitor antibiotic use .Monitoring Antibiotic Use (1) monitor responses to antibiotic use, and laboratory results when available, to determine if the antibiotic is still indicated .(3) Antibiotic orders obtained from emergency providers shall be reviewed for appropriateness.

Based on interview and record review, the facility failed to ensure it received, acted upon and maintained, a record of a pharmacy report after a pharmacist Medication Regimen Review (MRR) for one resident (R1) out of 5 residents reviewed for high-risk medications. Findings Include:Review of a facility Face Sheet reflected R1 admitted to the facility on [DATE] with diagnoses that included type 2 diabetes, bipolar disorder, atrial fibrillation, chronic obstructive pulmonary disease (COPD), seizure disorder, high blood pressure, weakness and anemia (too few red blood cells). Review of a Pharmacist Drug Regimen Review dated 1/20/2026 reflected the pharmacist had recommendations based on the review as evidenced by a notation Please take the following action described below. The space below the request for action Please take the following actions: See report. Review of the Documents tab in the Electronic Medical Record (EMR) did not reveal any pharmacy records. During an interview on 2/11/2026 at 3:46 PM, the Assistant Director of Nursing (ADON) Q reported the pharmacy report/review for R1 could not be located and the facility did not know what medication the pharmacist requested action on. Review of a facility policy Medication Regimen Review (MRR) last revised 6/01/2024 reflected 1. The consultant pharmacist will conduct MRRs if required under a Pharmacy Consultant Agreement and will make recommendations based on the information made available in the resident's health record. The policy specifies The consultant pharmacist will provide the resident's MRRs to facility identified personnel who will ensure that the attending physician, medical director, director of nursing and other necessary facility staff receive the recommendations. Facility should encourage physician/prescriber or other responsible parties receiving the MRR and the director of nursing to act upon the recommendations contained in the MRR. The facility should maintain readily available copies of the consultant pharmacist reports on file in the facility and as part of the resident's permanent health record.

Based on observation, interview and record review, the facility failed to provide an effective way to communicate for 1(R52) of one resident reviewed for communication.Findings include:Resident #52 (R52)Review of a Face Sheet revealed R52 admitted to the facility on [DATE] and her preferred language was Castilian Spanish. During an observation and an interview on 2/9/26 at 11:07 AM, R52 was lying on her bed receiving intravenous therapy. R52 was asked some questions but responded in a different language. With verbal gestures and hand signaling, she indicated she could not speak English. At this time, she reached for a handheld device in her drawer and tried to turn it on. The window of the device indicated it needed a Wi-Fi connection and R52 did not know how to use this device at this time. During an interview on 2/9/26 at 11:39 AM, Licensed Practical Nurse (LPN) C reported R52 could speak a little English but is fluent in Spanish. The facility utilizes a telephone translator service and LPN C reported R52 can speak a few words, but the facility also has staff who are fluent in the Spanish language too. During an interview on 2/10/26 at 8:43 AM, Certified Nursing Assistant (CNA) K reported she was caring for R52 this day and does not speak any Spanish. CNA K reported R52 can gesture with her hands to indicate the need for a pain pill. CNA K reported R52 has a phone that she can communicate for translation through her family members. CNA K reported there were no other ways of communicating basic needs of R52 and was not aware of any communication boards. During an interview on 2/10/26 at 9:22 AM, CNA L reported she can speak in the Spanish language but is assigned to another hall for resident care. R52 had another CNA this day who could not speak in Spanish. Upon entering R52's room for an interview through CNA L translating, R52 reported she does have her own personal communication device in her drawer and pulled it out. R52 reported she could not figure out how to connect it to the Wi-Fi or how to use it but thought she had since figured it out and was now working. When asked if her needs are being met, R52 reported staff are not always able to communicate with her. R52 reported she had had some of her laundry in the closet that needed to be cleaned but was not able to convey that to the staff. When asked about using a communication board to point to things that would be easy to address like toileting, pain, and laundry, R52 said that would be nice. At this time R52 had some pain and was able to rate her chronic pain at a 7/10 scale. Review of the Activities Care Plan intervention dated 1/27/26 for R52 revealed: Possible need for staff to repeat/reword conversation to enable resident to understand and follow conversations. Possible language barrier. No other Care Plan Problem or Approach to address R52's primary language of Spanish.In an interview on 2/11/26 at 9:06 AM, the Director of Nursing (DON) reported there is an interpreter service phone number located at the nursing station and R52 has a phone in her room. If staff need to communicate with R52, they can call and get assistance. The DON was not aware of any communication board available to convey simple needs or a pain scale residents could point to.

Based on interview and record review, the facility failed to administer and document the administration of controlled substances for 4 residents (Resident #39, #25, #50 and #24), reviewed for medication administration, resulting in medication errors and inaccurate documentation of controlled drugs. Findings: Resident #39 Review of an Admission Record revealed R39 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: pain. Review of R39's Order Summary dated 12/5/24 revealed oxycodone 15mg 1 tablet by mouth every 4 hours as needed for pain. Review of R39's Controlled Substances Proof of Use log revealed: *On 1/1/25 a dose of oxycodone was administered at 4:45 AM. *On 1/3/25 a dose of oxycodone was administered at 4:15 AM. *On 1/4/25 a dose of oxycodone was administered at 8:00 AM. *On 1/4/25 a dose of oxycodone was administered at 2:00 PM. *On 1/5/25 a dose of oxycodone was administered at 8:34 AM. Review of R39's Medication Administration Record revealed the above listed oxycodone administrations were not documented in R39's Electronic Medical Record. (Accurate documentation of pain medication administration is essential for ensuring adequate pain control as well as ensuring narcotics are not diverted.) Resident #25 Review of an Admission Record revealed R25 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: pain. Review of R25's Order Summary dated 1/21/21 revealed Norco (hydrocodone-acetaminophen) 7.5/325 mg 1 tablet three times a day. Review of R25's Controlled Substances Proof of Use log revealed that on 1/5/25 the evening dose of Norco was not administered. Review of R25's Medication Administration Record revealed on 1/5/25 the evening dose of Norco was not administered for Not Administered: Drug/Item Unavailable despite there being 24 tablets available for R25. Review of R25's Electronic Medical Record revealed no documentation regarding the withholding of R25's Norco or that the provider was notified that the prescribed medication was not administered. Resident #50 Review of an Admission Record revealed R50 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: anxiety and osteoporosis. Review of R50's Order Summary dated 11/17/24 revealed, clonazepam 0.5 mg; Give 1 tablet by mouth daily at bedtime. Review of R50's Controlled Substances Proof of Use log revealed that on 1/4/25 R50's clonazepam was not documented as administered. Review of R50's Medication Administration Record revealed that on 1/4/25 R50's clonazepam was documented as administered. Review of R50's Order Summary dated 10/23/24 revealed, oxycodone 5 mg; 1/2 tablet = 2.5mg; oral Twice A Day . Review of R50's Controlled Substances Proof of Use log revealed that on 1/5/25 R50's evening dose of oxycodone was not documented as administered. Review of R50's Medication Administration Record revealed that on 1/5/25 R50's evening dose of oxycodone was documented as administered. Resident #24 Review of an Admission Record revealed R24 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: insomnia. Review of R24's Order Summary dated 11/12/24 revealed, Belsomra (suvorexant) 15 mg; 1 tablet; oral At Bedtime. Belsomra is a hypnotic used to treat insomnia. Review of R24's Controlled Substances Proof of Use log revealed: *On 1/4/25 a dose of belsomra was administered at 1200 (unable to determine if it was 12:00 AM or 12:00 PM). *On 1/4/25 or 1/5/25 (a 4 and 5 were written on top of each other) a dose of belsomra was administered at 11:30 PM *On 1/5/25 a dose of belsomra was administered at 1145 (presumably 11:45 PM at the time it was due). Indicating 2 doses of belsomra was administered on either 1/4/25 or 1/5/25. Review of R24's Electronic Health Record revealed no documentation regarding the additional dose of belsomra or physician notification of the double dose. During an interview on 01/10/25 at 10:21 AM, Regional Clinical Director (RCD) B confirmed the medication/documentation errors for R39, R25, R50 and R24 and reported licensed nurses are expected to administer medications following professional standards of practice. Review of the facility policy Control Substances Standards of Practice last updated 9/2022 revealed, .Nurses removing controlled substances from the narcotic storage require documentation on the Proof-of-Use Sheet the amount removed using a full last name signature. Nurse documentation of inventory balance on Proof-of Use sheet MUST be made as soon as the controlled substance is removed from the package/cart. Avoid waiting until the end of med pass or end of shift. Once the nurse completes the administration, then the nurse is to document on the MAR paper record or E0Mar electronic record. If PRN medication is administered, additional documentation regarding reason, result, time and initials are required . Review of Fundamentals of Nursing ([NAME] and [NAME]) 10th edition revealed, The National Coordinating Council for Medication Error Reporting and Prevention (2018) defines a medication error as any preventable event that may cause inappropriate medication use or jeopardize patient safety. Medication errors include inaccurate prescribing, administering the wrong medication, giving the medication using the wrong route or time interval, administering extra doses, and/ or failing to administer a medication. Preventing medication errors is essential. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 605). Elsevier Health Sciences. Kindle Edition.

Based on observations, interviews and record review, the facility failed to keep the 100-hall medication refrigerator in the safe temperature storage range, resulting in the potential for medication to became ineffective. Findings included: On 1/8/25 at 8:09 AM the 100-hall medication refrigerator was observed to be stuffed full of medications. There were no shelves to put the medications on. The thermometer was stuffed into the middle of the medications. There was no freezer door, and the freezer had approximately 1 inch of ice build up in it. Licensed Practical Nurse (LPN) K had to dig around in the refrigerator to locate the thermometer. The thermometer read 32 degrees Fahrenheit. LPN K went with the Surveyor to notify the Director of Nursing (DON). At approximately 9:00 AM the DON said pharmacy said to destroy the medications and they were shipping new medications. They notified the physician about any medications that would be late due to having to destroy the current medications. The Surveyor requested an inventory of all medications that were in the refrigerator that need to be destroyed. Review of the 100-hall medication temperature log revealed the temperature was to be kept between 36 degrees Fahrenheit and 46 degrees Fahrenheit. If it was not in this range action should be taken. The log indicated the temperatures were to be taken every AM and every PM. The boxes for January 1 to [DATE], were all marked as being 38 degrees Fahrenheit. The AM temperature on 1/8/25 was marked as 39 degrees Fahrenheit. Review of the facility 100 hall medication refrigerator revealed 9 Residents had medications stored in the refrigerator. The medications included insulin, Trulicity (medication used to control blood sugar) and pain medications. The medications require storage in a safe temperature as indicated on the refrigerator log sheet or they can become ineffective. Total number of vials, pens or amount of liquid was not included in the inventory.

Based on interview and record review, the facility failed to ensure appropriate treatment and services to maintain and carry out communication for 1 of 8 residents (R25) reviewed for activities of daily living, resulting in R25 feeling frustrated and isolated. Findings: Resident #25 Review of an Admission Record revealed R25 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: contracture right hand, stroke affecting dominant right side, and expressive aphasia. Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, Expressive aphasia, a motor type of aphasia, is the inability to name common objects or express simple ideas in words or writing. For example, a patient understands a question but is unable to express an answer .The temporary or permanent loss of the ability to speak is extremely traumatic to an individual .Determine whether the patient has developed a sign-language system or symbols to communicate needs. [NAME], [NAME] A.; [NAME], [NAME] G.; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 1396). Elsevier Health Sciences. Kindle Edition. Review of R25's Progress Notes revealed: 10/5/24 Resident is alert and oriented 12/20/24 Resident in bed upon arrival, alert and oriented . Confirming R25 was cognitively intact. Review of R25's Speech Therapy-SLP Evaluation and Plan of Treatment documentation from 6/6/23-7/5/23 revealed, .Caregiver Goals: want pt (patient) to communicate more with them about pt needs/wants/desires/etc .Was referred to ST (speech therapy) for evaluation of aphasia and communication d/t (due to) decrease in communication with caregivers and staff after losing communication book .Prior Level of Function: Previously was using communication board provided by SLP (speech language pathology), however has since misplaced it and requires a new one . Pt presets with severe expressive aphasia and moderate receptive aphasia. Pt demonstrates ability to understand and correctly respond to simple yes/no questions (both verbally and non-verbally). Pt is mostly nonverbal, with the only verbalizations made during evaluation being yes no take me home and what . In order to facilitate return to prior level of living, patient requires continued ST services in order to analyze communication abilities and improve ability to communicate self-care and/or medical needs in order to enhance patient's quality of life by an improved ability to communicate basic wants/needs and improve expressive communication. Due to the documented physical impairments and associated functional deficits, without skilled therapeutic intervention, the patient is at risk for: anxiety, social isolation and decreased participation with functional tasks . Discharge recommendations: To facilitate optimal cognitive-communicative performance, the following strategies are recommended: consistent words/verbal directions to increase comprehension, concrete, one step directions by speak to increase comprehension and slower rate of speech to facilitate communication request clarification. Use communication book (AAC) as often as possible . During an observation and interview on 01/07/25 at 11:49 AM, R25 was sitting up awake in his room. R25 was able to answer yes or no questions but became visibly frustrated (rolling eyes, refusing to make eye contact, grunting) when he was unable to make his needs and thoughts known and this writer was unable to determine what he was attempting to express. R25 was asked if he utilized any tools such as a communication board or electronic device to communicate his needs/wants with staff and he responded by shaking his head no. When asked if the facility staff knew him well enough to understand/identify what he needed he shook his head no. When asked if he was frustrated that staff could not understand his needs, he shook his head yes. R25 then pointed behind his bed towards the nightstand that was not within his reach. Underneath a stuffed animal and a positioning pillow were a few paper flashcards with sign language and a word in poor condition (dirty, ripped, difficult to see) and a hard cover 3 ring binder with keep next to (R25) at all times written on it. Inside of the binder was large printouts of communication forms (example: the first page was a large yes and a large no, sports teams, etc.). R25 was asked if the communication binder was helpful in communicating his needs, he responded by shaking his head no. R25 did not have the use of his right arm/hand and when asked if it was difficult to turn pages and navigate the book with the use of only his left hand, he shook his head yes. When asked if the staff would attempt to use the communication binder when they could not identify his needs, he shook his head no. When asked if he was ever questioned about changing to a different communication style, he shook his head no. At that time Certified Nursing Assistant (CNA) D entered the room and told R25 it was time to get up for a weight. She did not attempt to utilize the communication binder or flash cards. CNA D was asked how she determined R25's wants/needs and she reported the communication binder was not utilized but the facility staff would ask him yes or no questions until they could figure it out. R25 became visibly frustrated and was saying incoherent words over and over and shaking his head no. This surveyor asked R25 if we could use the communication binder, and he aggressively shook his head no. CNA D reported that she could tell by his frustration that he wanted this writer out of the room. R25 then grabbed my right hand with his left hand and shook his head no. R25 was asked if he wanted an assessment/evaluation into a new style of communication he shook his head yes emphatically. During an observation and interview on 01/09/25 at 09:09 AM, R25 was sitting up in his bed with the communication binder on his nightstand out of reach. R25 was asked if he used his iPad as a communication tool and he shook his head no. R25 was asked if he participated in care conferences with his wife/legal guardian and facility staff and he shook his head no. R25 was asked if he would join care conferences if he had a way to communicate easily/efficiently so he could have a say in his care and he shook his head yes. R25 was shown different forms of communication boards, tools, and flashcards on the computer and he appeared excited and started shaking his head yes vigorously. R25 pointed to sad on a communication board on the computer. When asked if he would be less sad if he could communicate more efficiently, he shook his head yes. During an interview on 01/09/25 at 09:24 AM, Licensed Practical Nurse (LPN) J confirmed that R25 was cognitively intact but suffered from expressive aphasia. LPN J reported that R25's iPad was locked in the medication room on the unit and would be brought to R25 when he requested it. LPN J reported that the iPad was not used as a form of communication and was only used by R25 to watch movies. During an interview on 01/09/25 at 01:31 PM, Social Services (SS) I reported that R25's wife was his legal guardian and would attend the care conferences. SS I reported that R25 did not consistently attend. SS I reported she did not know the last time ST/OT (speech therapy and occupational therapy) evaluated him for communication needs and/or tools and was not aware that staff were not using the communication binder. SS I confirmed that R25's stroke affected his dominant hand, and the communication binder may be difficult for R25 to maneuver. SS I reported that R25 would get frustrated and quit interacting with staff when staff could not identify what he needed. SS I reported that she was not aware that the iPad was care planned for his communication tool and confirmed it was not used for that purpose. SS I reported that she would meet with R25 and identify a more suitable communication tool for him to utilize. During an interview on 01/09/25 at 03:12 PM, Legal Guardian (LG) C reported that communication tools and his frustrations with communication had not been discussed in care conferences. LG C stated that R25 might have something in one of his drawers be he can't use it referring to the communication binder. LG C reported that R25 would communicate by pointing and shaking his head yes or no, but he would often get frustrated and refuse to answer after he's asked a few questions and the staff could not identify what he needed/wanted. LG C reported that a communication tool would be beneficial for him so he could participate in his care and have more autonomy and not shut down when he's frustrated. Review of R25's contracted psychiatric Progress Note dated 12/23/24 revealed, .Long-Term Memory: Unable to assess due to communication deficit . Indicating a more in-depth psychiatric evaluation could have been completed had R25 been able to communicate effectively. There was no documentation the communication binder was utilized or refused. Review of R25's March 2024 Care Conference revealed R25 had not been invited to the care conference. Is this resident able to express choice? No. wife has noted residents depression has increased since she was discharged from the facility, resident has voiced wanting to go home, wife reminds him that he cannot go home d/t needing 24-hour care, he understands once he talks to wife . There was no documentation that R25's communication had been addressed despite R25 being cognitively intact and documenting that he was unable to express himself. Review of R25's June 2024 Care Conference revealed R25 had not been invited to the care conference. Is this resident able to express choice? No. Resident is bed bound mostly, no changes in participation with activities . There was no documentation that R25's communication had been addressed. Review of R25's September 2024 Care Conference revealed, Is this resident able to express choice? No. There was no documentation that R25's communication had been addressed. Review of R25's December 2024 Care Conference revealed R25 had not been invited to the care conference. Is this resident able to express choice? No. There was no documentation that R25's communication had been addressed. Review of R25's Care Plan revealed Communication Resident experiences a communication deficit r/t (related to) CVA (stroke), impaired cognition, aphasia, limited speech, rarely/never understood but understands others. Review of the interventions dated 4/9/18 revealed: Resident use IPAD/tablet and gestures to assist with communication . Address resident's emotional needs: Use IPAD/tablet and gestures to determine resident's needs, resident is aphasic and easily frustrated when not able to communicate needs . Staff to encourage resident to use gestures, motions, communication board . Encourage resident to not become frustrated if at first staff does not understand what it is they are trying to say. Seek assistance from other staff PRN (as needed) . ST (speech therapy) referral as needed . R25's Care Plan did not include the use of the communication binder/book despite speech therapy recommendation but instead reflected the us of the iPad as a communication device although not utilized for that purpose. Review of R25's Electronic Medical Record revealed no recent assessments or SLP evaluations for the use of a more appropriate communication tool or documentation of steps taken to improve R25's ability to communicate with staff despite R25's noted dissatisfaction and difficulty utilizing the communication binder.

This citation pertains to intake #: MI00148539 Based on observations, interview and record review the facility failed to assess residents with new medical conditions in a timely manner, accurately assess pain and address pain in a timely manner, follow physician orders for wound treatment for 3 Residents of 3 Residents sampled (R20, R36, and R57), resulting in delay of physician notification of culture results and wound treatment, and uncontrolled pain. Findings included: R20 Review of R20's face sheet, no date revealed he was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses that included: end stage renal disease (kidney failure), unsteady on feet, need for assistance with personal care, cervical disc disorder myelopathy (muscle disorder) and diabetes mellitus with diabetic neuropathy (nerve disease). R20 was his own responsible party. During an interview with R20 on 1/8/25 at 10:19 AM, R20 reported that he went to the podiatrist yesterday and his great toe treatment caused it to bleed, and he was very concerned about his follow up care. He also reports that he feels ignored and upset that the facility is not addressing his pain. He said he asked to see the doctor again this week about his pain and he witnessed the physician assistant being here that day and the physician assistant left without talking to him. He said when he is in dialysis 3 days a week his pain always gets to 10/10. Today prior to being given his narcotic pain medication his pain was 9 and currently it was 8/10. He knows he will always have pain but feels that there is room for improvement, but no one listens to him. During an interview with Licensed Practical Nurse (LPN) K on 1825 at 12:29 PM, LPN K said she recorded a 0 for R20's pain that morning when she gave his morning medication because he did not complain of pain. When LPN K was asked if she asked R20 to rate his pain she said no she did not ask him. During an interview with the Director of Nursing (DON) on 1/8/25 at 12:32 PM in R20's room with R20 present. R20 repeated the information he told the surveyor at 10:19 AM about the podiatrist, feeling ignored, the wound on his right great toe, and his pain concerns. During an interview with the Director of Nursing (DON) on 1/8/25 at 2:07 PM the DON confirmed that R20 had an outside Podiatry (foot doctor) appointment on 1/7/25. The DON was not able to locate any new orders or documents from the podiatrist. The DON could not locate any nursing notes or message to R20 physician about follow up care related to R20' nail removal on 1/7/25. The DON confirmed that R20 had a dressing on his right great toe and nursing staff should have noted that on his return, she was getting documents from the pediatrist and placed him on the list to be seen by the medical staff. The DON removed the dressing, contacted the podiatrist and notified the medical staff of the condition of R20's right great toe. During an interview on 1/10/25, Regional Clinical Director (RCD) B said she interviewed R20 about his pain and he reports it is consistently around 8/10. She reported the physician assistant increased one pain medication yesterday. They are in the process of educating the nurses to properly assess pain and they are adding an additional assessment for pain after his narcotic pain medication to assess if that medication is effective. Review of R20's January 2025 Medication Administration Record (MAR) revealed he was to have pain assessments 3 times a day. Most entries were 0 for no pain. On 1/8/25 the morning assessment was 0. There was no pain assessment for the morning of 1/7/25. For 1/5/25 morning pain was recorded as 9. See interviews above. Record does not reflect interviews. Review of R20's progress notes revealed no documentation of R20 having a podiatry appointment or a procedure requiring a dressing done on 1/7/25. Record review revealed treatment orders for R20's right great toe started on 1/7/25 when he had the nail partially removed on that toe by the podiatrist. Review of R20's progress note dated 1/8/25 at 1:14 PM revealed the DON charted, physician notified of resident's pain level. Physician increasing Lyrica to 100 mg BID (pain medication increased to twice a day). States not appropriate to perform two med (medication) adjustments at once. (name of PA) stated she will meet with him next week to review his pain and increase his Norco (narcotic pain medication) this if he feels his pain is still not controlled. Resident notified of plan. R36 Review of R36's face sheet, no date, revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included: lymphedema (swollen legs), rheumatoid arthritis, and severe morbid obesity. R36 was her own responsible party. Review of R36's physician orders revealed an order dated 1/3/25 right anterior and posterior lower leg. Cleanse with NS (normal saline). Apply Gentle blue ready to wound beds. Cover with silicone superabsorbent dressing. Every other day as needed. 3:00 PM to 11:00 PM. During an interview with R36 on 1/7/25 at 10:01 AM, R36 complained of the dressing on the back of her right leg not getting changed on Saturday. R36 said there were no supplies. R36 said she asked again last night at 8:30 PM and again was told there were no supplies. The dressing on the back of R36's right leg did not have a date noted. On 1/7/25 at 10:40 AM the Director of Nursing (DON) changed the dressing on the back of R36's leg. The DON confirmed that there was no date on dressing and confirmed that the dressing on the back of R36's leg did not have the Gentle Blue as ordered. The DON confirmed the nurses are to date and initial dressings when they replace them. The pillowcase under R36 right leg was soiled (dry brown large spot). The DON removed the soiled pillowcase and assured R36 she would look into what happened with wound treatments. 39056 Resident #57 Review of an Admission Record revealed R57 was a [AGE] year-old female, admitted to the facility on [DATE]. Review of R57's hospital After Visit Summary dated 10/6/24 revealed .START taking: ceftriaxone (ROCEPHIN) (and) cefuroxime (CEFTIN) . Review of R57's Order Summary revealed: 10/7/24-10/8/24: cefuroxime 500mg tablet; Take 1 tablet twice daily x 7 days for UTI 10/8/24-10/14/24: cefuroxime 500mg tablet; Take 1 tablet daily x 7 days for UTI Review of R57's Electronic Medical Record revealed no culture results or documentation that the provider reviewed culture results to ensure the correct and/or most effective antibiotic was ordered/administered. During an interview via email on 01/10/2025 at 11:54 AM, Regional Clinical Director (RCD) B confirmed that there was no follow-up culture available for review. Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, .resistance to key antibiotics are becoming more common in all health care settings .The increased resistance is associated with the frequent and sometimes inappropriate use of antibiotics over the years in all settings (i.e., acute care, ambulatory care, clinics, and long-term care) .A culture result may show growth of an organism in the absence of infection. For example, in the older adult bacterial growth in urine without clinical symptoms does not always indicate the presence of a UTI .Many laboratory studies are often necessary when a patient is suspected of having an infectious or communicable disease (Box 28.14). You collect body fluids and secretions suspected of containing infectious organisms for culture and sensitivity tests. After a specimen is sent to a laboratory, the laboratory technologist identifies the microorganisms growing in the culture. Additional test results indicate the antibiotics to which the organisms are resistant or sensitive. Sensitivity reports determine which antibiotics used in treatment are effective and need to be ordered for treatment. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (pgs. 425-443). Elsevier Health Sciences. Kindle Edition.

Based on interview and record review, the facility failed to follow and implement policies and procedures for hospice care and implement communication, coordination of cares and services, and have complete hospice medical records readily available for one (R41) of 3 residents reviewed for hospice services. Findings include: Review of a policy titled End of Life Care last reviewed 1/2025 revealed: 6a. Hospice must designate a registered nurse from hospice to coordinate the implementation of the plan of care. b. The coordinated plan of care must identify the care and services, which the facility and hospice will provide in order to be responsive to the unique needs of the resident and his/her, expressed desire for hospice care. d. When a resident participates in the hospice program, a coordinated plan of care between the facility, hospice agency and resident/family/resident representative will be developed and shall include directives for managing pain and other uncomfortable symptoms. The care plan shall be revised and updated as necessary to reflect the resident's status. e. The facility and hospice are responsible for performing each other their respective functions that have been agreed upon and included in the plan of care. g. The hospice and facility are aware of each other's responsibilities in implementing the plan of care to include hospice personnel schedules. h. All hospice services are provided under contractual arrangement. Complete details outline the responsibilities of the facility and the hospice agency are contained in this agreement. A copy of this agreement is available upon request from the administrator/or the hospice agency. i. The agreement with the hospice provider must be signed by a representative from this facility and a representative from the hospice agency before hospice services are furnished to any resident. Resident #41 (R41) Review of a Face Sheet revealed R41 admitted to the facility on [DATE] and has pertinent diagnoses of hospice, cerebral infarction (stroke), and dementia without behavioral disturbances, psychotic disturbance, mood disturbance, and anxiety. Review of the Hospice Care plan revealed 12/10/24 hospice services were implemented. During an observation and an interview on 1/7/25 at 10:45 AM, R41 had complaints of chronic pain and the inability to sleep due to his past military life. He rated his pain at a 5 on a 1-10 scale. R41 randomly removed his slippers, and his toenails were very long and reported the staff will file and clip the nails on his hands, but not on his feet. He reported he is receiving hospice services. Review of the electronic medical records (EMR) for R41 revealed no hospice agreement, no hospice orders, no hospice communications, no hospice visitations and services were documented. In an interview on 1/8/25 at 12:25 PM, R41 reported the hospice nurse visited him this morning. Review of the EMR revealed no documentation documenting this visit or services provided this day. In an interview on 1/8/25 at 12:44 PM, the Regional Clinical Consultant (RCC) reported the hospice documentation should be in the EMR and verified there is no documentation. In an interview on 1/8/25 at 12:53 PM, Licensed Practical Nurse (LPN) J reported some residents have paper binders with hospice communications at the nursing station, and confirmed R41 did not have any paper binders with hospice communications, services, or visitations. In an interview on 1/8/25 at 2:09 PM, Social Worker (SW) I reported she and the Director of Nursing (DON) are responsible for hospice coordination. SW I reported R41 did not have any hospice documentation or communication at the facility. She reported this day she requested documentation from hospice that was sent via email this day and forwarded them to the DON. The hospice records sent via email was not available to the front-line staff who provided nursing services to R41 at this time. In an interview on 1/8/25 at 2:48 PM, the DON reported the facility did not have all the information needed from the hospice agency regarding the contract/agreement, visits, progress notes, and orders. The DON reported it was a work in progress. Review of a Hospice Certification document provided in paper form from the facility before the end of this survey for R41 dated 12/9/24 revealed he was certified for hospice from 11/22/24 to 2/19/25.

Based on observations, interviews and record review, the facility failed to properly clean 1 Resident's (R20) BiPap (breathing machine) for 1 Resident reviewed for respiratory equipment. Findings included: Review of R20's face sheet, no date revealed he was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses that included: end stage renal disease (kidney failure), unsteady on feet, need for assistance with personal care, cervical disc disorder myelopathy (muscle disorder) and diabetes mellitus with diabetic neuropathy (nerve disease). R20 was his own responsible party. On 1/8/25 at 10:14 AM R20 was observed in bed, and he had a BiPap (breathing assistance machine used during sleep) on his nightstand. The mask was still attached to the hose and there was no cleaning equipment observed in the room. R20 said no one had cleaned his BiPap equipment since admission. During an interview with the Director of Nursing (DON) on 1/8/25 at 12:04 PM she confirmed that she did some checking into the cleaning of R20's BiPap machine, she could not confirm that it had ever been cleaned and she was not sure who had checked the boxes on R20's Medication Administration Recorded indicating they had cleaned his BiPap machine. The DON said she had to get the supplies so they would be available for the staff to use and would start training the staff. Review of R20's Medication Administration Record (MAR) for January 2025 revealed, BIPAP WEEKLY Cleaning: Wash mask, headgear with warm water & mild dish detergent, rinse well, air dry. Wipe foam cushion with damp cloth, DO NOT submerse foam in water. Ensure completely dry prior to use. Wash humidifier with water & mild dish detergent, rinse well. The box for Sunday January 5th was marked as completed. Review of R20's Medication Administration Record (MAR) for January 2025 revealed, Bipap DAILY Cleaning: Wipe mask with damp cloth, rinse out humidifier, refill with distilled water. Every box was marked as completed.

This citation pertains to intake M100144670. Based on interview and record review, the facility failed to operationalize policies and procedures to ensure controlled substances are continuously and accurately accounted for between staff rotations, involving 4 of the 4 controlled substance logs in the facility, resulting in the potential for medication diversion. Findings include: Review of a policy titled Controlled Substances Standards of Practice last reviewed 1/2024 revealed: In order to accurately account for all controlled substances through the process of ordering, receiving, storage, administration and destruction, the following procedures have been provided. The Narcotic Page count sheet is updated with the addition of controlled substances at the time of delivery to include resident name, drug, and amount at the time of delivery. The Proof-of-use sheet is to be placed in binder and to be counted each change in nurse ownership of narcotic keys. Both on-going and off-going Nurses will count the number of containers and narcotic Proof-of-Use sheets to ensure accuracy reconciliation and provide signatures on the Narcotic Page and Card Count sheet. Both on-going and off-going nurses reconcile the Narcotic EDK (sic) and Narcotic Refrigerator EDK by checking and signing that the tag numbers on the boxes to ensure accuracy of safekeeping. Counts will occur with each change in ownership of narcotic keys, at shift change and change in assigned. If the Emergency Controlled Substance Box (EDK) is opened, nurse must sign the removal on an EDK Usage sheet, a new tag is placed on the box, and the number of the tag is documented on the Emergency Controlled Substance Inventory Kit Verification log sheet. Review of the August Narcotic Page Count Sheets for the 100-hall cart 1 and 2, and the 200-hall cart 1 and 2 revealed several missing nursing signatures verifying complete and accurate narcotic counts, incomplete information documented in the column for adding or subtracting narcotics and several entries missing resident information. Review of the August Emergency Controlled Substance Inventory Kit Verification log sheets on the medication carts revealed there were several opportunities of nursing signatures not verifying that the Emergency Controlled Substance storage was locked with a numbered green or red tag to ensure its locked and secured. There are 3 tags to be tracked and logged. Some entries show all 3 tags were changed with new numbers and no other nurse signature verifying or witnessing the change. There are several days of documentation missing. In an interview on 9/10/24 at 2:15 PM, the Director of Nursing (DON) reported the Narcotic Logs were not complete and accurate. The Pharmacy Representative comes to the facility on ce a month to do reviews and not sure if they look at the narcotic logs. She was not aware the documents were incomplete until this survey and reported she had some education to do.

Based on observations, interviews, and record review, the facility failed to prevent and heal pressure ulcers for 3 Residents (R3, R7 and R44) resulting in R3 developing a stage 2 pressure ulcer and R7 and R44 developing unstageable pressure ulcers. Findings include: R3 Review of R3's face sheet, no date, revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/29/22 at 1:28 PM, R3 was observed in the bathroom with CNA F. R3 had a 2 x 2 dressing over her coccyx with no date or initials for the treatment. R3 yelled out in pain when Certified Nurse Aide (CNA) F wiped her excoriated buttock after using the toilet. CNA F did not apply any barrier cream to R3's excoriated buttock. CNA F had Licensed Practical Nurse (LPN) D remove R3's dressing for observation. The wound over the coccyx was about 0.2 cm round and directly over a bony area with no muscle visible. R3 yelled out in pain when LPN D did hygiene care. LPN D did not apply any barrier cream prior to pulling up R3's brief. R3 had a cushion in her wheelchair that looked flat. During an interview with CNA F on 11/29/22 at 1:30 PM, CNA F said R3 sits up in her wheelchair all day unless she requests to go to bed. R3 confirmed that she had been in her wheelchair since breakfast. On 11/29/22 at 2:27 PM, Occupational Therapist (OT) P said the cushion R3 had in her wheelchair had the wrong cover on and needed to be inflated. OT P reviewed R3's care plan and there were no directions for care of the wheelchair seat cushion located. OT P said it needed to be checked by putting 2 fingers under the cushion when R3 was sitting in it to ensure that it was properly inflated. OT P was unable to verify the last time the seat cushion was checked. Review of R3's wound timeline provided by LPN I revealed R3's coccyx wound was discovered on 7/6/22 (facility acquired) and measured 0.3 cm x 0.2 cm x 0.2 cm, the wound was measured weekly and occasionally increased in size to 0.5 cm x 0.3 cm x .03 cm at the largest. The measurement was last done on 11/20/22 and it measured 0.3 cm x 0.1 cm x 0.1 cm. Wound treatment was changed from time to time but at no time did the facility increase the wound offloading times. Review of R3's Activities of Daily Living (ADL) care plan dated 4/1/21 revealed, she required assist of one person to walk with a wheeled walker, dressing, oral care, toileting, transfers, and bathing. Review of R3's care plan dated 7/10/22 for a pressure ulcer, sacral, revealed, Goal, pressure ulcer will heal without complications. Interventions did not reveal any schedule for offloading the sacral pressure ulcer. R3's wound timeline was reviewed with LPN I on 11/29/22 at 2:00 PM. LPN I confirmed the R3's coccyx wound was facility acquired. LPN I was aware R3 sits in her wheelchair all day. LPN I confirmed the facility had not encouraged, educated, or implemented any wound offloading plan of care. R7 Review of R7's face sheet, no date, revealed he was an [AGE] year-old male, admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R7's wound timeline made by LPN I revealed he was admitted with a 1 cm x 1 cm purple area (non-stageable area) on his left heal on 10/13/22. On 10/20/22 the ulcer on R7's left heel was listed as resolved. On 11/29/22 at 2:08 PM R7's skin was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . R7 had two purple areas on his left lateral heel (unstageable). One was dime size the other the size of a nickel. LPN I confirmed she was not aware of these wounds on R7's left heel LPN I said they did a facility wide skin sweep last week and these wounds were not noted on the skin sweep. Review of R7's care plan revealed he was at risk of skin breakdown D/T (due to) severe muscle deconditioning, impaired mobility, incontinence, and polyneuropathy (nerve malfunction), dated 10/31/22, revealed he should have his heels floated while in bed, there were no interventions for pressure relief for his feet when out of bed. Review of R7's ADL (activities of daily living) care plan dated 10/31/22 revealed, he required extensive assistance of one person for bed mobility, assistance of 2 people for transfers and he was not able to walk. R44 Review of R44's face sheet, no date, revealed he was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R44 skin was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . R 44 had a dime size black area on his right heel (unstageable wound). The DON said she was not aware of that wound and would look into it. The DON returned to report the wound was recently discovered on a facility wide skin sweep (facility acquired). The DON did not have orders to treat or any wound measurements. Review of R44's progress note dated 11/23/22 at 6:23 PM revealed, Completed skin sweep assessment of resident. Observed light purple/red hue area on sole of right heel measures 0.4 cm L x 0.5 cm W. Areas do not blanch. Observed resident during skin assessment that his soles of feet are up against the footboard, DON and this writer moved resident up in bed. Applied blue moon boots. Review of R44's pressure ulcer, DTI (deep tissue injury) to sole of right foot by 5th metatarsal area, care plan dated 11/23/22 revealed moon boots and a APM (alternating pressure mattress) were initiated on 11/23/22. Review of R44's ADL (Activities of Daily Living) care plan dated 10/24/22 revealed, he required extensive assist with transfers and wheelchair mobility. Walking was referred to therapy.

This citation pertains to intakes M100131927 and M100131928. Based on observation, interview and record review, the facility failed to assess, implement measures for appropriate hydration and nutrition, and follow orders for 1 (Resident #8) resulting in dehydration, malnutrition, and hospitalization . Findings include: Resident #8 (R8) Review of a Face Sheet revealed R8 originally admitted to the facility on [DATE] with pertinent diagnoses of dementia, femur fracture and congestive heart failure. Review of the Minimum Data Set (MDS) dated [DATE] for R8 revealed a Brief Interview for Mental Status (BIMS) was not completed to indicate if the resident was cognitively intact. She required minimum assistance of one staff for bed mobility and extensive assistance of one staff for toileting. She is always incontinent of urine and frequently incontinent of bowel. She was independent for meals and required to be set up only. Review of the MDS dated [DATE] revealed the resident was severely cognitively impaired. In an interview on 11/9/22 at 3:09 PM, FM 1 reported R8 went to the hospital on 10/5/22 for a change of condition and has since passed away. FM 1 received a phone call from the nursing facility the morning of 10/5/22 to inform her that R8 had pneumonia and was being sent to the hospital and found to be severely dehydrated, had a severe urinary tract infection and her urine had a very foul odor and she smelled bad. Her brief was heavily soiled, and a pressure ulcer was found on her tailbone. She had a fever of 102 in the ambulance on her way to the hospital. FM 1 reported she was not notified of any refusals of cares from the facility. R8 received antibiotics in the hospital to treat her infection. FM 1 reported there was a staffing change of some sort in July or August and resident cares went downhill. R8 had a weight loss of about 10 pounds and had been complaining the food was starting to taste bad. She was not on a restricted diet and there was always fresh water on her table when FM 1 would come to visit. R8 was able to feed herself and was not told otherwise. Review of a complaint submission reported to the State Agency on 10/6/22 for R8 revealed she was admitted to the hospital and was very deconditioned and had urosepsis (a urinary tract infection that can enter the blood stream). R8 presented to the hospital very disheveled and unkempt with feces under her fingernails and a sacral pressure ulcer. Review of a Hospital Medical Record dated 10/5/22 for R8 revealed she admitted with several diagnoses including but not limited to 1. Evidence of acute encephalopathy. 2. Acute Kidney injury with significant azotemia (A condition where there are abnormally high levels of waste products in the blood due to kidney failure). 3. Dehydration. 4. Acute Urinary tract infection positive for E. coli (Escherichia coli, a bacterium usually found in fecal matter). The resident complained of burning with urination. 5. Dehydration. 6. Hypernatremia (electrolyte imbalance caused by decreased fluid intake/nutrition intake.) 7. Severe protein calorie malnutrition. 8. Respiratory failure. Review of a policy titled Dehydration/Fluid Maintenance last reviewed 1/2022 revealed: Purpose: To determine the risk status of residents to develop dehydration and to implement measures to assure adequate fluid/maintenance hydration. Goal: To prevent dehydration from happening by identifying risk factors which lead to dehydration and provide the resident with sufficient fluid intake to maintain proper hydration and health. Risk factors include: .c. Dependence on staff for the provision of fluid intake. d. Use of medications that cause fluid loss. g. Limited fluid intake, lacking thirst sensation. Review of a Policy titled Nutritional Assessment last revised 4/21 revealed this policy addresses new admissions and residents returning from COA. Residents whose admission is governed by other more restrictive federal or state guidelines will follow the documentation time frames established by these regulations. Collect Data, Complete Nutritional Assessment Form, A. Analyze Data, B. Analyze Diet Order including eating ability and intake data, C. Analyze Lab Values/Medications including diuretics, D. Identify Nutritional Related Problems and Risk Factors including mental status, weight loss of 5 pounds a month if above 100 pounds, decubitus ulcer or potential for decubitus ulcer, and communicate the data. Review of a Dietary Progress note dated 8/10/22 for R8 revealed she had 6.0% weight loss in 30 days. Weight on 8/3/22 was 108 pounds and continues on Lasix (diuretic). She averages 51-75% of meals and 76-100% of snacks at bedtime. She is getting Mighty shakes twice a day with varying acceptance and accepting fluids from staff and appears adequate. Recommendations: weekly weights X3 weeks, discontinue Mighty shakes and add 120 milliliters of med Pass (nutrition supplement) twice a day. No other follow up from the dietician documented. Review of the August, September and October 2022 Medication Administration Record and the Treatment Administration Record (MAR/TAR) for R8 revealed from 9/13/22 to 10/4/22 there is no skin assessment documented as done. The Proheal supplements were documented as unavailable 6 times and refused 3 times in September 2022. October 4th and 5th the Proheal supplement was documented as unavailable. The Med Pass nutritional supplement was not given to the resident several times in August, not available 21 times in September, and not given in October prior to hospitalization . Lasix 40 milligrams given once a day since 3/12/21. Review of weights for R8 revealed weights as follows: 7/3/22 is 114.9 pounds, 8/3/22 is 108 pounds, and 10/3/22 is 107.5 pounds. Review of an Intake document of meals and snacks for R8 dated 9/1/22 to 10/5/22 revealed several meals not documented and some meals with minimal intake including fluids and snacks. Review of the Output Point of Care document for R8 revealed from August to October 2020, the resident did not have any output such as urine, emesis, or bowel movements documented as done daily and many days her output was documented once or twice, indicating the potential for no incontinence care provided. There were also male care givers documented as providing incontinence care for R8. No fluid intake noted on October 3rd and October 4th. Review of the Electronic Medical Records (EMR) including nursing progress notes, Certified Nursing Assistants (CNA) progress notes, and other pertinent documents revealed no documentation indicating the resident was assessed for hydration, infections, or care. Review of the Nutritional Status Care Plan for nutrition and hydration dated 6/4/20 indicated the resident is to be assisted with meals as needed, a regular diet with mechanical soft foods and thin liquids, encourage fluids at bedside, and observe for signs and symptoms of fluid imbalance. One revision on 2/3/22 is to provide supplements as ordered and ice cream with lunch and dinner. Review of the Nursing Progress notes dated 9/28/22 for R8 revealed the nurse documented the resident was more accepting of care this shift with little resistance which was an improvement for her and that her diet was stable. Review of a document titled Skin Body assessment dated [DATE] for R8 revealed an 18cm (centimeter) X 9cm dark red area on buttocks and a 0.5 cm open area. During an observation on 11/2/22 at 1:25 PM residents in the 200-hall dining area received their lunch trays. At 4:29 PM, the same hall started to receive their dinner trays. Meals were 3 hours apart. During observations on 11/7/22 at 9:47 AM, the 100 hall dining room residents were slowly receiving their breakfast trays and at 10:00 AM, three residents still did not have their breakfast. At 1:00 PM, lunch trays observed on 200 hall still on the cart. No alternative menu was available during this survey. Review of a list of mealtimes posted in the dining rooms revealed breakfast is from 8:30 to 9:30 AM, lunch is from 12:30 to 1:30 PM, and dinner is from 5:00 to 6:00 PM. During an observation on 11/2/22 at 1:25 PM residents in the 200-hall dining area received their lunch trays. At 4:29 PM, the same hall started to receive their dinner trays. Meals were 3 hours apart. During observations on 11/7/22 at 9:47 AM, the 100 hall dining room residents were slowly receiving their breakfast trays and at 10:00 AM, three residents still did not have their breakfast. At 1:00 PM, lunch trays observed on 200 hall still on the cart. In an interview on 11/15/22 at 9:49 AM, the Agency Certified Nursing Assistant (CNA) U reported this was her second shift at this facility. When queried how she knows how to take care of the residents at the facility, she showed this surveyor a list of resident's names typed up on a piece of paper with dots next to some of the names. A brief handwritten note next to some residents' names had words that indicated how the residents' transfer. The CNA did not know where any resident care guides were or any other ways to care for residents who may need to be turned frequently, be assisted with meals, or provide incontinence care etc. CNA U reported the residents with dots next to their names meant it was their shower day but did not know if they already got their showers or still needed their showers. CNA U reported if she had any questions or concerns about a resident's care, she would just ask the nurse. In an interview on 11/16/22 at 10:20 AM, Registered Nurse (RN) O reported she did not take care of R8 for a couple days before she discharged to the hospital, but recalled the resident was declining. RN O reported R8 liked to eat slow and graze the food on her tray from one meal to the next. She started to decline participating in activities and showers but would do bed baths. The day R8 went to the hospital, she had a dry brief and new pressure ulcer that was noticed by the night shift nurse. RN O reported she did take the residents vital signs but will sometimes document them late in the computer. The nurse reported she assessed her lung sounds and a chest x-ray was ordered that later showed the resident had pneumonia. In an interview on 11/16/22 at 1:18 PM, the Director of Nursing (DON) reported that staff are now being specifically assigned to residents as of last week to help assist with the continuity of care and hold people accountable for the care of residents. The nurses will be held accountable too. The DON reported there are to be care guides on the floor at the nurses' station so staff, including agency staff know how to care for the residents. When queried why the agency staff during this survey did not know about the care guides, the DON did not have an answer. The DON reported she remembered looking at R8s pressure ulcer on 10/5/22 before she went to the hospital and said there was blanching on her coccyx when she observed the residents' skin, but remembered the resident had a white cream covering the area and there was a non-blanchable area.

This citation pertains to intake M100131928. Based on interview and record review, the facility failed to provide incontinence care for 1 (Resident #8), resulting in a urinary tract infection and hospitalization . Findings include: Resident #8 (R8) Review of a Face Sheet revealed R8 originally admitted to the facility on [DATE] with pertinent diagnoses of dementia, femur fracture and congestive heart failure. Review of the Minimum Data Set (MDS) dated [DATE] for R8 revealed a Brief Interview for Mental Status (BIMS) was not completed to indicate if the resident was cognitively intact. She required minimum assistance of one staff for bed mobility and extensive assistance of one staff for toileting. She is always incontinent of urine and frequently incontinent of bowel. Review of the MDS dated [DATE] revealed the resident was severely cognitively impaired. In an interview on 11/9/22 at 3:09 PM, FM 1 reported R8 went to the hospital on 10/5/22 for a change of condition and has since passed away. FM 1 received a phone call from the nursing facility the morning of 10/5/22 to inform her that R8 had pneumonia and was being sent to the hospital and found to be severely dehydrated, had a severe urinary tract infection and her urine had a very foul odor and she smelled bad. Her brief was heavily soiled, and a pressure ulcer was found on her tailbone. She had a fever of 102 in the ambulance on her way to the hospital. FM 1 reported she was not notified of any refusals of cares from the facility. R8 received antibiotics in the hospital to treat her infection. FM1 reported one of the aides at the facility was a male and knows her mother would not want a male changing her brief. FM 1 reported there was a staffing change of some sort in July or August and resident cares went downhill. Review of a complaint submission reported to the State Agency on 10/6/22 for R8 revealed she was admitted to the hospital and was very deconditioned and had urosepsis (a urinary tract infection that can enter the blood stream). R8 presented to the hospital very disheveled and unkempt with feces under her fingernails and a sacral pressure ulcer. Review of a Hospital Medical Record dated 10/5/22 for R8 revealed she admitted with several diagnoses including but not limited to 1. Evidence of acute encephalopathy likely toxic metabolic from urinary tract infection, dehydration, and hyponatremia. 2. Acute Kidney injury with significant azotemia (A condition where there are abnormally high levels of waste products in the blood due to kidney failure). 3. Dehydration. 4. Acute Urinary tract infection positive for E. coli (Escherichia coli, a bacterium usually found in fecal matter). The resident complained of burning with urination. Review of the Output Point of Care document for R8 revealed from August to October 2020, the resident did not have any output such as urine, emesis, or bowel movements documented as done daily and many days her output was documented once or twice, indicating the potential for no incontinence care provided. There were also male care givers documented as providing incontinence care for R8. No fluid intake noted on October 3rd and October 4th. Review of the Electronic Medical Records (EMR) including nursing progress notes, Certified Nursing Assistants (CNA) progress notes, and other pertinent documents revealed no documentation indicating the resident was assessed for hydration, infections, or care. Review of a Urinary Incontinence Care plan for R8 dated 5/28/20 revealed the Resident experiences incontinence (related to) impaired cognition, impaired mobility, history of right hip nailing, history of (cardiovascular accident), impaired mobility and medications. Potential for skin breakdown, infection, loss of dignity. The resident is to get incontinence care after each incontinence episode and report any signs of skin breakdown and encourage fluid intake. The ADL (activities of daily living) Care Plan reveals R8 is a 1 assist with transfers to the toilet but frequently incontinent of bowel and bladder last revised 5/2/22. She is to be offered toileting assistance first upon entering her room as of 7/29/20. She is to be encouraged and toileted after every meal. Review of the Nutritional Status Care Plan for nutrition and hydration dated 6/4/20 indicated the resident is to be assisted with meals as needed, a regular diet with mechanical soft foods and thin liquids, encourage fluids at bedside, and observe for signs and symptoms of fluid imbalance. One revision on 2/3/22 is to provide supplements as ordered and ice cream with lunch and dinner. Review of the Care Plan for R8 revealed no preferences listed to not have male care givers. Review of a document titled Skin Body assessment dated [DATE] for R8 revealed there were no areas of skin impairment. Review of the Nursing Progress notes dated 9/28/22 for R8 revealed the nurse documented the resident was more accepting of care this shift with little resistance which was an improvement for her and that her diet was stable. Review of a document titled Skin Body assessment dated [DATE] for R8 revealed an 18cm (centimeter) X 9cm dark red area on buttocks and a 0.5 cm open area. In an interview on 11/15/22 at 9:49 AM, the Agency Certified Nursing Assistant (CNA) U reported this was her second shift at this facility. When queried how she knows how to take care of the residents at the facility, she showed this surveyor a list of residents names typed up on a piece of paper with dots next to some of the names. A brief handwritten note next to some residents' names had words that indicated how the residents' transfer. The CNA did not know where any resident care guides were or any other ways to care for residents who may need to be turned frequently, be assisted with meals, or provide incontinence care etc. CNA U reported the residents with dots next to their names meant it was their shower day but did not know if they already got their showers or still needed their showers. CNA U reported if she had any questions or concerns about a resident's care, she would just ask the nurse. In an interview on 11/16/22 at 10:20 AM, Registered Nurse (RN) O reported she did not take care of R8 for a couple days before she discharged to the hospital, but recalled the resident was declining. RN O reported R8 liked to eat slow and graze the food on her tray from one meal to the next. She started to decline participating in activities and showers but would do bed baths. The day R8 went to the hospital, she had a dry brief and new pressure ulcer that was noticed by the night shift nurse. RN O reported she did take the residents vital signs but will sometimes document them late in the computer. The nurse reported she assessed her lung sounds and a chest x-ray was ordered that later showed the resident had pneumonia. In an interview on 11/16/22 at 1:18 PM, the Director of Nursing (DON) reported that staff are now being specifically assigned to residents as of last week to help assist with the continuity of care and hold people accountable for the care of residents. The nurses will be held accountable too. The DON reported there are to be care guides on the floor at the nurses' station so staff, including agency staff know how to care for the residents. When queried why the agency staff during this survey did not know about the care guides, the DON did not have an answer. The DON reported she remembered looking at R8s pressure ulcer on 10/5/22 before she went to the hospital and said there was blanching on her coccyx when she observed the residents' skin, but remembered the resident had a white cream covering the area and there was a non-blanchable area.

This citation pertains to intakes M100131927, M100131928, and MI00128909 Based on interview and record review, the facility failed to assess, implement measures, and evaluate outcomes to prevent pressure ulcers for 2 (Resident #8 and Resident #15), resulting in the residents obtaining pressure ulcers. Findings include: Resident #8 (R8) Review of a Face Sheet revealed R8 originally admitted to the facility on [DATE] with pertinent diagnoses of dementia, femur fracture and congestive heart failure. Review of the Minimum Data Set (MDS) dated [DATE] for R8 revealed a Brief Interview for Mental Status (BIMS) was not completed to indicate if the resident was cognitively intact. She required minimum assistance of one staff for bed mobility and extensive assistance of one staff for toileting. She was at risk for pressure ulcers and did not have one at the time of the assessment and is documented as having pressure reducing devices in her chair and bed. Review of the MDS dated [DATE] revealed the resident was severely cognitively impaired. In an interview on 11/9/22 at 3:09 PM, FM 1 reported R8 went to the hospital on 10/5/22 for a change of condition. R8 had a pressure ulcer on her tailbone and one on her hip. She was not aware of it prior to the resident going to the hospital and she is her Power of Attorney (POA). FM 1 reported the facility did not communicate with her about the residents' care or any refusals of care. At the hospital, R8 was super dehydrated, and her brief was heavily soiled when she went to the hospital. R8 complained a while ago that the food was tasting bad and wouldn't eat. Another concern was that one of the CNAs was a male and her mother would not have wanted any males taking care of her. Review of a Hospital Medical Record dated 10/5/22 for R8 revealed she admitted with several diagnoses including but not limited to a deep tissue pressure injury of bilateral buttocks, physical deconditioning, severe protein and calorie malnutrition, dehydration, and acute kidney injury. Review of the Pressure Ulcer Care Plan for R8 dated 5/28/20 revealed no new interventions or revisions since the start date. One intervention was to turn and reposition the resident every 2 hours and as needed. Another intervention included weekly skin inspections to be conducted by the nurse. Review of a Urinary Incontinence Care plan for R8 dated 5/28/20 revealed the Resident experiences incontinence (related to) impaired cognition, impaired mobility, history of right hip nailing, history of (cardiovascular accident), impaired mobility and medications. Potential for skin breakdown, infection, loss of dignity. The resident is to get incontinence care after each incontinence episode and report any signs of skin breakdown , and encourage fluid intake. The ADL (activities of daily living) Care Plan reveals R8 is a 1 assist with transfers to the toilet but frequently incontinent of bowel and bladder last revised 5/2/22. She is to be offered toileting assistance first upon entering her room as of 7/29/20. She is to be encouraged and toileted after every meal. Review of a Nutritional Status Care Plan for R8 dated 6/4/20 revealed no new interventions/revisions since date of creation and no indication/documentation that the approaches were implemented. Review of the Care Plan for R8 revealed no preferences listed to not have male care givers. Review of the Physician Orders for R8 revealed on 7/17/22 an order for weekly skin assessments on Tuesdays. On 8/14/22 an order for 30 milliliters (mL) of Proheal (protein supplement) was ordered twice a day. A Med Pass nutritional supplement was ordered for 60 mLs twice a day on 8/14/22. Review of the August, September and October 2022 Medication Administration Record and the Treatment Administration Record (MAR/TAR) for R8 revealed from 9/13/22 to 10/4/22 there is no skin assessment documented as done. The Proheal supplements were documented as unavailable 6 times and refused 3 times in September 2022. October 4th and 5th the proheal supplement was documented as unavailable. The Med Pass nutritional supplement was not given to the resident several times in August, not available 21 times in September, and not given in October prior to hospitalization . Review of a document titled Skin Body assessment dated [DATE] for R8 revealed there were no areas of skin impairment. Review of a document titled Skin Body assessment dated [DATE] for R8 revealed an 18cm (centimeter) X 9cm dark red area on buttocks and a 0.5 cm open area. Review of the Point of Care (POC) Turn Schedule history for September and October 2022 for R8 revealed there is no documentation indicating the resident was provided care for repositioning as indicated in the care plan. Review of the Nursing Progress notes dated 9/28/22 for R8 revealed the nurse documented the resident was more accepting of care this shift with little resistance which was an improvement for her and that her diet was stable. In an interview on 11/15/22 at 9:49 AM, the Agency Certified Nursing Assistant (CNA) U reported this was her second shift at this facility. When queried how she knows how to take care of the residents at the facility, she showed this surveyor a list of residents typed up on a piece of paper with dots next to some of the names. A brief handwritten note next to some residents with the words that indicated how the residents' transfer. The CNA did not know where any resident care guides were or any other ways to care for residents who may need to be turned frequently or be assisted with meals etc. CNA U reported the residents with dots next to their named meant it was their shower day but did not know if they already got their showers or still needed their showers. CNA U reported if she had any questions or concerns about a residents care, she would just ask the nurse. In an interview on 11/15/22 at approximately 11:30 AM, Licensed Practical Nurse (LPN) S reported she would expect the aides to report any skin changes noticed in residents right away. The regular staff are better at reporting changes to the nurses as opposed to the agency staff. LPN S reported she took care of R8 only a short time before she was discharged to the hospital and remembers her being weak with a poor appetite. LPN S did not know if the dietician was notified but was made aware when new supplements were noted on her orders. In an interview on 11/16/22 at 10:20 AM, Registered Nurse (RN) O reported she did not take care of R8 for a couple days before she discharged to the hospital, but recalled the resident was declining. The morning she discharged to the hospital, the night shift nurse did a skin assessment and noticed the resident had a reddened area that was blanchable but had a darker spot on her coccyx and felt the night shift nurse should have measured it. The resident could have benefited from an air mattress, and she did not have one while at the facility. In an interview on 11/16/22 at 1:18 PM, the Director of Nursing (DON) reported that staff are now being specifically assigned to residents as of last week to help assist with the continuity of care and hold people accountable for the care of residents. The nurses will be held accountable too. The DON reported there are to be care guides on the floor at the nurses' station so staff, including agency staff know how to care for the residents. When queried why the agency staff during this survey did not know about the care guides, the DON did not have an answer. The DON reported she remembered looking at R8s pressure ulcer on 10/5/22 before she went to the hospital and said there was blanching on her coccyx when she observed the residents' skin, but remembered the resident had a white cream covering the area and there was a non-blanchable area. 28101 R15 Review of R15's face sheet (no date) revealed she was a [AGE] year-old female admitted to the facility on [DATE] at 1:04 PM and had diagnoses that included: malignant neoplasm of colon (colon cancer), acute kidney failure, wound infection, encounter for ileostomy (surgery resulting in a colostomy (fecal bag), diabetes mellitus and acute and chronic respiratory failure with hypoxia. R15 was her own responsible party. Review of R15's ADL (activities of daily living) care plan with start date of 10/20/22 revealed she was not able to walk, required extensive assistance of one person for bathing, bed mobility, and dressing. Review of R15's care plan for pressure ulcer dated 10/20/22 revealed she was at risk for skin breakdown due to impaired mobility, malnutrition, diabetes mellitus, incontinence, morbid obesity and admitted with existing pressure ulcer. The care plan did not address the amount of time R15 could be sitting on her buttock or the frequency of turning her in bed. The care plan did not address the location of pressure ulcers of wounds. Review of R15's admission nursing assessment dated [DATE] at 2:01 PM (8 days after admission noted on R15's face sheet) revealed no skin concerns or problems. Review of R15's progress note dated 9/15/22 at 7:08 PM revealed the note was entered late on 9/17/22 at 1:25 AM). The note was written by Licensed Practical Nurse (LPN) B. The note revealed R15 was admitted with multiple large wounds on her right lateral, medial and posterior right leg. R15 also had a pressure ulcer on her coccyx. There were no measurements of any of the wounds. (The admission assessment completed 8 days after admission did not mention any wounds). Review of R15's progress note dated 9/23/22 at 7:37 PM revealed, recorded as late entry on [DATE], at 7:37 PM, Measurements of sacral wound on admit was 3.2 L x 2.1 W and D .2. Pink wound bed resembling a split with intermittent maceration edges and redness resembling MASD (moisture associated skin damage). This note was written by LPN B. Review of R15's progress note dated 9/30/22 at 12:55 PM revealed, Weekly wound rounds: Resident had initial wound visit with name of wound care service on 9/29/22 for right posterior lower extremity wounds and sacral wound. Sacral wound is a stage 3 pressure ulcer that measured 3 x 1.2 x 0.3 cm with small amount of serosanguineous drainage and no order. The note went on to descript right leg wounds. Review of R15's progress note dated 9/30/22 at 3:59 PM revealed a supply company was contacted to deliver a APM (alternating pressure mattress) for R15. (15 days after she was admitted with a pressure ulcer and multiple wounds). Review of R15's progress noted dated 10/8/22 at 11:34 PM revealed, Weekly wound rounds - Resident seen by name of wound service for wounds to right leg and pressure wound to sacrum. Sacral wound is stage 3 pressure wound that measured 4.5 x 3 x 0.3 cm. Small amount of serosanguineous drainage noted with no odor. Wound is noted to be deteriorating. No change in treatment noted despite wound known to be deteriorating. Review of R15's progress note dated 10/27/22 at 9:49 PM revealed, (recorded as Late Entry on 10/30/22 at 9:59 PM). Wound rounds - Resident continues to be seen by wound specialist. Sacral wound measure 5 cm L x 6 cm W x 0.2 cm D. Moderate amount of serosanguineous drainage noted. No foul odor. No change noted in wound progression. Note goes on to describe right leg wounds than continues with noting a new wound. New wound noted with this current visit to right posterior thigh that measures 2 cm L x 1.5 cm W x 0.2 cm D. Scant amount of serosanguineous drainage noted, but no foul odor. Wound bed 50% granulation, 50% dermis. Surrounding skin and temp WNL (within normal limits) No s/sx (signs or symptoms) of infection. Resident tolerates dressing changes well. Treatment for new wound is to apply hydrocolloid dressing to the site and change three time a week and prn if soiled/dislodged. Review of R15's progress note dated 11/6/22 at 7:49 PM revealed, Coccyx/Sacral wound measures 2.0 cm L x 0.3 cm W by 0.3 D There was no measurement of the wound that was identified in the note on 10/27/22. R15 was observed in her room on 11/7/22 at 8:25 PM sitting in a chair next to her bed. R15 was not sitting on any seat/pressure reducing cushion. R 15 said she had been up in her chair for about one hour. R15 was concerned about the food she was receiving. R15 said she has been hungry a lot since she has been here. R15 said she does not get food that she likes and is not provided enough food. R15 said she has reported her food concerns to multiple supervisors, but she continues to served food she does not like and provided examples of broccoli and potatoes with the skin on. On 11/7/22 at 9:19 AM, R15 was served her breakfast. R15 had a chocolate magic cup, strawberry yogurt, omelet, toast with peanut butter, a chocolate mighty shake and a bowl of oatmeal. R15 said this was the best meal she had been served since she was admitted here. R15 was still up in her chair. On 11/7/22 at 10:09 AM, R15 had her call light on, and Certified Nurse Aide (CNA) H responded. R15 was still in her chair at bedside with no seat cushion. R15 asked CNA H for help with her colostomy bag as it was filled to capacity with feces and gas. When CNA H attempted to empty the bag, it broke loose at the wafer (part attached to R15's stomach) and fecal matter went all over R15, her chair and the floor. R15 said this happens daily because they do not change it enough and she normally sits in her chair the majority of the day. CNA H put R15 back in bed, changed her clothing and cleaned R15's skin where the fecal matter had soiled her. CNA H did not offer to change R15's brief. R15's brief was visibly soiled. CNA H said a licensed nurse would need to change R15's colostomy bag. R15 specialty mattress was set at firm, auto firm and low pressure. On 11/7/22 at 11:02 AM, LPN G removed R15's brief to assess the condition of her skin and dressings. R15 had a small dressing approximately 2 by 2 over her coccyx area. No date or initial were located on the dressing. There was a open area on R15's right buttock under her gluteal fold about dime size with no dressing on it. R15's brief was saturated with urine. R 15's entire buttock was discolored (purple) skin was all excoriated. R15 said the last time anyone one changed her brief was before she got out of bed around 7:30 AM and she normally goes 3 to 4 hours before anyone changes her even when she puts on her call light for help. LPN G said she needed to get help to change R15's brief and do the dressing change. On 11/7/22 at 11:11 AM CNA A and LPN G returned to do care and the dressing change. CNA A was not able to stay as some of the infection control equipment needed to do care was not stocked in the room. LNP G provided R15 with care to change her brief and do the dressing change. LPN G placed a large dressing on R15 and reported the dressing she removed was not the correct dressing. LPN G said she would have to report the new wound before she could treat it as she did not have orders. R15's mattress remained in the low pressure, firm auto firm mode. Over 3.5 hours since R15 was assisted with changing she soiled brief. On 11/7/22 at 12:32 PM, R15 was in bed, she was turned slightly to her right side. No pillows or positioning equipment was located. R15 complained of her buttock hurting. R15 put on her call light and CNA A responded. CNA A checked R15's mattress setting and said they normally set the mattress to alternation pressure and a softer setting. CNA A was not able to change the settings on the mattress. CNA A contacted maintenance. Maintenance responded and fixed R15's mattress as a hose had been unplugged. (It was not known how long the mattress had not been functioning correctly). On 11/7/22 at 1:23 PM the surveyor requested a timeline for all R15's wound with all supporting documents for wound assessments and treatment. (orders, treatment records, assessments, care plan and measurement). On 11/7/22 at 4:03 PM, LPN B was interviewed about a handwritten timeline she was provided for R15. LPN B was asked where the admission assessment and measurements for R15's wounds were located. LPN B said she entered the information late in R15's record and she was able to locate R15 had a stage III PU on her sacrum when she was in the hospital. LPN B was not able to recall the first date and time she assessed R15's wounds and said she has not had time to complete all of R15's wounds documentation timely due to staffing issues. LPN B did not have R15's wounds all located on the timeline and did not have all the supporting documents she used when she created the timeline. The surveyor request all supporting documents and a complete list of wounds and measurements. On 11/9/22 at 11:55 AM the NHA was notified that the timeline the facility provided did not match the facility documents for wound discovery and treatment. Measurements and treatments for the wound that was documented as being found on 10/27/22 were not received. A second request for all wound documentation was done at this time.

This citation pertains to intakes M100130676 and M100130372. Based on interview and record review, the facility failed to operationalize their policies and procedures to provide pain medication timely for 1 (Resident #9), resulting in the police being called to remove the resident and transfer to the hospital. Findings include: Resident #9 (R9) Review of a Face Sheet revealed R9 admitted to the facility on [DATE] with pertinent diagnoses of a fractured cervical vertebra, dementia, and osteoarthritis. Review of the Minimum Data Set (MDS) Entry Tracking record revealed an admission assessment was not completed. In an interview on 11/7/22 at 11:43 AM, Family Member (FM) 1 reported R9 came to the facility on [DATE] for therapy. He was not getting his pain medication as ordered and could not find the nurse for hours. When FM 1 came to the facility, she could hear R9 moaning from the front door. Review of Hospital Progress notes dated 7/27/22 to 8/10/22 for R9 revealed complaints of pain in his left heel that is relieved by offloading. He had a mechanical ground-level fall that resulted in a Type II odontoid fracture and odontoid screws on 8/2/22. He had right shoulder pain, right knee pain and an old left arm fracture cast that was removed but splinted. Review of an Order Summary for R9 revealed orders dated 8/10/22 for 325 mg (milligrams) acetaminophen every 4 hours as needed for pain, 5 mg oxycodone every 4 hours as needed for pain. Review of the August Medication Administration Record (MAR) for R9 revealed he did not receive any acetaminophen since 8/11/22 when he rated his pain at a 9 at 6:58 PM. The resident only received Oxycodone on 8/17/22 at 8:02 AM and again at 12:05 PM. Review of the Proof of Use document for R9 dated as received on 8/11/22 for Oxycodone 5 mg every 4 hours as needed for pain does not match the times documented as given in the MAR for the 8 doses provided to the facility for the resident. Review of the Proof of Use document for R9 dated as received on 8/12/22 for 15 doses of Oxycodone 5 mg every 4 hours as needed for pain does not match the MAR for medication administrations and no available doses left to administer for 8/17/22. The Proof of Use document shows more administrations of medications were administered than documented on the MAR in the electronic medical record. Review of the Care Plan for R9 revealed the document only addressed nutrition and hydration and no pain or other person centered focus' or interventions. Review of a Practitioner Progress Note dated 8/15/22 for R9 revealed the resident was seen for a follow up after a recent emergency room visit and complained of severe right-hand pain that was so severe that even touching his hand caused excruciating pain. The plan was to apply war compresses and continue Tylenol and oxycodone 5 mg as needed every 4 hours. Review of a Late Entry Nursing progress note entered 8/23/22 at 11:20 PM for 8/17/22 at 7:11 PM for R9 revealed: Nurse returned from break to find police officer there and asked what was going on. The officer informed nurse that family had called 911 stating that resident had been waiting for pain medication for 2 hours. Nurse stated no one notified nurse resident needed pain medication prior to leaving for break or during break. Nurse did not leave the building so there was no reason someone couldn't notify her if there was a problem. When nurse last observed resident, he was in his recliner asleep. Officer stated they were taking resident to ER for evaluation. Nurse offered to give pain medication, but resident refused to take at that time. Even had given to another nurse to administer but he refused. Medication disposed of per facility protocol and witnessed by both nurses. Administrator informed and managers notified that resident sent out notified doctor that resident sent out per family request to ER. (sic) Review of a Late Entry Nursing progress note entered 8/23/22 at 10:39 PM for 8/17/22 at 4:34 PM for R9 revealed: Resident requested a blanket because he was cold nurse brought blanket in and covered resident. Noted at this time both resident and wife were in the room asleep. Resident did not appear to be in any distress or appear to be having any discomfort at this time. Call light within reach. (sic) Review of a Late Entry Nursing progress note entered on 8/24/22 at 4:33 AM for 8/17/22 at 5:14 PM for R9 revealed: Nurse waiting for dinner trays to arrive before checking blood sugar scheduled to be checked before meals. Review of a Police Report for and incident dated 8/17/22 at 5:58 PM revealed the police responded to an incident at the facility involving R9 complaining of being in pain since 3:00 PM and the Certified Nursing Assistant (CNA) did not know where the nurse was. When the officer arrived to the facility, the officer noticed the nurse was standing behind the desk as he walked to R9s room. The resident had been complaining of pain since 3:00 PM this day. The officer talked to the nurse on duty who reported she was not gone for over an hour and was not aware of R9 asking for his pain medication. The nurse reported she was in the hallway of the other wing in the facility and talking to the nurse manager. The nurse reported she last saw R9 around 5:00 PM. The CNA reported she could not leave the floor to look for the nurse. In a telephone interview on 11/15/22 at 12:34 PM, Licensed Practical Nurse (LPN) V reported she started working her shift around 3 to 3:30 PM on 8/17/22 and took her break and was only gone for about 30 minutes. She could not verify the exact time she took her break and said she did not clock out for her break. When queried why she took a break when her shift just started, LPN V reported she had to get her break in before it was too late. LPN V reported she told the two CNAs she was going off the floor and the staff could have paged her or called her cell phone if they needed her. LPN V reported that was a busy hall she was working on and took the opportunity to take a break when she did. In an interview on 11/16/22 at 1:18 PM, the DON reported she expects nurses to tell aides when they leave the floor to go on break. If a resident wants pain medication, the expectations is for the resident to get their pain medications right away or within 5 - 10 minutes.

This citation pertains to intake number MI 327. Based on observation, interview, and record review, the facility failed to prevent an elopement for Resident #11 reviewed for elopement. This deficient practice resulted in an Immediate Jeopardy when Resident #11 (R11) who was assessed as an elopement risk, eloped from the front door of the facility, unbeknownst to staff, allowing R11 to ambulate away from the facility on 11/23/21 at approximately 4:30 PM, staff did not realize R11 was missing until 4:45 PM then returned to the facility approximately 5:00 PM by a good Samaritan who observed him walking down to the end of the subdivision and attempted to cross a 4 lane highway. This deficient practice placed R11, and other residents who were assessed as being at risk for elopement, at risk for serious harm, injury and or death from hazards outside the facility. Findings include: Resident #11 Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R11 admitted to the facility on [DATE]. Brief Interview for Mental Status (BIMS) reflected a score of 3 out of 15 which represents R11 had severe cognitive impairment. Resident #12 Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R12 admitted to the facility on [DATE]. Brief Interview for Mental Status (BIMS) reflected that R12 was cognitively intact. R11's progress note dated 10/20/21 at 11:55 AM reflected, Resident observed by staff member outside through front door. Noted that a visitor had just left and resident must have went out the door with them, with visitor unaware that he is a resident. Staff immediately brought resident back into building. Elopement checks continue and all staff on unit notified of incident. Informed administrator and unit manager. R11's progress note dated 11/5/21 at 8:03 PM reflected, Resident was witnessed by another resident, (initials of R12) exit the front door, walk into the parking lot like he was looking for his car and then started walking down drive to the right of the facility. (Witness was outside the facility at this time smoking). Resident was transported to the facility without incident . During a telephone interview on 11/23/21 at 10:30 AM, Good Samaritan (GS H) gave the following account of the incident that he witnessed on 11/5/21 at approximately 4:45 PM. GS H stated he was visiting at a house across the street from the facility when he saw a man (R11) walking. GS H stated he got in his vehicle to leave a few minutes later and noticed R11 attempting to cross M-45 (a four-lane highway). GS H stated R11 pushed back traffic and they weren't stopping for him. GS H stated, I was afraid for him. I pulled out on the edge of the street, offered him a ride and he got in. GS H stated that R11 told him that someone had stole his car and he needed to find it. R11 told him that he lived right over here. GS H stated R11 seemed confused and was carrying a couple of books. GS H drove R11 back into the subdivision when he soon put it together that he might have come from the nursing home. GS H stated that he drove back to the nursing home and noticed staff looking for R11, so he drove up and the staff confirmed that R11 lived there. During an interview on 11/24/21 at approximately 10:50 AM, R12 stated while she was smoking outside the front door, she remembered seeing R11 by the cars in the parking lot at approximately 4:30 PM on 11/5/21. R12 denied assisting R11 out of the building and stated, He looks like a visitor. During an interview on 11/23/21 at approximately 3:50 PM, the Nursing Home Administrator (NHA) stated the facility investigation after R11's attempted elopement on 10/20/21 revealed that a visitor let R11 out the front door, so the facility changed the door code and placed R11 on every 15-minute checks. The NHA stated that the 11/5/21 elopement investigation (the second one) revealed staff were attempting to locate R11 for a 15-minute check and were unable to find him. R12 stated that she saw R11 out in the parking lot by the front door. The NHA stated that R12 most likely learned the facility door code and let R11 out. The NHA stated the facility changed the door code again and staff were advised not to give out the code. When asked if there was documentation of this new implemented safety measure to prevent reoccurrence, the NHA stated, No. The NHA informed on 11/23/21 at 12:30 PM that Immediate Jeopardy had been identified, starting on 11/5/21 at approximately 4:30 PM when the facility failed to adequately supervise R11 (who was identified as an elopement risk with severe cognitive impairment including safety awareness) on 11/5/21 at approximately 4:30 PM, when he eloped from the front door of the facility, unbeknownst to staff. Staff did not realize R11 was missing until approximately 4:45 PM. R11 had ambulated to the end of the subdivision (approximately 0.3 miles away) and attempted to cross a 4 lane highway when a good Samaritan intervened and returned R11 back to the facility at approximately 5:00 PM. It was 48.2-degree weather. R11 previously wandered outside the front door approximately 48 feet from the front door unsupervised on 10/20/21. The facility did not adequately supervise R11, allowing a severely cognitive impaired resident who is a known elopement risk to leave the grounds without supervision. This deficient practice placed R11 and all residents assessed to be elopement risks at risk for serious injury and/or death. Immediacy was removed on 11/24/21 when the facility had the following in place: Removal Plan Tag Cited: F 689 Reason for elopement abatement plan for IJ Purpose of AP: 1. To ensure all residents assessed appropriately for risk of elopement 2. To ensure all care plans current and reflect appropriate interventions 3. To ensure all Elopement Binders reflect current information 4. To ensure all staff are educated on Elopement process. Concern leading to AP development: Facility identified that resident currently at risk for elopement and on 15-minute checks was witnessed exiting the front of the building. This was witnessed by another resident (R12) who was outside in front of facility smoking. Action Plan Element #1: Identified resident was reassessed for elopement on 11/5/21 Identified resident was placed on a 1:1 staff supervision 11/5/21 Identified residents care plan was updated to reflect the 1:1 supervision 11/5/21 Motion sensor alarm placed on resident's bedroom door to alert direct caregivers to resident leaving his room 11/12/21 Door code changed 11/16/21 Element #2: All residents who are exit seeking and new admissions are identified as being at potential risk. The DON or designee will: o Review the medical records of residents for elopement assessments in last 90 days and update accordingly. 11/6/21 o All residents that are at risk of elopement based on assessment are to be reviewed for: o Appropriate care plan and interventions 11/6/21 o Appropriate photo and information in Elopement Binder 11/6/21 Element #3: Facility began to educate and continues to educate staff on Elopement process, identification, interventions. 11/5/21 Drill to be conducted quarterly with results brought to monthly QAPI meeting 11/6/21 Review residents who are at risk for Elopement in Standards of Care meeting monthly to evaluate the effectiveness of interventions and behaviors. 11/6/21 Facility began to educate and continues to educate staff on not providing residents with the door bypass code. 11/23/21 Facility began to educate and continues to educate staff on the [facility] Addendum to Elopement risk policy. 11/23/21 Element #4: Facility will do monthly audits on door alarms and functioning. Facility will do monthly audits on windows to ensure secure. Audits to be completed monthly on Elopement Binder for accuracy. All audits to be brought to monthly QAPI meetings for review. Education to be continued for all new staff and agency staff ongoing. All audits and Elopement information/education will be presented to the facility QAPI committee monthly for further monitoring, recommendations or follow-up to ensure ongoing compliance. Elopement Risk Policy Addendum In the case that a resident were to need 1:1 supervision due to an elopement attempt or successful elopement and the following criteria were to be met then the intervention of placing a motion sensor alarm on the residents bedroom door leading to hallway will be implemented. Criteria includes: Resident has been assessed as being at risk for elopement Resident has a documented elopement attempt or success Resident is independently ambulatory with or without a device During an observation and interview on 11/24/21 at 10:22 AM. R11 was seated in his room watching TV. A surveyor walked in and out of R11's room and the motion sensor did not alarm. The NHA was alerted to this finding and stated that it needed to be positioned differently to work and repositioned the alarm. Then as NHA walked away and the alarm continued to go off randomly. During an observation on 11/24/21 at 2:00 p.m. Nurse I tested the motion sensor to R11's room and did not go off again. Nurse I stated that it should work and then played with it and then it continued to go off randomly. During an interview on 11/24/21 at 2:30 PM the NHA and Regional Nurse Consultant A was advised that the motion sensor alarm on R11's door was still not working and that not all staff were aware of what code was used for elopement and their duties in the event of an elopement. During an interview and record review on 11/30/21 at 9:45 AM, the NHA provided an addendum to the removal plan of an added magnetic alarming door alarm in addition to the motion sensor alarm that will alert staff that R11 is exiting his room and provided additional staff education of the removal plan with the date initiated of 11/24/21. The surveyor confirmed the last removal plan item was started on 11/24/21 instead of 11/23/21. Although the IJ was removed on 11/24/21, the facility remained out of compliance at a scope of isolated and severity of Actual harm with the potential for more than minimal harm that is not Immediate Jeopardy due to all staff had not been in-serviced on the corrective action implemented to remove the immediacy and sustained compliance has not been verified by the state agency.

Based on observation, interview and record review, the facility failed to provide adequate nutrition monitoring and interventions for 3 residents (R 6, 63, and 117) of 6 residents reviewed for nutrition/hydration resulting in an Immediate Jeopardy (IJ) that began on 7/15/2021 when R 6's experienced a significant weight loss and the facility failed to notify the physician, failed to have R 6's chart reviewed by the regional dietician, failed to add additional interventions to prevent weight loss and R 6 continued to lose weight. This deficient practice has the high likelihood to affect all residents in this facility potentially resulting in harm, serious injury or death. Findings include: R 6 Review of R 6's face sheet revealed he was a [AGE] year old male resident who most recently admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 09/19/21 at 12:45 PM an interview was completed with R 6 in his room. He appeared to be very thin and small in stature. R 6 presented with some confusion and often when asked questions would talk about various unrelated topics. Review of R 6's MDS (Minimum Data Set) records revealed he initially admitted to the facility on [DATE], discharged to the hospital on 05/01/21 and then readmitted on [DATE]. Review of R 6's admission assessment dated [DATE] revealed in section K he had a weight of 165 lbs. Review of R 6's quarterly MDS dated [DATE], in section K he is coded as having a weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months. His most recent weight is recorded as 133 pounds. Review of R 6's vital signs in the electronic medical record (EMR) revealed he was not weighed on his initial admission on 4/29/21, but a height was entered. The first weight for R 6 was documented 05/08/21 at 2:08 AM as 165 lbs. The next recorded weight was on 7/15/21 at 1:31 PM as 133 lbs. The next weight was taken on 8/27/21 at 11:20 AM and was 131 lbs. The next weight was 9/14/21 at 9:15 AM and was 127 lbs. He was reweighed on 09/14/21 at 3:23 PM and this was also 127 lbs. Review of R 6's Hospital discharge paperwork from a hospital stay from 05/01/21-05/07/21 revealed one of his diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The document also contained results for R 6's echocardiography report completed 5/1/21 which had a weight of 75 kg or 165 lbs noted. Review of R 6's food intake logs revealed frequent meals with less than 50% intake and many meals not entered. Snacks were sporadically entered. For the month of May 2021, starting from 5/8/21 out of 72 meals and 24 snacks, approximately 4 meals or snacks were noted as not taken or none, approximately 5 meals were noted as 1-25% consumed, approximately 12 meals were noted as 26-50% consumed and approximately 31 meals were not logged at all. Snacks were not logged on approximately 20 days. For the month of June 2021 out of 90 total meals and 30 total snacks approximately 2 meals or snacks were noted as not taken or none, approximately 9 meals were noted as 1-25% consumed, approximately 11 meals were noted as 26-50% consumed and approximately 50 meals were not logged at all. Snacks were not logged on any day in June. For the month of July 2021 out of 93 total meals and 31 total snacks approximately 1 meals or snacks were noted as not taken or none, approximately 13 meals were noted as 1-25% consumed, approximately 29 meals were noted as 26-50% consumed and approximately 16 meals were not logged at all. Snacks were not logged 24 days. For the month of August 2021 out of 93 total meals and 31 total snacks approximately 0 meals or snacks were noted as not taken or none, approximately 16 meals were noted as 1-25% consumed, approximately 13 meals were noted as 26-50% consumed and approximately 28 meals were not logged at all. Snacks were not logged 23 days. For the month of September 2021 from the 1st through the 21st out of 63 total meals and 21 total snacks approximately 0 meals or snacks were noted as not taken or none, approximately 11 meals were noted as 1-25% consumed, approximately 9 meals were noted as 26-50% consumed and approximately 29 meals were not logged at all. Snacks were not logged 19 days. Review of R 6's progress notes revealed limited notes regarding his dietary needs. There was a note from Dietary Manager (DM) M from 5/19/21: Nutr note: ht 68 in, wt 165#, BMI 34.63, class I obese. Res has dx of dysphagia, had video swallow while in the hospital, family elected no tube feeding. Res is receiving hospice care. Diet: Pureed consistency solids and Honey thick fluids, res is a vegetarian, likes eggs, cottage cheese and all cheese, yogurt, milk, beans/ rice. Average intake 51-76% .Pro-cal malnutrition. Est needs 2250 cal(kg x 30) 75gP and 2250 cc fluids. Diet plan providing approx. 2325 cal, 100gP and 1900cc fluids. Will continue to honor res preferences and requests. RD to review. A case conference note on 06/08/21 revealed R 6's appetite is poor. A note from 06/14/21 revealed a nursing note: resident uses left arm to pick up right arm and food on right side of tray not touched. repositioned food to left side of table and resident ate remainder. food needs to be placed in front of resident with HOB up tray lowered and food to the left side of tray and resident will eat all of food. puree diet with honey thick liquids, resident enjoys the small cups of honey thick drinks and to be cold, especially lemon resident states. It should be noted this specific information regarding food placement could not be found in the care plan. A note from DM M from 08/13/21 revealed: Quarterly Nutr note: res remains on Pureed consistency food and honey thick fluids(no straws). Intake fluctuates from 1-75%. Res reported to CDM I just can't eat any more. Does enjoy the reduced med pass supplement he receives and consumes this 100%. Res continues with hospice care. BMI 27.92, overweight. Current wt 133#, significant loss Recommend increasing med pass supplement to 6oz QID as res accepts this without difficulty and likes it. This will provide 1260 cal, 60 g P daily. Est needs: 1800 cal(kg x 30) 60-72gP(kg x 1-1.2) and 1800cc fluids. Will continue to coordinate with hospice. The resident's representative was not made aware of R 6's weight loss until 9/21/21 at 5:23 PM. The physician was notified per a note on 5/21/21 at 5:49 PM. The regional dietician (RD N) did not complete a dietary noted regarding R 6 until 9/22/21 at 8:47 AM. Review of R 6's care plan revealed a problem with start date 5/10/21: Resident is a Nutritional/Hydration risk r/t (related to) *mod pro-cal (moderate protein-calorie) malnutrition *dysphasia .*unplanned wt (weight) loss . Approaches included: offer substitutes if consumes less than 50% of meals, RD (dietician) to review PRN (as needed), Weigh every month and/or PRN, notify Dr. of significant change. Review of RN (registered nurse) hospice notes for R 6 from 08/02/21 at 11:32 AM revealed: Pts (patient's) dysphagia continues. He eats a pureed diet. Staff report that he will eat small portions of all 3 meals but prefers the 8 ounces of Ensure-type drink that is provided at med pass time (3 times a day). Staff report that he will drink that entire glass. His arm cric (circumference) has decreased 1 cm since last cert (certification) period (22.5 cm to 21.5 cm), he appears more frail and cachectic (loss of body weight and muscle mass). Muscle wasting noted at temples and on hands. Tendons of hands stick out. Pt is no longer able to wear his own clothes as they are too big for him and instead is provided hospital gowns by staff. Review of physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/10/21 R 6 is noted to be 165 lbs. He is again noted to be 165 lbs on 6/14/21. On 7/15/21 physician L notes: Dysphagia- despite no PEG (feeding tube), he is maintaining his weight and again notes R 6's weight as 165 lbs. On 8/26/21 physician L notes: Dysphagia- not eating well. Weight last visit was probably wrong. Has lost 32 lbs and R 6's weight is noted as 133 lbs. Review of facility provided Weight Variance Report for 03/21/21-09/21/21 revealed documentation for R 6. Between 5/8/21 and 7/15/21 the chart showed in bold print No weight in 83-97 day period and between 7/15/21 and 8/27/21 No weight in 23-37 day period. The chart indicated from 5/8/21 to 9/14/21, R 6 had lost 38 pounds and 23.0% of their body weight in 129 days. On 09/21/21 at 1:35 PM an interview was completed with Regional Dietician (RD) N regarding R 6's weight loss. RD N stated she could not find a progress note in R 6's record that she had reviewed his chart. RD N stated that generally she looks at all new admits, then would review the matrix and look more closely at any resident that flagged for a weight issue or if they have a special condition like a tube feed. The Dietary Manager M will also flag residents that may need extra attention and RD N did not recall this resident being flagged. RD M stated that typically, most residents she would review at least monthly, but for some reason she had not reviewed R 6 since his admission over 4 months ago. RD N stated she would expect weights for residents would be completed at least monthly. R 6's weights were reviewed and RD N agreed it would be likely that he was not weighed at 2:00 AM and staff sometimes don't actually weigh them, they would use the hospital discharge paperwork. It was discussed with RD N that his weight on the hospital discharge papers did not match that weight and there is no indication in the hospital records that R 6 was actually weighed while he was briefly admitted . RD N was able to find an email she stated she wrote on 8/16/21 stating she was re-requesting for more information since the month before for R 6 including a request for a reweigh. RD N could not find the initial correspondence where she requested any information or any additional follow up regarding R 6. RD N stated she would assume the initial weight was wrong, but admitted with no additional weight taken for 2 months there was no way to know exactly how much weight was lost if the initial weight was correct. It was discussed with RD N that many of R 6's intake logs around the time of weight loss indicated frequent intakes of 0-25% and she was informed that hospice notes indicated observations of significant weight loss and RD N admitted that even if the initial weight was incorrect, it was likely that R 6 had a significant weight loss. On 9/21/21 at 2:35 PM an interview was completed with Dietary Manager (DM) M regarding R 6's weight loss. DM M stated that she was aware R 6 had a significant weight loss. DM M stated that R 6 initially admitted with weight concerns and had declined at tube feed so the plan was to just get as much down as we could. It was discussed that many of R 6's food intake logs he had been frequently coded as 0-25% intake on meals and had been trying to increase his intake of things like yogurt, pureed cottage cheese and med pass supplement since those are items he enjoys. DM M stated that R 6 and his weight loss has been repeatedly talked about in morning meeting and the physician should have been notified of the weight loss. DM M stated it would be the job of nursing staff, such as the Director of Nursing, Assistant Director of Nursing or the MDS Nurse to reach out to the doctor when the weight loss was noted. DM M stated it would be her job to reach out to RD N if weight loss was noted with a resident, DM M could not recall if she had talked to RD N regarding R 6. DM M stated she is concerned residents are not having weights taken consistently. DM M stated it had been difficult to get weights consistently done due to staffing. DM M stated she has noticed weights were not always getting done and she was trying to do some herself if the resident did not need assistance with transfers. DM M stated she even brought in her own scale to try to obtain weights but the scale went missing. DM M stated she had been doing her best to help get weights but was exhausted due to the lack of staffing. Review of facility provided policy Weight Monitoring with a last reviewed date of 7/2021 revealed: All residents' height and weight will be determined by the appropriate method and recorded within 24 hours of admission. Weight will be measured monthly. The weight changes of all residents will be monitored monthly. Percentage weight changes will be determined for 30-day, 90-day, and 180-day periods. The procedure includes: 1. Dietician will obtain residents height from nursing 2. Dietician will calculate acceptable body weight range .3. It is the facilities policy that weights be completed and reviewed on a monthly basis. More frequent monitoring may be required due to a residents medical condition. All residents will be weighted upon admission to establish a baseline .4. Procedure: Residents will be weighed monthly in a timely manner (at least by the 10th of each month). Those residents that trigger for a significant weight loss (>5%) from the previous month will be placed on weekly weights. Each resident will be reviewed by the IDT committee and appropriate interventions will be put in place. Prior to the end of each month, the facility RD/CDM/RDT will provide the DON a list of those residents identified and tracked; which residents re-gained the weight and those residents who continue to lose weight .All hospice residents should be weighed a minimum of monthly .RD/CDM/RDT must document on weight gains and losses for those residents that experience 5% for 30 days 7.5% for 90 days and 10% for 180 days in the medical record to meet the professional standards for dieticians .Nursing services is responsible to obtain monthly weights on each resident. Weekly weights will be obtained as indicated. The results are given to the DON, designee or RD/CDM/RDT for input into the computer. Under the section Monthly and Weekly Weights: Monthly weights: conducted on residents whose weight has been stable from the time of admission to current. Weekly weights on residents that: a. Have experienced a significant weight loss/gain as indicated by the weight variance report b. Are newly admitted to the facility regardless of payer c. Are readmitted to the facility d. Have a gradual weight loss over a period of time. Under the section Weighing Procedure: Notify MD of significant weight loss of 5%, 7.5%, 10% .Notify resident representative. On 09/21/21 at approximately 4:29 PM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) were informed of an Immediate Jeopardy (IJ) related to F 692 that began on 07/15/2021 when the facility failed to prevent further weight loss for R 6 who has had a 23% weight loss in 4 months. R 6 admitted to the facility 5/7/21 with a weight of 165 lbs. He was not re-weighed until 7/15/21 and his weight at that time was 133 lbs. His most recent weight is 127 on 9/14/21. Review of R 6's record with Regional Dietary manager confirmed she had not yet completed a review of R 6's dietary needs and she should be reviewing every resident monthly. Review of a doctor note on 8/26/21 revealed they noted the weight loss but the weight was probably wrong. A progress note on 8/17/21 from the dietary manager confirms a significant weight loss for R 6. A hospice note on 8/2/21 indicated R 6's clothes were too large to wear and he was noted to have muscle wasting. The identified risk of serious injury, serious harm, serious impairment or death was evidenced by: R 6 has experienced a 23% weight loss in 4 months, he is likely to experience further weight loss, impairment or hastened death if the significant weight loss continues without assessment, monitoring and interventions to prevent further decline. The need for immediate action was: R 6 must be reviewed and monitored immediately by an interdisciplinary team to address the significant weight loss he has experienced and prevent further significant loss and change in condition. On 09/22/2021, the facility plan to remove the Immediate Jeopardy was accepted and the state agency began to validate the removal plan with which included: Reason for weight management abatement plan for IJ Purpose of AP: 1. To ensure all residents assessed appropriately for weight loss/gain. 2. To ensure MD notified of weight loss/gains in timely manner. 3. To ensure nutrition assessments and documentation from Dietary Manager in place to address weight loss/gain when applicable. Concern leading to AP development: 8/13/21 facility identified that resident [NAME] had experienced a 23% weight loss in 4 months. Regional dietitian had not yet completed a review of resident's dietary needs. MD was not notified timely of weight loss. Action Plan Element #1: Identified resident was weighed on 9/21/21. Facility spoke with residents POA to notify of residents fluctuating weight and discussed plan of care on 9/21/21. Facility left message with residents hospice case manager to discuss resident's plan of care on 9/21/21 . Facility collaborated with Regional dietitian to discuss recommendations for supplementation based on resident's POA suggestion on 9/21/21. Facility received new orders from MD for additional supplementation 9/21/21. Element #2: All residents who experience weight loss or gains and new admissions are identified as being at potential risk. The DON or designee will: o Review the medical records of residents for last 30 days for weights. 9/21/21 o Residents without a weight in last 30 days will be weighed. 9/22/21 o Residents noted to have a 5% weight gain or loss from the previous month if current weight is over 100 lbs. OR Have experienced a 3 lb. weight loss or gain from previous month if current weight is under 100 lbs will be re-weighed, per policy. 9/22/21 o Residents that are noted to experience weight loss/gains of 5% for 30 days 7.5% for 90 days and 10% for 180 days will be reviewed and documented on by RD/CDM/RDT. 9/22/21 o Weight scale calibration to be reviewed. 9/22/21 Element #3: o On 9/22/21 education will be started with all nursing staff on weight process, identification of loss and/or gain, interventions and/or orders to be implemented as well as notifications. o On 9/22/21 education will be started with all nursing staff on obtaining weights. o Review residents who are identified for weight loss or gain in Standards of Care meeting weekly to evaluate the effectiveness of interventions. o Dietary manager to run weight variance report and report weight concerns daily in morning clinical meeting. Element #4: o Random weekly audits will be completed on residents that are noted to experience weight loss/gains of 5% for 30 days 7.5% for 90 days and 10% for 180 days to ensure weights are being completed per order. o Random weekly audits will be completed on residents that are noted to experience weight loss/gains of 5% for 30 days 7.5% for 90 days and 10% for 180 days to ensure the MD has been notified per policy. o Random weekly audits will be completed on residents that are noted to experience weight loss/gains of 5% for 30 days 7.5% for 90 days and 10% for 180 days to ensure nutrition assessments and documentation from Dietary Manager is in place, and for food acceptance reviewed. ___________________________________________________________________________ Revised or Increased interventions implemented as part of weight management abatement plan for IJ: All audits to be brought to monthly QAPI meetings for review. Education to be continued for all new staff and agency staff ongoing. Weight variance reports to be reviewed in morning clinical meeting with monthly report to QAPI for review. Monitoring of Action Plan Interventions: All audits, weight variance reports, and weight information/education will be presented to the facility QAPI committee monthly for further monitoring, recommendations or follow-up to ensure ongoing compliance. Person responsible for Action plan compliance: Administrator Date weight management abatement plan for IJ compliance achieved: 9/22/21 Although the Immediate Jeopardy was removed on 09/22/2021, the facility remained out of compliance with a scope of pattern and severity of No actual harm with the potential for more than minimal harm that is not immediate jeopardy due to sustained compliance not being verified by the state agency. Resident #63 A review of Resident #63's Face Sheet, dated 9/20/21, revealed Resident #63 was an [AGE] year-old resident admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #63's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 9/7/21, revealed Resident #63 had a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 7 which revealed Resident #63 was severely cognitively impaired. In addition, Resident #63's MDS revealed Resident #63 did not have any teeth or tooth fragments (edentulous). Resident #63 was also independent with eating after her meal tray was set up for her. A review of Resident #63's weight record, dated 8/31/21 (admission) to 9/20/21 failed to reveal Resident #63 had been weighed at the facility. During an interview on 09/20/21 at 9:45 AM, Licensed Practical Nurse (LPN) I stated if Resident #63 was weighed when she was admitted to the facility, the admission weight should be recorded in the e-medical record (electronic medical record) under the weights section. A second review of Resident #63's weight record (in the e-medical record), dated 8/31/21 to 9/21/21, failed to reveal that Resident #63 had been weighed at the facility. A review of the facility's Weight Variance Report, dated 3/21/21 to 9/21/21, confirmed Resident #63 had not been weighed at the facility. During an interview on 09/22/21 at 08:40 AM, Certified Dietary Manager (CDM) M verified Resident #63 had not been weighed at the facility as of 9/22/21 (over 3 weeks after admission). A review of the facility's Weight and Height Records policy and procedure, revised 7/21, revealed, All residents' height and weight will be determined by the appropriate method and recorded within 24 hours of admission. R 117 Review of R 117's face sheet revealed he was an [AGE] year-old male admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . His daughter was his responsible party. During a telephone interview with R 117's responsible party (RP) Z on 9/20/21 at 11:59 AM, Z said she came to the facility on [DATE] when he was admitted . Z said the facility staff did not attempt to see him or meet with him for 4 hours. After 4 hours she went to find staff to find out what was going on. The staff were all very busy. Staff had her fill out forms for food dislikes Z said she returned to the facility on [DATE] and all the food he had on his meal tray were foods that he did not like. Z said staff are very nice, but they are all just busy. During an interview with the facility Dietary Manager M on 9/21/21 at 10:06 AM, M said she does not do a baseline care plan for residents. M said she normally completes a food preference questionnaire with the residents on admission, but she was busy that day (9/9/21). M recalled she had the family complete R 117's food preference questions. M said she normally puts down food the residents like and did not notice they put down foods he did not like. M said speech therapy had evaluated R 117 on 9/10/21 and determined he needed 1:1 assistance with meals. M had a handwritten note from Speech Therapy. M could not find this information in R 117's care plan and the Speech Therapy note was not in R 117's medical record. There was no indication R 117's responsible party had been provided this information. M confirmed R 117 did best with finger foods. M said she had not participated in a baseline care plan or any care plan meeting for R 117. 9/20/21 at 8:40 AM, R 117 was in the main dining room at table no assistance was eating oatmeal. He struggled but after some time he did get the spoon to his mouth. He had 2 drinks not touched yet. There were no staff in that section of the main dining room to assist or observe him struggle. R 117 had been assessed by Speech Therapy on 9/10/21 and they recommended 1:1 care with meals. On 9/20/21 at 1:05 PM, 10 residents including R 117 were in the 200-hall main dining room. All 10 residents had food trays with food on them in front of them. There were no staff assisting any residents eating. Licensed Practical Nurse (LPN) (I was assisting a resident that was being discharged . The Surveyor asked LPN I how many nurse aides were working the unit. LPN I said she had 3 but was down to 2 now because one nurse aide had to help transport a resident to an appointment. The Surveyor asked where the 2 were that were working as no one was helping the resident in the main dining room and LPN I the two nurse aides were in resident rooms assisting them.

Based on interview and record review, the facility failed to ensure 3 Residents received base line care plans (R14, R 117 and R 164) of 3 residents reviewed for baseline care plans, resulting in the potential for residents' needs and care not being met. Findings include: R 117 Review of R 117's face sheet revealed he was an [AGE] year-old male admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . His daughter was his responsible party. During a telephone interview with R 117's responsible party (RP) Z on 9/20/21 at 11:59 AM, Z said she came to the facility on [DATE] when he was admitted . Z said the facility staff did not attempt to see him or meet with him for 4 hours. After 4 hours she went to find staff to find out what was going on. The staff were all very busy. Staff had her fill out forms like food likes and dislikes. Z said they did not discuss his care plan or provide any copies of a care plan. Z stated she has not been notified of any care plan meeting. Z said she returned to the facility on [DATE] and all the food he had on his meal tray were foods that he did not like. Z said staff are very nice, but they are all just to busy. Review of R 117's paper medical record revealed a document BASELINE CARE PLAN. The box for RN (registered nurse) was marked and signed/dated 9/9/21 (admitted ). The Resident/Designee box was marked and signed by R 117's responsible party. No date was provided. There was no indication that R 117 or his responsible party received a copy of this document. There was no indication any other discipline participated in the completion of this document. There was no indication his medications or concerns were addressed. Under fall risk was handwritten toilet before dinner with no date. There were very few handwritten items. Most of the document was checking boxes. One box that was checked was barriers to residents' goals were identified, but there was no indication what these barriers were. The only care planned areas for a fall risk were, encourage use of call light, instruct on safety measures and toilet before dinner. R 117 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no indication of how the facility was going to supervise him to avoid falls or what his mobility status was at that time. There was no indication of what foods the resident did not like and no indication how much assistance he needed to eat. During an interview with the facility Social Worker (SW) D on 9/21/21 at 9:08 AM, D said the resident's baseline care plans were done by the MDS (Minimum Date Set) nurse, RN AA. SW D said she does not do a baseline care plan. The Surveyor asked when R 117 was scheduled for a care conference meeting and SW D said the MDS nurse AA scheduled his first care conference for 10/12/21. SW was not aware of any baseline care plan for R 117. During an interview with MDS nurse AA on 9/21/21 at 9:46 AM, AA said baseline care plans were completed by the nurse on admission and placed in the paper chart. Nurse AA said she does not get involved with the baseline care plan. AA said she schedules the first care conference for the residents within 30 days of admission. AA located a handwritten baseline in R 117's paper chart. AA could not find any information that indicated any facility staff other than the admission nurse had placed anything or had participated in the baseline care plan. AA confirmed R 117's first care conference was scheduled for 10/12/21 and the interdisciplinary team had not met to develop a care plan and goals with R 117 or his responsible party. During an interview with the facility Dietary Manager M on 9/21/21 at 10:06 AM, M said she does not do a baseline care plan for residents. M said she normally completes a food preference questionnaire with the resident on admission, but she was busy that day. M recalled she had the family complete R 117's food preference questions. M said she normally put down food the residents like and did not notice they put down foods he did not like. M said speech therapy had evaluated R 117 on 9/10/21 and determined he needed 1:1 assistance with meals. M had a handwritten note from Speech Therapy. M could not find this information in R 117's care plan and the Speech Therapy note was not in R 117's medical record. There was no indication R 117's responsible party had been provided this information. M confirmed R 117 did best with finger foods. M said she had not participated in a baseline care plan or any care plan meeting for R 117. R 164 Review of R 164's face sheet revealed he was an [AGE] year-old male admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R 164 was his own responsible party. During and interview with the Director of Nursing (DON) on 9/22/21 at 9:35 AM, the DON reviewed the baseline care plan located in R 164's paper medical record. The DON confirmed she signed the baseline care plan on 9/10/21. The said she completed the baseline care plan after she did his assessment. The DON said the other disciplines are to add their information. The DON could not locate any information from any other discipline. The DON could not locate any information to determine if R 164's advocate had participated in the baseline care plan. The DON could not find any information to verify that R 164 or his advocate had received a written copy of his base line care plan. R 14 Review of face sheet retrieved from the facility Electronic Medical Record on 9/19/21 for R 14 revealed she was a ninety-four-year-old resident who admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R 14 admission Minimum Data Set (MDS) record dated 8/26/21 revealed in Section M-Skin that she entered the facility with a Stage 2 pressure ulcer. Listed treatments included pressure reducing devices for the bed and chair and applications of ointments/medications. Review of the initial matrix provided by the facility on 9/19/21 revealed R 14 triggered for pressure ulcers. A subsequent corrected facility matrix that was provided on 9/20/21 showed no trigger for pressure ulcer for R 14. Review of R 14's progress notes revealed a note from 8/20/21 at 9:44 PM: Resident arrived at 4:15pm via ambulance .One small 0.5 cm dia. Stage 2 pressure area noted at the coccyx Review of R 14's Skin Check sheet revealed a diagram with notations regarding R 14's skin condition on 8/20/21. A Stage II 0.5 cm was marked on the coccyx area. Several more spots were noted on the resident's back and buttocks but were not labeled with what the spots were. The skin check was signed by RN U. Review of the New Admission Nurse to Nurse Report for R 14 revealed under the section skin .open areas: coccyx stage II. Review of the Medical Staff Assessment for R 14 signed by Physician L on 8/23/21 revealed under the Physical Exam Skin/Lymph section that R 14's skin was intact See NSG (nursing) full skin assessment. The Impression/Plan section made no mention of skin integrity or pressure ulcers. Review of Skin Body Assessment for R 14 observed 08/25/21 and completed 08/27/21 revealed skin impairments with the narrative: Stage 2 pressure ulcer on coccyx, red rash spread across back, bruises on left and right buttocks and created by LPN W but completed by the Director of Nursing. Review of Skin Body Assessment for R 14 dated 08/26/21 revealed skin impairments with the narrative: Resident with red areas on different parts of her body, receiving antibiotic treatment to left hip for left hip [CONDITION(S)] and completed by LPN V. There was not a skin assessment completed for R 14 from 08/26/21-09/09/21, a two week period. Review of Skin Body Assessment for R 14 dated 09/09/21 revealed skin impairments with the narrative: rash continues with redness, left hip [CONDITION(S)] resolving and completed by LPN V. Review of Skin Body Assessment for R 14 dated 09/16/21 revealed no areas of skin impairment was checked and the assessment was completed by RN U. On 9/21/21 at 8:31 AM an observation of care for R 14 was completed. Certified Nursing Assistants (CNA) S and T were providing care. CNA T said she worked last Thursday and R 14 had an open area on her butt on Thursday that was about dime size. Today the area is still open but less than dime size. The open area is at the upper gluteal fold right side. CNA T has been putting [MEDICATION(S)] cream on the open area. R 14's entire body was viewed to have red blotchy areas her back, chest and arm are the worst areas. In general, her feet appeared to be scaly and dry. R 14 was also viewed to have an unstageable blister on her right foot (ball area) approximately 2 cm by 0.5 cm. The skin concerns were reported to LPN (Licensed Professional Nurse) C. On 9/21/21 at 8:41 AM, the NHA (Nursing Home Administrator) was informed the pressure ulcer list was not accurate and asked again for an accurate list. The NHA was made aware R 14 has pressure ulcer and she was not on the pressure ulcer list provided. On 09/21/21 at 10:55 AM, an interview was completed with the assistant director of nursing (ADON) J, who was also the wound nurse. Documents related to R 14's skin was discussed. ADON J stated that the initial skin assessment completed when R 14 admitted to the facility shows she had a wound on her coccyx region, but no one created an event related to the wound, so it was not tracked and measured and the doctor was not informed so orders for treatment were not entered. ADON J acknowledged that several different subsequent skin assessments had been completed and the coccyx wound was not noted in any of them. ADON J was informed that an observation of R 14's skin had been made a couple hours ago and R 14 was viewed with the coccyx wound as well as an unstageable blister on her foot. ADON J stated she had not been informed of the new wound yet and stated they have a concerning communication breakdown and she should have been made aware of the new wound. The baseline care plan for R 14 was briefly reviewed with ADON J and she was asked how it could be determined when it was completed and who was present, ADON J stated she would check on this and would follow up if she found any further information. ADON J had not brought a current care plan for R 14 to review and admitted that interventions related to R 14 having a pressure ulcer were not there, and only prevention measures were mentioned in the care plan. On 09/22/21 at 10:55 AM, R 14 was found in bed, moaning, and said my crack hurts, and she clarified her butt and lower back area were in pain. RN (Registered Nurse) H was informed about R 14's discomfort stated it was probably time to turn her and would check on her as soon as she could. Review of facility provided Baseline Care Plan for R 14 revealed it was not signed or dated by any participant and no participants were listed. Pressure sore/skin at risk' was checked and the location was listed as coccyx. Listed prevention was turn q (every) 2 hr (hours). On 9/21/21 at 3:39 PM and email was sent to the NHA: For [R 14] I have a baseline care plan but no indication or proof of when it was completed or who was present, do you have any further information on this? No additional information was provided by the facility regarding the base line care plan by the exit of survey.

Based on observation, interview and record review, the facility failed to develop and implement care plans for 4 Residents (R 6, R 14, R 27 and R 117), resulting in significant weight loss for R 6, a new unstageable pressure ulcer and untreated stage 2 pressure ulcer for R 14, the potential for pressure ulcers for R 27 and R 117 sustaining a fall and the potential for ongoing falls and the potential for additional unmet care needs. Findings include: R 14 Review of face sheet retrieved from the facility Electronic Medical Record on 9/19/21 for R 14 revealed she was a ninety-four-year-old resident who admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R 14 admission Minimum Data Set (MDS) record dated 8/26/21 revealed in Section M-Skin that she entered the facility with a Stage 2 pressure ulcer. Listed treatments included pressure reducing devices for the bed and chair and applications of ointments/medications. Review of the initial matrix provided by the facility on 9/19/21 revealed R 14 triggered for pressure ulcers. A subsequent corrected facility matrix that was provided on 9/20/21 showed no trigger for pressure ulcer for R 14. Review of R 14's progress notes revealed a note from 8/20/21 at 9:44 PM: Resident arrived at 4:15pm via ambulance .One small 0.5 cm dia. Stage 2 pressure area noted at the coccyx Review of R 14's Skin Check sheet revealed a diagram with notations regarding R 14's skin condition on 8/20/21. A Stage II 0.5 cm was marked on the coccyx area. Several more spots were noted on the resident's back and buttocks but were not labeled with what the spots were. The skin check was signed by RN U. Review of the New Admission Nurse to Nurse Report for R 14 revealed under the section skin .open areas: coccyx stage II. Review of the Medical Staff Assessment for R 14 signed by Physician L on 8/23/21 revealed under the Physical Exam Skin/Lymph section that R 14's skin was intact See NSG (nursing) full skin assessment. The Impression/Plan section made no mention of skin integrity or pressure ulcers. Review of Skin Body Assessment for R 14 observed 08/25/21 and completed 08/27/21 revealed skin impairments with the narrative: Stage 2 pressure ulcer on coccyx, red rash spread across back, bruises on left and right buttocks and created by LPN W but completed by the Director of Nursing. Review of Skin Body Assessment for R 14 dated 08/26/21 revealed skin impairments with the narrative: Resident with red areas on different parts of her body, receiving antibiotic treatment to left hip for left hip [CONDITION(S)] and completed by LPN V. There was not a skin assessment completed for R 14 from 08/26/21-09/09/21, a two week period. Review of Skin Body Assessment for R 14 dated 09/09/21 revealed skin impairments with the narrative: rash continues with redness, left hip [CONDITION(S)] resolving and completed by LPN V. Review of Skin Body Assessment for R 14 dated 09/16/21 revealed no areas of skin impairment was checked and the assessment was completed by RN U. On 9/21/21 at 8:31 AM an observation of care for R 14 was completed. Certified Nursing Assistants (CNA) S and T were providing care. CNA T said she worked last Thursday and R 14 had an open area on her butt on Thursday that was about dime size. Today the area is still open but less than dime size. The open area is at the upper gluteal fold right side. CNA T has been putting [MEDICATION(S)] cream on the open area. R 14's entire body was viewed to have red blotchy areas her back, chest and arm are the worst areas. In general, her feet appeared to be scaly and dry. R 14 was also viewed to have an unstageable blister on her right foot (ball area) approximately 2 cm by 0.5 cm. The skin concerns were reported to LPN (Licensed Professional Nurse) C. On 9/21/21 at 8:41 AM, the NHA (Nursing Home Administrator) was informed the pressure ulcer list was not accurate and asked again for an accurate list. The NHA was made aware R 14 has pressure ulcer and she was not on the pressure ulcer list provided. On 09/21/21 at 10:55 AM, an interview was completed with the assistant director of nursing (ADON) J, who was also the wound nurse. Documents related to R 14's skin was discussed. ADON J stated that the initial skin assessment completed when R 14 admitted to the facility shows she had a wound on her coccyx region, but no one created an event related to the wound, so it was not tracked and measured and the doctor was not informed so orders for treatment were not entered. ADON J acknowledged that several different subsequent skin assessments had been completed and the coccyx wound was not noted in any of them. ADON J was informed that an observation of R 14's skin had been made a couple hours ago and R 14 was viewed with the coccyx wound as well as an unstageable blister on her foot. ADON J stated she had not been informed of the new wound yet and stated they have a concerning communication breakdown and she should have been made aware of the new wound. The baseline care plan for R 14 was briefly reviewed with ADON J and she was asked how it could be determined when it was completed and who was present, ADON J stated she would check on this and would follow up if she found any further information. ADON J had not brought a current care plan for R 14 to review and admitted that interventions related to R 14 having a pressure ulcer were not there, and only prevention measures were mentioned in the care plan. On 09/22/21 at 10:55 AM, R 14 was found in bed, moaning, and said my crack hurts, and she clarified her butt and lower back area were in pain. RN (Registered Nurse) H was informed about R 14's discomfort stated it was probably time to turn her and would check on her as soon as she could. Review of facility provided Baseline Care Plan for R 14 revealed it was not signed or dated by any participant and no participants were listed. Pressure sore/skin at risk' was checked and the location was listed as coccyx. Listed prevention was turn q (every) 2 hr (hours). On 9/21/21 at 3:39 PM and email was sent to the NHA: For [R 14] I have a baseline care plan but no indication or proof of when it was completed or who was present, do you have any further information on this? No additional information was provided by the facility regarding the base line care plan by the exit of survey. Review of R 14's orders revealed an order began on 08/25/21: Skin Assessment Weekly .Once a Day on Thu. Another order began on 08/20/21: DIABETIC FOOT CHECK: Daily (inspect for concerns/change in condition) . An order was added on 9/21/21: [MEDICATION(S)] oxide to coccyx q (every) shift. An order was added 09/22/21: Bilateral lower extremity apply moisturizing cream. Twice A Day. Review of R 14's care plan revealed the problem: Resident has a Stage 2 coccyx with potential for infection and discomfort and interventions was not added until 9/21/21. There was no intervention or problem listed specific to the unstageable wound found on R 14's foot. A problem with the start date 8/20/2021 was Pressure Ulcer Resident is at risk for pressure ulcers . Interventions included Conduct a systemic skin inspection eekly (weekly) ., Encourage frequent position changes when in bed, report any signs of skin breakdown . Another problem listed with a start date of 8/27/2021 was: Resident is a Nutritional/Hydration risk r/t (related to) Sacral region stage I . R 6 Review of R 6's face sheet revealed he was a [AGE] year old male resident who most recently admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 09/19/21 at 12:45 PM, an interview was completed with R 6 in his room. He appeared to be very thin and small in stature. R 6 presented with some confusion and often when asked questions would talk about various unrelated topics. Review of R 6's MDS (Minimum Data Set) records revealed he initially admitted to the facility on [DATE], discharged to the hospital on 05/01/21 and then readmitted on [DATE]. Review of R 6's admission assessment dated [DATE] revealed in section K he had a weight of 165 lbs. Review of R 6's quarterly MDS dated [DATE], in section K he is coded as having a weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months. His most recent weight is recorded as 133 pounds. Review of R 6's vital signs in the electronic medical record (EMR) revealed he was not weighed on his initial admission on 4/29/21, but a height was entered. The first weight for R 6 was documented 05/08/21 at 2:08 AM as 165 lbs. The next recorded weight was on 7/15/21 at 1:31 PM as 133 lbs. The next weight was taken on 8/27/21 at 11:20 AM and was 131 lbs. The next weight was 9/14/21 at 9:15 AM and was 127 lbs. He was reweighed on 09/14/21 at 3:23 PM and this was also 127 lbs. Review of R 6's Hospital discharge paperwork from a hospital stay from 05/01/21-05/07/21 revealed one of his diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The document also contained results for R 6's echocardiography report completed 5/1/21 which had a weight of 75 kg or 165 lbs noted. Review of R 6's food intake logs revealed frequent meals with less than 50% intake and many meals not entered. Snacks were sporadically entered. For the month of May 2021, starting from 5/8/21 out of 72 meals and 24 snacks, approximately 4 meals or snacks were noted as not taken or none, approximately 5 meals were noted as 1-25% consumed, approximately 12 meals were noted as 26-50% consumed and approximately 31 meals were not logged at all. Snacks were not logged on approximately 20 days. For the month of June 2021 out of 90 total meals and 30 total snacks approximately 2 meals or snacks were noted as not taken or none, approximately 9 meals were noted as 1-25% consumed, approximately 11 meals were noted as 26-50% consumed and approximately 50 meals were not logged at all. Snacks were not logged on any day in June. For the month of July 2021 out of 93 total meals and 31 total snacks approximately 1 meals or snacks were noted as not taken or none, approximately 13 meals were noted as 1-25% consumed, approximately 29 meals were noted as 26-50% consumed and approximately 16 meals were not logged at all. Snacks were not logged 24 days. For the month of August 2021 out of 93 total meals and 31 total snacks approximately 0 meals or snacks were noted as not taken or none, approximately 16 meals were noted as 1-25% consumed, approximately 13 meals were noted as 26-50% consumed and approximately 28 meals were not logged at all. Snacks were not logged 23 days. For the month of September 2021 from the 1st through the 21st out of 63 total meals and 21 total snacks approximately 0 meals or snacks were noted as not taken or none, approximately 11 meals were noted as 1-25% consumed, approximately 9 meals were noted as 26-50% consumed and approximately 29 meals were not logged at all. Snacks were not logged 19 days. Review of R 6's progress notes revealed limited notes regarding his dietary needs. There was a note from Dietary Manager (DM) M from 5/19/21: Nutr note: ht 68 in, wt 165#, BMI 34.63, class I obese. Res has dx of dysphagia, had video swallow while in the hospital, family elected no tube feeding. Res is receiving hospice care. Diet: Pureed consistency solids and Honey thick fluids, res is a vegetarian, likes eggs, cottage cheese and all cheese, yogurt, milk, beans/ rice. Average intake 51-76% .Pro-cal malnutrition. Est needs 2250 cal(kg x 30) 75gP and 2250 cc fluids. Diet plan providing approx. 2325 cal, 100gP and 1900cc fluids. Will continue to honor res preferences and requests. RD to review. A case conference note on 06/08/21 revealed R 6's appetite is poor. A note from 06/14/21 revealed a nursing note: resident uses left arm to pick up right arm and food on right side of tray not touched. repositioned food to left side of table and resident ate remainder. food needs to be placed in front of resident with HOB up tray lowered and food to the left side of tray and resident will eat all of food. puree diet with honey thick liquids, resident enjoys the small cups of honey thick drinks and to be cold, especially lemon resident states. It should be noted this specific information regarding food placement could not be found in the care plan. A note from DM M from 08/13/21 revealed: Quarterly Nutr note: res remains on Pureed consistency food and honey thick fluids(no straws). Intake fluctuates from 1-75%. Res reported to CDM I just can't eat any more. Does enjoy the reduced med pass supplement he receives and consumes this 100%. Res continues with hospice care. BMI 27.92, overweight. Current wt 133#, significant loss Recommend increasing med pass supplement to 6oz QID as res accepts this without difficulty and likes it. This will provide 1260 cal, 60 g P daily. Est needs: 1800 cal(kg x 30) 60-72gP(kg x 1-1.2) and 1800cc fluids. Will continue to coordinate with hospice. The resident's representative was not made aware of R 6's weight loss until 9/21/21 at 5:23 PM. The physician was notified per a note on 5/21/21 at 5:49 PM. The regional dietician (RD N) did not complete a dietary noted regarding R 6 until 9/22/21 at 8:47 AM. Review of R 6's care plan revealed a problem with start date 5/10/21: Resident is a Nutritional/Hydration risk r/t (related to) *mod pro-cal (moderate protein-calorie) malnutrition *dysphasia .*unplanned wt (weight) loss . Approaches included: offer substitutes if consumes less than 50% of meals, RD (dietician) to review PRN (as needed), Weigh every month and/or PRN, notify Dr. of significant change. Review of RN (registered nurse) hospice notes for R 6 from 08/02/21 at 11:32 AM revealed: Pts (patient's) dysphagia continues. He eats a pureed diet. Staff report that he will eat small portions of all 3 meals but prefers the 8 ounces of Ensure-type drink that is provided at med pass time (3 times a day). Staff report that he will drink that entire glass. His arm cric (circumference) has decreased 1 cm since last cert (certification) period (22.5 cm to 21.5 cm), he appears more frail and cachectic (loss of body weight and muscle mass). Muscle wasting noted at temples and on hands. Tendons of hands stick out. Pt is no longer able to wear his own clothes as they are too big for him and instead is provided hospital gowns by staff. Review of physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/10/21 R 6 is noted to be 165 lbs. He is again noted to be 165 lbs on 6/14/21. On 7/15/21 physician L notes: Dysphagia- despite no PEG (feeding tube), he is maintaining his weight and again notes R 6's weight as 165 lbs. On 8/26/21 physician L notes: Dysphagia- not eating well. Weight last visit was probably wrong. Has lost 32 lbs and R 6's weight is noted as 133 lbs. Review of facility provided Weight Variance Report for 03/21/21-09/21/21 revealed documentation for R 6. Between 5/8/21 and 7/15/21 the chart showed in bold print No weight in 83-97 day period and between 7/15/21 and 8/27/21 No weight in 23-37 day period. The chart indicated from 5/8/21 to 9/14/21, R 6 had lost 38 pounds and 23.0% of their body weight in 129 days. On 09/21/21 at 1:35 PM, an interview was completed with Regional Dietician (RD) N regarding R 6's weight loss. RD N stated she could not find a progress note in R 6's record that she had reviewed his chart. RD N stated that generally she looks at all new admits, then would review the matrix and look more closely at any resident that flagged for a weight issue or if they have a special condition like a tube feed. The Dietary Manager M will also flag residents that may need extra attention and RD N did not recall this resident being flagged. RD M stated that typically, most residents she would review at least monthly, but for some reason she had not reviewed R 6 since his admission over 4 months ago. RD N stated she would expect weights for residents would be completed at least monthly. R 6's weights were reviewed and RD N agreed it would be likely that he was not weighed at 2:00 AM and staff sometimes don't actually weigh them, they would use the hospital discharge paperwork. It was discussed with RD N that his weight on the hospital discharge papers did not match that weight and there is no indication in the hospital records that R 6 was actually weighed while he was briefly admitted . RD N was able to find an email she stated she wrote on 8/16/21 stating she was re-requesting for more information since the month before for R 6 including a request for a reweigh. RD N could not find the initial correspondence where she requested any information or any additional follow up regarding R 6. RD N stated she would assume the initial weight was wrong, but admitted with no additional weight taken for 2 months there was no way to know exactly how much weight was lost if the initial weight was correct. It was discussed with RD N that many of R 6's intake logs around the time of weight loss indicated frequent intakes of 0-25% and she was informed that hospice notes indicated observations of significant weight loss and RD N admitted that even if the initial weight was incorrect, it was likely that R 6 had a significant weight loss. On 9/21/21 at 2:35 PM, an interview was completed with Dietary Manager (DM) M regarding R 6's weight loss. DM M stated that she was aware R 6 had a significant weight loss. DM M stated that R 6 initially admitted with weight concerns and had declined at tube feed so the plan was to just get as much down as we could. It was discussed that many of R 6's food intake logs he had been frequently coded as 0-25% intake on meals and had been trying to increase his intake of things like yogurt, pureed cottage cheese and med pass supplement since those are items he enjoys. DM M stated that R 6 and his weight loss has been repeatedly talked about in morning meeting and the physician should have been notified of the weight loss. DM M stated it would be the job of nursing staff, such as the Director of Nursing, Assistant Director of Nursing or the MDS Nurse to reach out to the doctor when the weight loss was noted. DM M stated it would be her job to reach out to RD N if weight loss was noted with a resident, DM M could not recall if she had talked to RD N regarding R 6. DM M stated she is concerned residents are not having weights taken consistently. DM M stated it had been difficult to get weights consistently done due to staffing. DM M stated she has noticed weights were not always getting done and she was trying to do some herself if the resident did not need assistance with transfers. DM M stated she even brought in her own scale to try to obtain weights but the scale went missing. DM M stated she had been doing her best to help get weights but was exhausted due to the lack of staffing. Review of facility provided policy Weight Monitoring with a last reviewed date of 7/2021 revealed: All residents' height and weight will be determined by the appropriate method and recorded within 24 hours of admission. Weight will be measured monthly. The weight changes of all residents will be monitored monthly. Percentage weight changes will be determined for 30-day, 90-day, and 180-day periods. The procedure includes: 1. Dietician will obtain residents height from nursing 2. Dietician will calculate acceptable body weight range .3. It is the facilities policy that weights be completed and reviewed on a monthly basis. More frequent monitoring may be required due to a residents medical condition. All residents will be weighted upon admission to establish a baseline .4. Procedure: Residents will be weighed monthly in a timely manner (at least by the 10th of each month). Those residents that trigger for a significant weight loss (>5%) from the previous month will be placed on weekly weights. Each resident will be reviewed by the IDT committee and appropriate interventions will be put in place. Prior to the end of each month, the facility RD/CDM/RDT will provide the DON a list of those residents identified and tracked; which residents re-gained the weight and those residents who continue to lose weight .All hospice residents should be weighed a minimum of monthly .RD/CDM/RDT must document on weight gains and losses for those residents that experience 5% for 30 days 7.5% for 90 days and 10% for 180 days in the medical record to meet the professional standards for dieticians .Nursing services is responsible to obtain monthly weights on each resident. Weekly weights will be obtained as indicated. The results are given to the DON, designee or RD/CDM/RDT for input into the computer. Under the section Monthly and Weekly Weights: Monthly weights: conducted on residents whose weight has been stable from the time of admission to current. Weekly weights on residents that: a. Have experienced a significant weight loss/gain as indicated by the weight variance report b. Are newly admitted to the facility regardless of payer c. Are readmitted to the facility d. Have a gradual weight loss over a period of time. Under the section Weighing Procedure: Notify MD of significant weight loss of 5%, 7.5%, 10% .Notify resident representative. R 27 Review of R 27's face sheet revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 09/21/21 at 10:39 AM, R 27 was up in her wheelchair in her room. Certified Nurse Aide (CNA) S said other CNA got her up in the last hour. CNA S R 27 she uses the toilet frequently and her skin check could be done when she uses the toilet. R 27 said she did need to use the toilet at this time. R 27's entire sacral area was red and had a small scab approximately 1 cm by 1 cm in the left upper gluteal fold. Mid right gluteal fold scaring approximately 2 cm x 2 cm was also observed. After R 27 used the toilet CNA S did not apply any barrier cream. CNA S said they should put [MEDICATION(S)] cream on her, but the nurse did not give them any today. No white substance was noted on buttock. 09/21/21 at 10:59 AM, the Assistant Director of Nursing (ADON) J said she was the wound nurse. The ADON was asked how the CNA's are able to get [MEDICATION(S)] cream to apply to residents during care. The ADON said [MEDICATION(S)] cream needed to be ordered and they are able to get the cream from the licensed nurse. ADON J said she was not sure if CNA's can apply [MEDICATION(S)] cream. 09/22/21 at 10:10 AM record review showed licensed nurses were signing that [MEDICATION(S)] cream is applied to R 27's the buttock 3 times a day. Licensed Practical Nurse (LPN) C signed day shift 9/21/21 [MEDICATION(S)] applied. During an interview with LPN C on 09/22/21 01:04 PM, when asked about CNA's applying [MEDICATION(S)] cream during resident care, LPN C said CNA can apply [MEDICATION(S)] cream to is not prescription. LPN C was not aware CNA's working on 9/21/21 did not have access to [MEDICATION(S)] cream. Review of R 27's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R 27's care plan found that applying [MEDICATION(S)] oxide cream to buttock/coccyx with each toileting episode was not care planned. R 117 Review of R 117's face sheet revealed he was an [AGE] year-old male admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . His daughter was his responsible party. During a telephone interview with R 117's responsible party (RP) Z on 9/20/21 at 11:59 AM, Z said she came to the facility on [DATE] when he was admitted . Z said the facility staff did not attempt to see him or meet with him for 4 hours. After 4 hours she went to find staff to find out what was going on. The staff were all very busy. Staff had her fill out forms like food likes and dislikes. Z said they did not discuss his care plan or provide any copies of a care plan. Z she has not been notified of any care plan meeting. Z said she returned to the facility on [DATE] and all the food he had on his meal tray were foods that he did not like. Z said staff are very nice, but they are all just busy. Review of R 117's paper medical record revealed a document BASELINE CARE PLAN. The box for RN (registered nurse) was marked and signed/dated 9/9/21 (admitted ). The Resident/Designee box was marked and signed by R 117 responsible party. No date was provided. This care plan indicated R 117 was at risk for falls. Interventions listed were keep call light in reach, toilet before diner and instruct on safety measures. There was no information on amount of assistance needed for mobility, needs for assistive devices for safety were not identified or how they planned to supervise him. Review of R 117's Activity of Daily Living, care plan dated 9/20/21 revealed he needed extensive assistance of one person for bed mobility and toilet use. Extensive assistance of 2 people for transfers. Review of R 117's fall care plan dated 9/20/21 (11 days after admission) revealed, pressure alarm to self at all times, keep bed in lowest position with brakes locked, keep call light in reach, keep personal items and frequently used items in reach, observe frequently and place in supervised area when out of bed. Review of R 117's Event Report dated 9/13/21 revealed, Resident # 117 fell out of his wheelchair at 4:45 PM. Prior to the event he was moving himself about the unit in his wheelchair independently. His fall was not observed by staff (left unsupervised and known history of falls with fracture). This form did not indicate the last time resident was seen or when he last had any care. There was no indication who had last provided care or what his mood or behaviors were prior to the fall. There was no indication what the facility felt the root cause of the fall was however the box for root cause analysis was marked yes. The box for care plan has been updated was also marked yes. There were no care plan interventions that matched this date on the baseline care plan or on the care plan dated 9/20/21. This document was singed as completed 9/14/21 by the Director of Nursing (DON). During an interview with the DON on 09/21/21 at 1:37 PM, she reviewed fall event dated 9/13/21 at 4:45 PM. The DON said the fall was witness by a resident that was listed by a room number. The DON could not find any note that indicated that resident had been interviewed. The DON said that resident had been discharged and she did not know the name of the resident. The DON was not able to find any information on when and what care R 117 had received prior to the fall. The DON was not able to locate a care plan with any interventions placed after this fall.

Based on observation, interview and record review, the facility failed to assess and monitor 2 residents (R 14, and 63) for skin changes and current pressure ulcers, out of 6 residents reviewed for pressure ulcers, resulting in pressure ulcers not being monitored and treated, additional pressure ulcers developing and the potential for ongoing unrecognized and assessed skin changes. Findings include: R 14 Review of face sheet for R 14 retrieved from the facility Electronic Medical Record on 9/19/21 at 4:08 PM revealed she was a ninety-four-year-old resident who admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R 14 admission Minimum Data Set (MDS) record dated 8/26/21 revealed in Section M-Skin that she entered the facility with a Stage 2 pressure ulcer. Listed treatments included pressure reducing devices for the bed and chair and applications of ointments/medications. Review of the initial matrix provided by the facility on 9/19/21 revealed R 14 triggered for pressure ulcers. A subsequent corrected facility matrix that was provided on 9/20/21 showed no trigger for pressure ulcer for R 14. Review of R 14's progress notes revealed a note from 8/20/21 at 9:44 PM: Resident arrived at 4:15pm via ambulance .One small 0.5 cm dia. Stage 2 pressure area noted at the coccyx Review of R 14's Skin Check sheet revealed a diagram with notations regarding R 14's skin condition on 8/20/21. A Stage II 0.5 cm was marked on the coccyx area. Several more spots were noted on the resident's back and buttocks but were not labeled with what the spots were. The skin check was signed by RN U. Review of the New Admission Nurse to Nurse Report for R 14 revealed under the section skin .open areas: coccyx stage II. Review of the Medical Staff Assessment for R 14 signed by Physician L on 8/23/21 revealed under the Physical Exam Skin/Lymph section that R 14's skin was intact See NSG (nursing) full skin assessment. The Impression/Plan section made no mention of skin integrity or pressure ulcers. Review of Skin Body Assessment for R 14 observed 08/25/21 and completed 08/27/21 revealed skin impairments with the narrative: Stage 2 pressure ulcer on coccyx, red rash spread across back, bruises on left and right buttocks and created by LPN W but completed by the Director of Nursing. Review of Skin Body Assessment for R 14 dated 08/26/21 revealed skin impairments with the narrative: Resident with red areas on different parts of her body, receiving antibiotic treatment to left hip for left hip [CONDITION(S)] and completed by LPN V. There was not a skin assessment completed for R 14 from 08/26/21-09/09/21, a two week period. Review of Skin Body Assessment for R 14 dated 09/09/21 revealed skin impairments with the narrative: rash continues with redness, left hip [CONDITION(S)] resolving and completed by LPN V. Review of Skin Body Assessment for R 14 dated 09/16/21 revealed no areas of skin impairment was checked and the assessment was completed by RN U. On 9/21/21 at 8:31 AM an observation of care for R 14 was completed. Certified Nursing Assistants (CNA) S and T were providing care. CNA T said she worked last Thursday and R 14 had an open area on her butt on Thursday that was about dime size. Today the area is still open but less than dime size. The open area is at the upper gluteal fold right side. CNA T has been putting [MEDICATION(S)] cream on the open area. R 14's entire body was viewed to have red blotchy areas her back, chest and arm are the worst areas. In general, her feet appeared to be scaly and dry. R 14 was also viewed to have an unstageable blister on her right foot (ball area) approximately 2 cm by 0.5 cm. The skin concerns were reported to LPN (Licensed Professional Nurse) C. On 9/21/21 at 8:41 AM the NHA (Nursing Home Administrator) was informed the pressure ulcer list was not accurate and asked again for an accurate list. The NHA was made aware R 14 has pressure ulcer and she was not on the pressure ulcer list provided. On 09/21/21 at 10:55 AM an interview was completed with the assistant director of nursing (ADON) J, who was also the wound nurse. Documents related to R 14's skin was discussed. ADON J stated that the initial skin assessment completed when R 14 admitted to the facility shows she had a wound on her coccyx region, but no one created an event related to the wound, so it was not tracked and measured and the doctor was not informed so orders for treatment were not entered. ADON J acknowledged that several different subsequent skin assessments had been completed and the coccyx wound was not noted in any of them. ADON J was informed that an observation of R 14's skin had been made a couple hours ago and R 14 was viewed with the coccyx wound as well as an unstageable blister on her foot. ADON J stated she had not been informed of the new wound yet and stated they have a concerning communication breakdown and she should have been made aware of the new wound. The baseline care plan for R 14 was briefly reviewed with ADON J and she was asked how it could be determined when it was completed and who was present, ADON J stated she would check on this and would follow up if she found any further information. ADON J had not brought a current care plan for R 14 to review and admitted that interventions related to R 14 having a pressure ulcer were not there, and only prevention measures were mentioned in the care plan. On 09/22/21 at 10:55 AM R 14 was found in bed, moaning, and said my crack hurts, and she clarified her butt and lower back area were in pain. RN (Registered Nurse) H was informed about R 14's discomfort stated it was probably time to turn her and would check on her as soon as she could. Review of facility provided Baseline Care Plan for R 14 revealed it was not signed or dated by any participant and no participants were listed. Pressure sore/skin at risk' was checked and the location was listed as coccyx. Listed prevention was turn q (every) 2 hr (hours). On 9/21/21 at 3:39 PM and email was sent to the NHA: For [R 14] I have a baseline care plan but no indication or proof of when it was completed or who was present, do you have any further information on this? No additional information was provided by the facility regarding the base line care plan by the exit of survey. Review of R 14's orders revealed an order began on 08/25/21: Skin Assessment Weekly .Once a Day on Thu. Another order began on 08/20/21: DIABETIC FOOT CHECK: Daily (inspect for concerns/change in condition) . An order was added on 9/21/21: [MEDICATION(S)] oxide to coccyx q (every) shift. An order was added 09/22/21: Bilateral lower extremity apply moisturizing cream. Twice A Day. Review of R 14's care plan revealed the problem: Resident has a Stage 2 coccyx with potential for infection and discomfort and interventions was not added until 9/21/21. There was no intervention or problem listed specific to the unstageable wound found on R 14's foot. A problem with the start date 8/20/2021 was Pressure Ulcer Resident is at risk for pressure ulcers . Interventions included Conduct a systemic skin inspection eekly (weekly) ., Encourage frequent position changes when in bed, report any signs of skin breakdown . Another problem listed with a start date of 8/27/2021 was: Resident is a Nutritional/Hydration risk r/t (related to) Sacral region stage I . Resident #63 A review of Resident #63's Face Sheet, dated 9/20/21, revealed Resident #63 was an [AGE] year-old resident admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #63's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 9/7/21, revealed Resident #63 had a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 7 which revealed Resident #63 was severely cognitively impaired. In addition, Resident #63's MDS revealed Resident #63 needed extensive assistance (resident involved in activity, staff providing weight-bearing support) of one person for bed mobility. Resident #63's MDS also revealed, at the time of the assessment, Resident #63 was At Risk for pressure ulcers, but none were noted. A review of Resident #63's Braden Scale (a scale used to determine pressure ulcer risk), dated 9/2/21, revealed Resident #63 had a score of 18. This score revealed Resident #63 was at Risk for developing pressure ulcers. A review of Resident #63's progress notes, dated 8/31/21 to 9/21/21, revealed the following: - Social Work note, dated 9/13/21, revealed, Received a call from [name of Resident #63's daughter] asking about the blister than had broken on resident's heel. While SS (social services) conversated with her for a bit to continue with building rapport; deferred to ADON (Assistant Director of Nursing)regarding the wound. Call t/f (transferred) to ADON. - Registered Nurse (RN) note, dated 9/11/21, revealed, right heal noted to be raw looking during shower. area covered with [MEDICATION(S)] (a type of bandage). A review of Resident #63's skin and wound assessments, dated 8/31/21 to 9/21/21, revealed the following: - Skin Assessment, dated 9/16/21, revealed Resident #63 had a right heel blister. No measurements were noted. - Non-Pressure Sore assessment form, dated 9/11/21, revealed Resident #63 had an open right heel blister measuring 2 cm (centimeters). - Skin Assessment, dated 9/10/21, revealed Resident #63 had a Heel skin impairment. No location (e.g. right or left) or measurements were noted. - Skin Assessment, dated 9/3/21, revealed Resident #63 did not have any skin issues. During an interview on 9/21/21 at 11:00 AM, ADON J stated she was the wound nurse. She stated she was told by Resident # 63's daughter that Resident #63 was admitted to the facility with a closed heel blister. ADON J was asked if the closed heel blister was noted on Resident #63's admission skin assessment when she was admitted to the facility. ADON J stated, probably not. Requested copies of all measurements and skin assessments, dated 8/31/21 to 9/21/21 from ADON J. The facility failed to provide any additional documentation related to Resident #63's right heel blister (besides what was noted above) prior to the conclusion of the survey and exit from the facility. A review of the Staging Classification per National Pressure Injury Advisory Panel, revised 3/2021, revealed, A pressure injury is localized damage to the skin and 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 . Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis (top layer of skin). The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister . These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. A review of the facility's Pressure Injury Prevention and Care policy and procedure, revised 3/2021, revealed, 5. Pressure injuries will be assessed and documented upon admission, re-admission, upon discovery, and weekly thereafter. Assessment may include the size, location, category/stage, odor (if any), drainage (if any), per-wound condition, wound edges, undermining, tunneling, exudate, pain, and current treatment order.

Based on observation, interview, and record review, the facility failed to ensure adequate and timely documentation and physician notification of a pressure ulcer in 1 resident (R14), and of a significant weight loss in 1 resident (R 6) of 6 residents reviewed, resulting in physician being uniformed of resident medical conditions and not ordering treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: R 14 Review of face sheet retrieved from the facility Electronic Medical Record on 9/19/21 for R 14 revealed she was a ninety-four-year-old resident who admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R 14 admission Minimum Data Set (MDS) record dated 8/26/21 revealed in Section M-Skin that she entered the facility with a Stage 2 pressure ulcer. Listed treatments included pressure reducing devices for the bed and chair and applications of ointments/medications. Review of the initial matrix provided by the facility on 9/19/21 revealed R 14 triggered for pressure ulcers. A subsequent corrected facility matrix that was provided on 9/20/21 showed no trigger for pressure ulcer for R 14. Review of R 14's progress notes revealed a note from 8/20/21 at 9:44 PM: Resident arrived at 4:15pm via ambulance .One small 0.5 cm dia. Stage 2 pressure area noted at the coccyx Review of R 14's Skin Check sheet revealed a diagram with notations regarding R 14's skin condition on 8/20/21. A Stage II 0.5 cm was marked on the coccyx area. Several more spots were noted on the resident's back and buttocks but were not labeled with what the spots were. The skin check was signed by RN U. Review of the New Admission Nurse to Nurse Report for R 14 revealed under the section skin .open areas: coccyx stage II. Review of the Medical Staff Assessment for R 14 signed by Physician L on 8/23/21 revealed under the Physical Exam Skin/Lymph section that R 14's skin was intact See NSG (nursing) full skin assessment. The Impression/Plan section made no mention of skin integrity or pressure ulcers. Review of Skin Body Assessment for R 14 observed 08/25/21 and completed 08/27/21 revealed skin impairments with the narrative: Stage 2 pressure ulcer on coccyx, red rash spread across back, bruises on left and right buttocks and created by LPN W but completed by the Director of Nursing. Review of Skin Body Assessment for R 14 dated 08/26/21 revealed skin impairments with the narrative: Resident with red areas on different parts of her body, receiving antibiotic treatment to left hip for left hip [CONDITION(S)] and completed by LPN V. There was not a skin assessment completed for R 14 from 08/26/21-09/09/21, a two week period. Review of Skin Body Assessment for R 14 dated 09/09/21 revealed skin impairments with the narrative: rash continues with redness, left hip [CONDITION(S)] resolving and completed by LPN V. Review of Skin Body Assessment for R 14 dated 09/16/21 revealed no areas of skin impairment was checked and the assessment was completed by RN U. On 9/21/21 at 8:31 AM an observation of care for R 14 was completed. Certified Nursing Assistants (CNA) S and T were providing care. CNA T said she worked last Thursday and R 14 had an open area on her butt on Thursday that was about dime size. Today the area is still open but less than dime size. The open area is at the upper gluteal fold right side. CNA T has been putting [MEDICATION(S)] cream on the open area. R 14's entire body was viewed to have red blotchy areas her back, chest and arm are the worst areas. In general, her feet appeared to be scaly and dry. R 14 was also viewed to have an unstageable blister on her right foot (ball area) approximately 2 cm by 0.5 cm. The skin concerns were reported to LPN (Licensed Professional Nurse) C. On 9/21/21 at 8:41 AM the NHA (Nursing Home Administrator) was informed the pressure ulcer list was not accurate and asked again for an accurate list. The NHA was made aware R 14 has pressure ulcer and she was not on the pressure ulcer list provided. On 09/21/21 at 10:55 AM an interview was completed with the assistant director of nursing (ADON) J, who was also the wound nurse. Documents related to R 14's skin was discussed. ADON J stated that the initial skin assessment completed when R 14 admitted to the facility shows she had a wound on her coccyx region, but no one created an event related to the wound, so it was not tracked and measured and the doctor was not informed so orders for treatment were not entered. ADON J acknowledged that several different subsequent skin assessments had been completed and the coccyx wound was not noted in any of them. ADON J was informed that an observation of R 14's skin had been made a couple hours ago and R 14 was viewed with the coccyx wound as well as an unstageable blister on her foot. ADON J stated she had not been informed of the new wound yet and stated they have a concerning communication breakdown and she should have been made aware of the new wound. The baseline care plan for R 14 was briefly reviewed with ADON J and she was asked how it could be determined when it was completed and who was present, ADON J stated she would check on this and would follow up if she found any further information. ADON J had not brought a current care plan for R 14 to review and admitted that interventions related to R 14 having a pressure ulcer were not there, and only prevention measures were mentioned in the care plan. On 09/22/21 at 10:55 AM R 14 was found in bed, moaning, and said my crack hurts, and she clarified her butt and lower back area were in pain. RN (Registered Nurse) H was informed about R 14's discomfort stated it was probably time to turn her and would check on her as soon as she could. Review of facility provided Baseline Care Plan for R 14 revealed it was not signed or dated by any participant and no participants were listed. Pressure sore/skin at risk' was checked and the location was listed as coccyx. Listed prevention was turn q (every) 2 hr (hours). On 9/21/21 at 3:39 PM and email was sent to the NHA: For [R 14] I have a baseline care plan but no indication or proof of when it was completed or who was present, do you have any further information on this? No additional information was provided by the facility regarding the base line care plan by the exit of survey. Review of R 14's orders revealed an order began on 08/25/21: Skin Assessment Weekly .Once a Day on Thu. Another order began on 08/20/21: DIABETIC FOOT CHECK: Daily (inspect for concerns/change in condition) . An order was added on 9/21/21: [MEDICATION(S)] oxide to coccyx q (every) shift. An order was added 09/22/21: Bilateral lower extremity apply moisturizing cream. Twice A Day. Review of R 14's care plan revealed the problem: Resident has a Stage 2 coccyx with potential for infection and discomfort and interventions was not added until 9/21/21. There was no intervention or problem listed specific to the unstageable wound found on R 14's foot. A problem with the start date 8/20/2021 was Pressure Ulcer Resident is at risk for pressure ulcers . Interventions included Conduct a systemic skin inspection eekly (weekly) ., Encourage frequent position changes when in bed, report any signs of skin breakdown . Another problem listed with a start date of 8/27/2021 was: Resident is a Nutritional/Hydration risk r/t (related to) Sacral region stage I . R 6 Review of R 6's face sheet revealed he was a [AGE] year old male resident who most recently admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 09/19/21 at 12:45 PM an interview was completed with R 6 in his room. He appeared to be very thin and small in stature. R 6 presented with some confusion and often when asked questions would talk about various unrelated topics. Review of R 6's MDS (Minimum Data Set) records revealed he initially admitted to the facility on [DATE], discharged to the hospital on 05/01/21 and then readmitted on [DATE]. Review of R 6's admission assessment dated [DATE] revealed in section K he had a weight of 165 lbs. Review of R 6's quarterly MDS dated [DATE], in section K he is coded as having a weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months. His most recent weight is recorded as 133 pounds. Review of R 6's vital signs in the electronic medical record (EMR) revealed he was not weighed on his initial admission on 4/29/21, but a height was entered. The first weight for R 6 was documented 05/08/21 at 2:08 AM as 165 lbs. The next recorded weight was on 7/15/21 at 1:31 PM as 133 lbs. The next weight was taken on 8/27/21 at 11:20 AM and was 131 lbs. The next weight was 9/14/21 at 9:15 AM and was 127 lbs. He was reweighed on 09/14/21 at 3:23 PM and this was also 127 lbs. Review of R 6's Hospital discharge paperwork from a hospital stay from 05/01/21-05/07/21 revealed one of his diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The document also contained results for R 6's echocardiography report completed 5/1/21 which had a weight of 75 kg or 165 lbs noted. Review of R 6's food intake logs revealed frequent meals with less than 50% intake and many meals not entered. Snacks were sporadically entered. For the month of May 2021, starting from 5/8/21 out of 72 meals and 24 snacks, approximately 4 meals or snacks were noted as not taken or none, approximately 5 meals were noted as 1-25% consumed, approximately 12 meals were noted as 26-50% consumed and approximately 31 meals were not logged at all. Snacks were not logged on approximately 20 days. For the month of June 2021 out of 90 total meals and 30 total snacks approximately 2 meals or snacks were noted as not taken or none, approximately 9 meals were noted as 1-25% consumed, approximately 11 meals were noted as 26-50% consumed and approximately 50 meals were not logged at all. Snacks were not logged on any day in June. For the month of July 2021 out of 93 total meals and 31 total snacks approximately 1 meals or snacks were noted as not taken or none, approximately 13 meals were noted as 1-25% consumed, approximately 29 meals were noted as 26-50% consumed and approximately 16 meals were not logged at all. Snacks were not logged 24 days. For the month of August 2021 out of 93 total meals and 31 total snacks approximately 0 meals or snacks were noted as not taken or none, approximately 16 meals were noted as 1-25% consumed, approximately 13 meals were noted as 26-50% consumed and approximately 28 meals were not logged at all. Snacks were not logged 23 days. For the month of September 2021 from the 1st through the 21st out of 63 total meals and 21 total snacks approximately 0 meals or snacks were noted as not taken or none, approximately 11 meals were noted as 1-25% consumed, approximately 9 meals were noted as 26-50% consumed and approximately 29 meals were not logged at all. Snacks were not logged 19 days. Review of R 6's progress notes revealed limited notes regarding his dietary needs. There was a note from Dietary Manager (DM) M from 5/19/21: Nutr note: ht 68 in, wt 165#, BMI 34.63, class I obese. Res has dx of dysphagia, had video swallow while in the hospital, family elected no tube feeding. Res is receiving hospice care. Diet: Pureed consistency solids and Honey thick fluids, res is a vegetarian, likes eggs, cottage cheese and all cheese, yogurt, milk, beans/ rice. Average intake 51-76% .Pro-cal malnutrition. Est needs 2250 cal(kg x 30) 75gP and 2250 cc fluids. Diet plan providing approx. 2325 cal, 100gP and 1900cc fluids. Will continue to honor res preferences and requests. RD to review. A case conference note on 06/08/21 revealed R 6's appetite is poor. A note from 06/14/21 revealed a nursing note: resident uses left arm to pick up right arm and food on right side of tray not touched. repositioned food to left side of table and resident ate remainder. food needs to be placed in front of resident with HOB up tray lowered and food to the left side of tray and resident will eat all of food. puree diet with honey thick liquids, resident enjoys the small cups of honey thick drinks and to be cold, especially lemon resident states. It should be noted this specific information regarding food placement could not be found in the care plan. A note from DM M from 08/13/21 revealed: Quarterly Nutr note: res remains on Pureed consistency food and honey thick fluids(no straws). Intake fluctuates from 1-75%. Res reported to CDM I just can't eat any more. Does enjoy the reduced med pass supplement he receives and consumes this 100%. Res continues with hospice care. BMI 27.92, overweight. Current wt 133#, significant loss Recommend increasing med pass supplement to 6oz QID as res accepts this without difficulty and likes it. This will provide 1260 cal, 60 g P daily. Est needs: 1800 cal(kg x 30) 60-72gP(kg x 1-1.2) and 1800cc fluids. Will continue to coordinate with hospice. The resident's representative was not made aware of R 6's weight loss until 9/21/21 at 5:23 PM. The physician was notified per a note on 5/21/21 at 5:49 PM. The regional dietician (RD N) did not complete a dietary noted regarding R 6 until 9/22/21 at 8:47 AM. Review of R 6's care plan revealed a problem with start date 5/10/21: Resident is a Nutritional/Hydration risk r/t (related to) *mod pro-cal (moderate protein-calorie) malnutrition *dysphasia .*unplanned wt (weight) loss . Approaches included: offer substitutes if consumes less than 50% of meals, RD (dietician) to review PRN (as needed), Weigh every month and/or PRN, notify Dr. of significant change. Review of RN (registered nurse) hospice notes for R 6 from 08/02/21 at 11:32 AM revealed: Pts (patient's) dysphagia continues. He eats a pureed diet. Staff report that he will eat small portions of all 3 meals but prefers the 8 ounces of Ensure-type drink that is provided at med pass time (3 times a day). Staff report that he will drink that entire glass. His arm cric (circumference) has decreased 1 cm since last cert (certification) period (22.5 cm to 21.5 cm), he appears more frail and cachectic (loss of body weight and muscle mass). Muscle wasting noted at temples and on hands. Tendons of hands stick out. Pt is no longer able to wear his own clothes as they are too big for him and instead is provided hospital gowns by staff. Review of physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/10/21 R 6 is noted to be 165 lbs. He is again noted to be 165 lbs on 6/14/21. On 7/15/21 physician L notes: Dysphagia- despite no PEG (feeding tube), he is maintaining his weight and again notes R 6's weight as 165 lbs. On 8/26/21 physician L notes: Dysphagia- not eating well. Weight last visit was probably wrong. Has lost 32 lbs and R 6's weight is noted as 133 lbs. Review of facility provided Weight Variance Report for 03/21/21-09/21/21 revealed documentation for R 6. Between 5/8/21 and 7/15/21 the chart showed in bold print No weight in 83-97 day period and between 7/15/21 and 8/27/21 No weight in 23-37 day period. The chart indicated from 5/8/21 to 9/14/21, R 6 had lost 38 pounds and 23.0% of their body weight in 129 days. On 09/21/21 at 1:35 PM an interview was completed with Regional Dietician (RD) N regarding R 6's weight loss. RD N stated she could not find a progress note in R 6's record that she had reviewed his chart. RD N stated that generally she looks at all new admits, then would review the matrix and look more closely at any resident that flagged for a weight issue or if they have a special condition like a tube feed. The Dietary Manager M will also flag residents that may need extra attention and RD N did not recall this resident being flagged. RD M stated that typically, most residents she would review at least monthly, but for some reason she had not reviewed R 6 since his admission over 4 months ago. RD N stated she would expect weights for residents would be completed at least monthly. R 6's weights were reviewed and RD N agreed it would be likely that he was not weighed at 2:00 AM and staff sometimes don't actually weigh them, they would use the hospital discharge paperwork. It was discussed with RD N that his weight on the hospital discharge papers did not match that weight and there is no indication in the hospital records that R 6 was actually weighed while he was briefly admitted . RD N was able to find an email she stated she wrote on 8/16/21 stating she was re-requesting for more information since the month before for R 6 including a request for a reweigh. RD N could not find the initial correspondence where she requested any information or any additional follow up regarding R 6. RD N stated she would assume the initial weight was wrong, but admitted with no additional weight taken for 2 months there was no way to know exactly how much weight was lost if the initial weight was correct. It was discussed with RD N that many of R 6's intake logs around the time of weight loss indicated frequent intakes of 0-25% and she was informed that hospice notes indicated observations of significant weight loss and RD N admitted that even if the initial weight was incorrect, it was likely that R 6 had a significant weight loss. On 9/21/21 at 2:35 PM an interview was completed with Dietary Manager (DM) M regarding R 6's weight loss. DM M stated that she was aware R 6 had a significant weight loss. DM M stated that R 6 initially admitted with weight concerns and had declined at tube feed so the plan was to just get as much down as we could. It was discussed that many of R 6's food intake logs he had been frequently coded as 0-25% intake on meals and had been trying to increase his intake of things like yogurt, pureed cottage cheese and med pass supplement since those are items he enjoys. DM M stated that R 6 and his weight loss has been repeatedly talked about in morning meeting and the physician should have been notified of the weight loss. DM M stated it would be the job of nursing staff, such as the Director of Nursing, Assistant Director of Nursing or the MDS Nurse to reach out to the doctor when the weight loss was noted. DM M stated it would be her job to reach out to RD N if weight loss was noted with a resident, DM M could not recall if she had talked to RD N regarding R 6. DM M stated she is concerned residents are not having weights taken consistently. DM M stated it had been difficult to get weights consistently done due to staffing. DM M stated she has noticed weights were not always getting done and she was trying to do some herself if the resident did not need assistance with transfers. DM M stated she even brought in her own scale to try to obtain weights but the scale went missing. DM M stated she had been doing her best to help get weights but was exhausted due to the lack of staffing. Review of facility provided policy Weight Monitoring with a last reviewed date of 7/2021 revealed: All residents' height and weight will be determined by the appropriate method and recorded within 24 hours of admission. Weight will be measured monthly. The weight changes of all residents will be monitored monthly. Percentage weight changes will be determined for 30-day, 90-day, and 180-day periods. The procedure includes: 1. Dietician will obtain residents height from nursing 2. Dietician will calculate acceptable body weight range .3. It is the facilities policy that weights be completed and reviewed on a monthly basis. More frequent monitoring may be required due to a residents medical condition. All residents will be weighted upon admission to establish a baseline .4. Procedure: Residents will be weighed monthly in a timely manner (at least by the 10th of each month). Those residents that trigger for a significant weight loss (>5%) from the previous month will be placed on weekly weights. Each resident will be reviewed by the IDT committee and appropriate interventions will be put in place. Prior to the end of each month, the facility RD/CDM/RDT will provide the DON a list of those residents identified and tracked; which residents re-gained the weight and those residents who continue to lose weight .All hospice residents should be weighed a minimum of monthly .RD/CDM/RDT must document on weight gains and losses for those residents that experience 5% for 30 days 7.5% for 90 days and 10% for 180 days in the medical record to meet the professional standards for dieticians .Nursing services is responsible to obtain monthly weights on each resident. Weekly weights will be obtained as indicated. The results are given to the DON, designee or RD/CDM/RDT for input into the computer. Under the section Monthly and Weekly Weights: Monthly weights: conducted on residents whose weight has been stable from the time of admission to current. Weekly weights on residents that: a. Have experienced a significant weight loss/gain as indicated by the weight variance report b. Are newly admitted to the facility regardless of payer c. Are readmitted to the facility d. Have a gradual weight loss over a period of time. Under the section Weighing Procedure: Notify MD of significant weight loss of 5%, 7.5%, 10% .Notify resident representative.

This citation pertains to intake #MI00- 0 Based on interview and record review, the facility failed to provide coordinated quality care for 1 resident (Resident #9) by not providing the resident with an ordered [CONDITION(S)] machine and failing to quickly respond to a change in condition and notify responsible parties in a timely manner of the change of condition, resulting in the need for emergency medical attention including intubation, manual warming of the core body temperature, fluid resuscitation, and admission to the Intensive Care Unit. Findings: Resident #9 (R9) Review of a Face Sheet revealed R9 was a [AGE] year old female, admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R9 had been hospitalized from 05/26/21 to 06/12/21 and was then transferred to the facility. On 05/31/21, while at the hospital, R9 had been intubated due to acute hypercapnic [CONDITION(S)](breathing stopped due to high levels of [MEDICATION(S)]). Review of a (Facility) Nursing and Rehabilitation New/Re-Admission Form (used as a nurse to nurse report document when accepting an admission) reflected Special Equipment Needed- yes- Bi-PAP. Included with the form were settings for the Bi-PAP. Review of an After Visit Summary (discharge instructions from the hospital sent to the nursing facility, for the hospital stay from 05/26/21 to 06/12/21) revealed: Instructions-will need full face Bi-PAP after discharge while sleeping. Bi-PAP settings were included. Review of a nursing Progress Note, dated 06/12/21 at 11:08 A.M., reflected R9 was at the nursing facility and was A&O (alert and oriented) x3. Review of a Critical Admission Assessment, completed on 06/12/21 at 3:26 P.M., reflected the following information about R9 at the time of the admission to the nursing facility: (a) communication was clear, (b) the word alert was used to describe the resident, (c) R9 was oriented to person, and (d) the assessment did not mention the order for a [CONDITION(S)] machine. Review of a Baseline Care Plan, developed at admission, did not include an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an Order History for R9, from 06/12/21 to 06/14/21, did not include an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . There was an order, written 06/13/21, for oxygen per nasal cannula at 2 liters, for resident comfort or oxygen saturation less than 90%. Review of a nursing Progress Note, dated 06/12/21 at 9:43 P.M., reflected .discussed [CONDITION(S)] order with on call supervisor (ADON A). placed oxygen at 2 liters NC(nasal cannula) for this night. During an interview on 07/13/21 at 10:40 A.M., Registered Nurse (RN) F reported working the day of 06/12/21, when R9 was admitted to the facility, called the on-call supervisor to ask about the order for the [CONDITION(S)], and was told to wait on getting the [CONDITION(S)] until Monday because DME (the company that supplies the facility with durable medical equipment) adds an extra charge when they have to come to the facility on the weekend. RN F was told to use oxygen instead for R9. RN F also indicated following up with the Director of Nursing after speaking with the on-call supervisor, because of the questionable instructions given. During an interview on 07/13/21 at 10:00 A.M., ADON A recalled receiving a telephone call from the nurse on duty, 06/12/21, the day R9 was admitted to the facility. ADON A reported the following: (1) advised the staff nurse on duty to utilize oxygen for R9 that evening (06/12/21), (2) called the DME company the next day, Sunday 06/13/21, and left a message, and (3) had not heard back from the DME company by the morning of Monday 06/14/21 and called the company again and had the [CONDITION(S)] sent over to the facility. ADON A recalled that R9 was a little more lethargic and not quite as responsive the morning 06/14/21 and that R9 may have developed hypercapnia without the use of a [CONDITION(S)] was not a consideration. During an interview on 07/12/21 at 10:45 A.M., an employee of the durable medical equipment (DME) company used by the facility, employee I, reported . we received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Work Order # 426 reflected that the DME company received a telephone call on 06/14/21 from ADON A, requesting a new set up for nursing home [CONDITION(S)] system to be dropped off, no instruction was needed. Review of a nursing Progress Note, dated 06/13/21 at 5:47 P.M., reflected .5. informed spouse that we are using oxygen at HS( bedtime) at this time, [CONDITION(S)] is pending at this time. Review of a nursing Progress Note, dated 06/14/21 at 3:38 A.M., reflected that R9 .denies any pain or discomfort. During an interview on 07/09/21 at 2:40 P.M., Speech Language Pathologist (SLP) BB reported arriving to work at 8 A.M. on Monday 06/14/21 and straight away went to assess R9 and found R9 unresponsive and did not have oxygen tubing on. SLP BB spoke with nursing after finding R9 unresponsive and was told by nursing that R9 had some sort of low oxygen event earlier that morning. This was SLP BB's only interaction with R9. Review of a Speech Language Pathology note for R9, dated 06/14/21 and authored by SLP BB, revealed the following: attempted assessment with resident, largely unresponsive, experienced low oxygen event this am, now very lethargic. opening eyes inconsistently to sternal rub (a maneuver used to safely induce a pain response from someone with an altered level of consciousness). Body posture is very stiff, occasional reflexive movement to pain/repositioning. Review of a lab result form, dated 06/14/21 and collected at 5:24 A.M., reflected R9's [MEDICATION(S)] level in the blood was at a critical level of 42. It was unclear when the results were received at the facility and who the results were reported to, as no documentation could be found to answer these questions. Review of a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .M., and the exam took place via video and audio telemedicine, reflected .today (R9) not able to give hx (history), had SOB (shortness of breath), is on O2 NC (oxygen via nasal cannula), CXR (chest X-ray ordered). The progress note did not mention the order for Bi-PAP or that R9 had not had the Bi-PAP for the past 2 nights. The physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a nursing Progress Note, dated 06/14/21 at 1:54 P.M., indicated (R9) responding poorly. no response to painful stimuli. sternal rub. PA (Physician Assistant) J here to see resident. wants her sent to (local hospital) hosp. Husband called and concurs. 911 called and are on the way. VS (vital signs) are stable. Review of an emergency room Physician Note, dated 6-14-21, reflected . R9 arrived to emergency room (ER) at 2:37 P.M. this patient arrives from her nursing home for decreased level consciousness. (R9) started appearing more somnolent around 8 AM this morning and was evaluated by the in-house physician, and ultimately when her responsiveness did not improve by 1:45 she was sent to the ER for further evaluation. She arrives and is completely unresponsive to voice. She does have some spontaneous movements of her legs and arms and some responsiveness to pain but nothing purposeful. Her eyes flutter to pain but do not open, and no verbal response. It sounds like she was supposed be on [CONDITION(S)], it is unclear if she was using this at the facility. She sometimes does choke on her secretions . Etiology of her acute hypercapnic [CONDITION(S)] is multifactorial and secondary to chronic debility, muscle weakness, neuromuscular disease, malnutrition and lack of noninvasive ventilation ([CONDITION(S)]) at subacute rehab (the facility). Review of a Critical Care History & Physical note, dated 06/14/21, revealed .(R9) was discharged on [DATE] to subacute rehab (the facility). She was supposed to use [CONDITION(S)] at night but this device was not ordered by the subacute rehab. She was found to have altered mental status today in the morning and was monitored for several hours before transfer to the ER. In the emergency department, she was found to be completely unresponsive to voice. With bagging she started to have some spontaneous movements of her legs and arms. The patient was intubated shortly after arrival. (R9) was hypothermic (very low body temperature) 91 F, tachypneic (fast rate of breathing) 28, hypotensive (low blood pressure) 81/41, saturating normally on room air. She was completely unresponsive to voice. (R9) required intravenous fluid resuscitation for [CONDITION(S)]. She was emergently intubated for hypercapnic (high levels of [MEDICATION(S)] in the blood) [CONDITION(S)]. Husband gives me most of the history and states he last spoke with her yesterday through a window at the nursing home, between 1-5pm, and she was not confused at all. Initially the nursing home was not giving her any meals per mouth and he had to have (the hospital where she was discharged from on 06/12/21) call them with the orders that she is okay to take per mouth and tube feeds. He was also told that they had ordered for a [CONDITION(S)] machine but it had not arrived yet, so he doesn't believe she used a machine for the past 2 nights .He is extremely disappointed with the care the pt received at (the facility). Review of an Inpatient Consult Pulmonology note, dated 06/15/21 at 6:14 A.M., reflected .(R9) presented with unresponsiveness from nursing home after being discharged there on 6/12 from (the hospital). Per pt and husband, pt was not provided with [CONDITION(S)] machine as they were waiting for it to arrive, and had ordered it. Pt did not use it for the past 2 nights. Pt's CO2 ([MEDICATION(S)]) level was over 120 (normal range 21-31) at time of admission to the ER. She has severe chronic hypercapnia and is a VERY poor ventilator and needs the [CONDITION(S)] every night .(R9's) body temperature was 91 F and required the use of a [NAME] (a machine that blows warm air over and under a patient to increase the body temperature) to warm the patient.

This citation pertains to intake # MI00- 0 and # MI00- 1 Based on interview, and record review, the facility failed to prevent the sexual abuse of 1 resident (Resident #1), resulting in fearfulness, apprehension, anxiety, and anger. Findings: Resident #1 (R1) Review of a Face Sheet revealed R1 was a [AGE] year old male, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 04/29/21 at 10:45 A.M., R1 indicated that a few days ago, a man came into his room, R1 did not ask the man to come into his room, and the man touched his pee-pee (penis). R1 stated he yelled help and that the incident made him feel mad. Resident #2 (R2) Review of a Face Sheet revealed R2 was a [AGE] year old male who originally admitted to the facility on [DATE]. During an interview on 04/29/21 at 11:00 A.M., R2 stated the other guy motioned me in (the room), pretty soon we were both naked, R2 stated that he touched R1's penis, and then someone came in and it all stopped. During an interview on 04/29/21 at 11:30 A.M. the Director of Nursing (DON), who was working in the facility at the time of the incident, reported the following regarding the incident between R1 and R2: (a) the resident's were separated immediately, (b) the DON did full assessments on both residents, (c) R2 was moved to a private room on the other side of the facility and was placed on a 1:1, (d) the Administrator and the police were notified, (e) staff were made aware of the need to keep R2 away from R1 and that R2 must be under staff supervision when out of the room, (f) care plans were updated to reflect the current needs for both residents, and (g) the facility requested behavioral health services to consult and assess both residents as soon as possible. The DON indicated that staff have had no concerns with R2 and any sexual acting out, gesturing, or behaviors prior to this incident. During an interview on 04/29/21 at 12:05 P.M., Registered Nurse (RN) D reported working the day of the incident, 04/25/21, and described the sequence of events as follows: (1) RN D heard R1 yell help and get away and ran into R1's room, (2) RN 'D observed the curtains pulled closed around R1's bed, (3) RN D opened the curtains and observed R2 on R1's bed with pants and brief down below the knees and R2's hand down the front of R1's pants, (4) RN D observed R1 trying to move away from R2, and (5) staff stopped R2, assisted R2 with getting out of the bed and with pulling up the brief and pants, and separated the two residents. RN D reported that R1 was trying so hard to get away from R2 and that earlier during the day on 04/25/21, R2 had been hang outside R1's room and at one point had tried to close the door to R1's room, but was unable to because of the equipment at the end of the bed nearest the door. During an interview on 04/29/21 at 2:00 P.M., R1's guardian indicated that the facility had notified him that there was an incident involving another male resident but was not told about any sexual contact between the two residents. During an interview on 04/29/21 at 2:30 P.M., Physical Therapy Assistant (PTA) N reported having worked with R1 during the past week and that R1 has talked about it (the incident on 04/25/21 involving R2). PTA N indicated that R1 needed reassurance that (R1) was safe and had asked questions such as; is somebody gonna do that to me again, they aren't are they? Review of a Physician's Progress Note for R1, dated 04-29-21, reflected the following: Notification made to myself that this patient was sexually approached by another male patient with subsequent fondling occurring. During an interview on 04/30/21 at 10:35 A.M., Detective P indicated interviewing both R1 and R2. Detective P stated (a) that both R1 and R2 reported that oral sex had occurred, (b) that R1 told the detective that (R2) sucked on it and it made R1's body feel bad, and (c) that R2 thought R1 was gay and that he was into it. Review of a facility policy Abuse Prevention Program, last revised 11/2018, reflected the following: INTENT: Each resident has the right to be free from abuse, neglect and corporal punishment of any type by staff or anyone . DEFINITIONS: Sexual Abuse, is defined as non-consensual sexual contact of any type with a resident.Resident to Resident Abuse: A resident to resident altercation should be reviewed as a potential situation of abuse. The facility Administrator and or Director of Nursing will initiate an investigation of a potential allegation of abuse between residents. Investigations for potential abuse will not be dismissed in cases where either or both residents have a cognitive impairment or mental disorder. Having a mental disorder or cognitive impairment does not automatically preclude a resident from engaging in deliberate or non-accidental actions. During the investigation it will be identified that the actions were willful were deliberate (not inadvertent or accidental), regardless of whether the individual intended to inflict injury or harm.Sexual Abuse-is non-consensual sexual contact of any type with a resident.

Based on observation, interview, and record review, the facility failed to implement measures to prevent or improve pressure ulcers in 1 (Resident # 5) reviewed for pressure sores, resulting the worsening of pressure sores. Findings include: Resident #5 Review of a Face Sheet for Resident #5 revealed a [AGE] year-old female originally admitted on [DATE] with pertinent [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #5 was severely cognitively impaired and was totally dependent on 2 staff for transfers and had a stage 3 pressure ulcer. During an observation on 5/13/19 at 1:40 p.m., Certified Nursing Assistant (CNA) J and CNA K performed incontinence care for Resident #5. Resident # 5 had a bowel movement and a white cotton [MEDICATION NAME] island dressing was on the residents' coccyx that covered a pressure sore and was damp and not adhered to the cleft of her buttock which could allow bodily fluids and excretions to enter the wound. Both CNA's reported the resident had a shower earlier that morning and the dressing may have come off at that time. Registered Nurse (RN) BB removed the old dressing from the resident and cleansed area. The nurse reported the wound was approximately the depth of the tip of the cotton swab and about 2 centimeters in width (approximately dime sized width), no drainage noted, rolled edges with possible tunneling. No slough or eschar noted. The nurse put approximately 6 inches of [MEDICATION NAME] gauze strip (a gauze that removes necrotic tissue from pressure wounds) inside the wound and then covered it with a Derma Levin dressing (an absorbent, waterproof dressing). RN BB reported they could use either dressing to cover the pressure ulcer and it was the preference of the nurse. RN BB reported the residents pressure ulcer opened again about 8-10 months ago and would need surgical interventions to close the wound and the family did not want that intervention. Review of Physician orders [REDACTED].#5 revealed: Wound treatment to coccyx: 1. Cleanse wound with wound cleanser 2. Pack wound bed with [MEDICATION NAME] gauze 3. Cover with 4x4 gauze 4. Cover 4x4 with Dermalevyn (dressing) change daily and prn (as needed). In an interview on 5/13/19 at 4:30 p.m., a request made to the Director of Nursing for a timeline of Resident #5's pressure ulcer and any supporting documentation for the next morning. On 5/14/19 at 11:00 a.m., this surveyor received a timeline for the year (YEAR). Requested documentation from the last year again and received documentation at approximately 4:00 p.m. prior to exit. Review of a Physicians Progress Note dated 8/2/18 for Resident #5 revealed: 2. Coccyx decub ulcer is nearly healed now, becoming difficult to get gauze into the wound (sic) Review of a Weekly Pressure Ulcer Progress Report dated 8/3/18 for Resident #5 revealed the resident had a stage 3 pressure ulcer on her coccyx that measured 0.3 cm (centimeters) x 0.3 cm x 0.1 cm. Review of a Weekly Pressure Ulcer Progress Report dated 8/8/18 for Resident #5 revealed: revealed the resident had a stage 3 pressure ulcer on her coccyx that measured 0.5 cm x 0.5cm x 0.7cm. Review of a Weekly Pressure Ulcer Progress Report dated 8/16/18 for Resident #5 revealed: revealed the resident had a stage 3 pressure ulcer on her coccyx that measured 1.0cm x 1.0cm x 1.5cm. Review of a Physicians Progress Note dated 8/21/18 for Resident #5 revealed: Seen at request of nursing to evaluate sacral pressure ulcer. Was nearly closed but is a little deeper Sacral PU (pressure ulcer) slightly worse this week than 2 weeks, but overall, I am very pleased. Continue pressure relief and current dressing (changes). (sic) Review of a Weekly Pressure Ulcer Progress Report dated 11/7/18 for Resident #5 revealed: revealed the resident had a stage 3 pressure ulcer on her coccyx that measured 0.8 cm x 0.8 cm x 0.5 cm. Review of a Weekly Pressure Ulcer Progress Report dated 11/14/18 for Resident #5 revealed: revealed the resident had a stage 3 pressure ulcer on her coccyx that measured 2.0 cm x 2.0 cm x 1.0 cm. Review of a Weekly Pressure Ulcer Progress Report dated 11/20/18 for Resident #5 revealed: revealed the resident had a stage 3 pressure ulcer on her coccyx that measured 1.0 cm x 1.0 cm x 1.0 cm. Review of a physician progress notes [REDACTED].#5 revealed: 1. Coccyx decub ulcer making good progress toward healing. No evidence of infection. No Weekly Pressure Ulcer Progress Reports received after 11/29/19 until 12/27/19. Review of a Weekly Pressure Ulcer Progress Report dated 12/29/18 for Resident #5 revealed: revealed the resident had a stage 3 pressure ulcer on her coccyx that measured 0.5 cm x 0.5 cm x 0.3 cm. Review of a Weekly Pressure Ulcer Progress Report with observation dates of 1/3/19, 1/10/19, 1/17/19, 1/24/19, 1/31/19, 2/7/19, 2/14/19, and 2/20/19 all had completion dates of 2/27/19. Review of a Weekly Pressure Ulcer Progress Report dated 1/10/19 for Resident #5 revealed: revealed the resident had a stage 3 pressure ulcer on her coccyx that measured 0.5 cm x 0.5 cm x 0.5 cm. Physician notified on 1/9/19. Review of a physician progress notes [REDACTED].#5 revealed no assessment, evaluation, or orders for a pressure ulcer. Review of a Weekly Pressure Ulcer Progress Report dated 2/2/19 for Resident #5 revealed: revealed the resident had a stage 3 pressure ulcer on her coccyx that measured 1.0 cm x 1.0 cm x 0.5 cm. Completion date was 4/3/19 and physician notified on 2/27/19. Review of a Weekly Pressure Ulcer Progress Report dated 4/10/19 for Resident #5 revealed: revealed the resident had a stage 3 pressure ulcer on her coccyx that measured 1.0 cm x 1.0 cm x 0.3 cm. Completion date of 5/1/19 and physician notified on 4/10/19. Review of a physician progress notes [REDACTED].#5 revealed no assessment, evaluation, or orders for a pressure ulcer. Review of a Weekly Pressure Ulcer Progress Report dated 5/7/19 for Resident #5 revealed: revealed the resident had a stage 3 pressure ulcer on her coccyx that measured 1.0 cm x 1.0 cm x 0.5 cm. Physician notified on 5/1/19. No new treatments ordered since 3/29/18. Review of the Care Plan for Resident #5 revealed: Pressure Ulcers, start date 11/22/17, Resident has a stage 3 to coccyx with potential for infection and discomfort. Goal: Ulcer will decrease in size by 1 centimeter quarterly, goal date is 7/6/19. Approach: Resident followed by wound clinic as needed.

This deficient practice statement has 2 parts. 1. Based on observation, interviews, and record review, the facility failed to provide (A) aspiration precautions, (B) an effective call light system, and (C) safe bed transfers for 1 of 6 sampled residents (Resident #39) reviewed for accident/falls, resulting in Resident #39 contracting aspiration pneumonia and being placed at risk for choking, bodily injury/falls, and unmet needs. Findings include: Resident #39 (A.) Review of a Face Sheet revealed Resident #39 was a [AGE] year old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. During an observation on 06/06/18 at 08:01 A.M., Resident #39 received supplement med pass 2.0 with her morning medications. Immediately after Resident #39 drank the supplement, Licensed Practical Nurse (LPN) I lowered the head of the bed for Resident #39 below 30 degrees and left the room. Review of Medication Administration Record [REDACTED]. During an interview on 06/06/18 at 12:21 P.M., Director of Nursing (DON) C stated that Resident #39 is at a very high risk for aspiration pneumonia if the head of the bed is not elevated between 30-45 degrees for at least 30 minutes after Resident #39 has anything to eat or drink. DON C indicated that Resident #39 had just recently been treated for [REDACTED]. Review of Resident #39's care plans, as provided by the facility, revealed there was not a specific care plan to address the resident's high risk for aspiration pneumonia. Review of an Interdisciplinary Progress Note, dated 5/30/18 and written by Physician Assistant (PA) BB , revealed that Resident #39 was seen for an increased cough over recent days and was a high risk for aspiration pneumonia, +fever +yellow sputum, will treat with antibiotics. Review of a New Antibiotic Order, dated 05/30/18, revealed that Resident #39 was started on [MEDICATION NAME] 875 milligrams twice daily for five days for a [DIAGNOSES REDACTED]. During an interview on 06/06/18 at 11:04 A.M., Certified Nurse Aid (CNA) AA stated that she was not aware of any precautions that were needed for Resident #39 to prevent choking or aspiration. During an interview on 06/06/16 at 11:46 A.M., PA BB indicated that aspiration precautions for Resident #39 would really be a good idea. During an interview on 06/06/18 at 1:15 P.M., Family Member (FM) Z stated that he has observed on several occasions that staff gave Resident #39 something to drink and then immediately put the head of the bed down. (B.) During an observation on 06/04/18 at 7:40 A.M. , Resident #39 was asked if she could demonstrate how she uses her flat pressure pad call light and was not able to do so. During an interview at the same time, Resident #39 stated no she was not able to use her flat pressure pad call light to get help if needed. Resident #39 also stated I don't know when asked how she would get help if it was needed. During an interview on 06/05/18 at 6:15 P.M., Licensed Practical Nurse (LPN) X stated that Resident #39 was able to use the flat pressure pad call light. She can use it. LPN X also indicated that she had never actually seen Resident #39 use the flat pressure pad call light. During an observation on 06/05/18 at 6:26 P.M., LPN X was present in Resident #39's room when Resident #39 was asked to activate her flat pressure pad call light. Resident #39, after multiple requests from staff, was not able to activate the call light. LPN X stated This will not work for her at all. During an interview on 06/06/18 at 11:02 A.M., CNA AA stated that Resident #39 was able to use her flat pressure pad call light when we place it right here on her chest. CNA AA also indicated that she had never actually seen Resident #39 use her flat pressure pad call light. During the same interview, CNA AA indicated that the resident was checked on every 2 hours for positioning needs. Review of Resident #39's OT/PT progress notes revealed (A) that therapy was preformed from 10/21/17 to 11/17 /17, and (B) that Resident #39 was evaluated by OT/PT on 10/21, 10/23, 10/24, 10/25 with no mention of her ability or inability to use a call light effectively to alert staff. Review of OT Daily Treatment Note, dated 10/27/17, revealed OT to continue to assess for pt ability to alert staff as she has difficulty with pressure pad call light. OT to continue to assess alternative style pressure pads for call light. Review of Resident #39's OT/PT progress notes revealed that Resident #39 was evaluated by OT/PT on 10/30, 10/31, 11/01, and 11/02 with no mention of her ability or inability to use a flat pressure pad call light effectively to alert staff. Review of OT Daily Treatment Note, dated 11/03/17, revealed Pt (patient) currently has flat pressure call light but she is not able to engage light consistently due to motor planning or coordination deficits. Review of OT-Therapist Progress, dated 11/03/17, revealed goal Safety .***NEW GOAL on 11/3/2017**The patient will demonstrate ability to independently use call light 100% of the time following modifications to call light style.Current Level of Function .The patient requires max assist for use of flat pressure style call light. Goal Date listed as 12/21/17. No additional documents were available related to goal date of 12/21/17. Review of Resident #39's OT/PT progress notes revealed that Resident #39 was evaluated by OT/PT on 11/06, 11/07, 11/08, 11/09, 11/10, 11/13, 11/14, 11/15, 11/16 and 11/17/17 with no mention of her ability or inability to use a flat pressure pad call light effectively to alert staff and no documentation of an assessment that was done related to an alternative style of call light that Resident #39 could use effectively. Review of Resident #39's OT/PT progress notes revealed that on 11/17/17 Resident #39 was to dc from OT due to plateau in progress and no further gains anticipated with continued skilled treatment due to underlying medical diagnosis. Pt will benefit most from time spent lying down or positioned sitting up in bed with current alternating air pressure mattress. Review of Resident #39's OT-Therapist Progress & Discharge Summary, dated 11/17/17, revealed the section for Safety .The patient will demonstrate ability to independently use call light 100% of the time following modifications to call style light. Start of Goal Status'', Prior Level, and End of Goal Status under Safety all were documented as The patient requires max assist for use of flat pressure style call light. (C) During an observation on 06/06/18 at 11:00 A.M., CNA AA repositioned Resident #39 in bed with only one staff person. Resident #39 was moved from her right side to her left side without a staff person to monitor her left arm, which became pinned underneath her left hip and thigh. During an interview in 06/06/18 at 11:02 A.M., CNA AA stated that she often repositions Resident #39 alone. Review of Care Plan .Category Falls . Approach .Call light to be within reach .instruct and remind to use call light to ask for assistance .and hand written on the bottom of the page, dated 1-31-18, 2 assists with transfers. Review of Occupational Therapy Plan of Care and OT Daily Treatment Note, dated 05/22/18 to 05/28/18, revealed Resident #39 had very limited range of motion in her left upper extremity and had endorsed pain with certain degrees of flexion or extension. 2. Based on observation, interview, and record review, the facility failed to analyze the cause of a fall, implement fall prevention measures and assess for the need for increased supervision for 1 resident (Resident #158) of 3 Residents reviewed for falls, resulting in Resident #158 having avoidable falls. Resident #158 Review of Resident #158's face sheet revealed she was an [AGE] year old female, admitted to the facility on [DATE], and had the following Diagnoses: [REDACTED]. Resident #158 was not her own responsible party. On 06/06/18 at 11:22 AM, Resident #158 was observed sitting in a wheel chair in the Physical Therapy room doing leg stretching exercises with Physical Therapy Assistant (PTA) M. Therapy Manager, Physical Therapist (PT) L stated that Resident #158 had been at the facility for 2 to 3 weeks. PT L said Resident #158 had been hospitalized for [REDACTED]. Resident #158 had a pressure alarm on the back of her wheel chair. Review of Resident #158's Safety Events - Fall Event documentation revealed that Resident #158 had 3 falls since admission (5/18/18, 5/23/18 and 5/31/18). Documentation did not include(A) who was caring for Resident #158 at the time of each fall, (B) if the fall care plan was being followed at the time of each fall, (C) what the condition was of Resident #158 prior to each fall and, (D) what was the root cause of the falls. Review of Resident #158's fall care plan, dated 5/14/18 documented, Resident at risk for falling R/T (related to) incontinence, cognition, immobility, mediation, [MEDICAL CONDITIONS] ([MEDICAL CONDITION]), DM (diabetes mellitus) wounds, Foley and PICC (peripherally inserted central catheter). No new interventions were implemented after the falls on 5/18/18 or 5/23/18. A new intervention was noted on 5/31/18 that documented, patient must not be left in room alone after an outside source has left, they must inform nursing. During an interview with the Director of Nursing (DON) C on 6/6/18 at 1:50 PM, Resident #158's fall documentation was reviewed with DON C. DON C confirmed she did not have witness statements or any documentation to confirm Resident #158's fall care plan was being followed at the time of the 3 falls. DON C could not locate a root cause of the 3 falls or any information on the Resident #158 condition/care care prior to the fall that would assist in forming a root cause analysis. DON C could not locate any new interventions placed in Resident #158's fall care plan after the falls on 5/18/18 and 5/23/18.

Based on observation, interviews, and record review, the facility failed to provide prompt dental services for 1 of 2 residents (Resident #46) reviewed for dental care, resulting in Resident #46 experiencing pain, difficultly eating and the potential for spread of infection. Findings include: Review of Resident #46's face sheet revealed he was a [AGE] year old male admitted to the facility on [DATE] and had the following Diagnoses: [REDACTED]. Review of Resident #46's Brief Interview of Mental Status (BIMS) score, dated 5/5/18, revealed he scored 13/15 (normal cognition). On 6/6/18 at 9:00 A.M., Resident #46 was observed in the dining room. Resident #46 complained of having an abscessed tooth for weeks that was causing him pain, difficulty eating and spitting up pus. Resident #46 pointed to the left side of his mouth and his left cheek appeared slightly swollen. Resident #46 said he had been telling nursing about the problem and he was told the dentist would come in to see him but he did not know when that was going to happen. During an interview with Assistant Director of Nursing (ADON) G on 6/6/18 at approximately 9:10 AM, ADON G stated she just found out Monday (6/4/18) that Resident #46 was having dental problems and ADON G said the doctor supposed to see him on 6/4/18. ADON G could not locate any documentation in Resident #46's medical record that he had been seen by the doctor on 6/4/18. ADON G could not find any documentation that Resident #46's Physician had been informed of his dental concerns. Review of Resident #46's nursing progress note, dated 5/26/18 at 10:44 PM (12 days prior), revealed Resident #46 had complained of mouth pain to Licensed Practical Nurse LPN X. Review of Resident #46's nursing progress note, dated 5/28/18 at 9:24 PM, revealed Resident #46 had complained of tooth pain to Licensed Practical Nurse LPN X. Review of Resident #46's nursing progress note, dated 5/31/18 at 10:56 PM, revealed Resident #46 had complained to LPN X of pain on the left side of his mouth and continued to have a toothache. Review of Resident #46's nursing progress note, dated 6/5/18 at 10:25 PM, revealed Resident #46 had complained to LPN X of continued toothache and not eating meals well. Review of Resident #46's physician progress notes [REDACTED].#46 had any dental or mouth pain. Review of Resident #46's physician note dated 6/6/18 (no time) revealed Resident #46 was seen as requested by nursing due to a question of a mouth abscess. Resident states he had a swelling in left lower gum area that drained a few days ago. Teeth were in poor repair. No pus or drainage seen. Pain with palpation (touch) in the left bottom outer gum area. Resident #46 was scheduled to see a dentist today in a few hours. All treatment was deferred to the dentist at that time. During an interview with the Assistant Nursing Home Administrator (ANHA) B on 6/6/18 at 9:41 AM, ANHA B was asked about the process of resident referral to the physician and dentist. ANHA had already been made aware of the concern that Resident #46 had been having dental pain for some time and there was no indication that the physician was aware or any referral had been made to a dentist. ANHA B informed the Surveyor the Resident #46 would be going out today for emergency dental services. ANHA B said they were already in the process of educating staff on the referral process. ANHA B was not aware of what the current process was for informing the physician of concerns. Late in the morning on 6/6/18, ANHA B informed the Surveyor that Registered Nurse (RN) W had a file at the nurses desk with forms for the nurses to complete with concerns for the physician. RN W made rounds with the physician and if the physician did not see the resident or address the concern, RN W was to document the reason for not addressing the issue. ANHA B said RN W was not in the facility today but she had called her and RN W had no recall of Resident #46 having any dental concerns. ANHA B said RN W does not keep any of the forms after the physician rounds so there was no way to determine if LPN X had completed a form. During an interview with LPN X on 6/6/18 at 2:50 PM, LPN X said she had informed RN W (nurse that rounds with physician) about Resident #46's dental problem and she thought RN W had the physician see Resident #46 and had made a referral to the dentist.

Based on interview and record review, the facility failed to provide necessary care and services for a residents worsening depression symptoms in 1 of 6 residents reviewed with depressive symptoms (Resident #4), in a total sample of 12 residents, resulting in a deterioration of the residents condition. Findings include: The Centers for Medicare & Medicaid Services, Long-Term Facility Resident Assessment Instrument (RAI) User's Manual, Version 3.0, September 2010; under Section D: Mood indicated the intent of the assessment was to .address mood distress, a serious condition that is under-diagnosed and under-treated in the nursing home and is associated with significant morbidity. The same source indicated that it was .important to identify signs and symptoms of mood distress because these signs and symptoms can be treatable. The same RAI manual revealed that depression can be associated with psychological and physical distress, decreased participation in therapy and activities, decreased functional status and poorer outcomes. The RAI Manual indicated the Resident Mood Interview (PHQ-9) was a screen for symptoms of depression and provided a standardized severity score and rating for evidence of a [MEDICAL CONDITION]. The same manual instructed to complete the interview the day before or the day of the assessment reference date (ARD) (refers to the last day of the observation or look back period) of the Minimum Data Set (MDS) assessment. The look-back period was 14 days for the PHQ-9 assessment. Resident #4's Face Sheet,revealed Resident #4 was a [AGE] year old with the [DIAGNOSES REDACTED].). Resident #4's March 2016 Medications Flowsheet revealed [MEDICATION NAME] (duloxetine) 20 milligrams (mg) was ordered every morning since 11/11/13 for depression. Resident #4's quarterly MDS assessment with an ARD of 12/17/15, revealed a PHQ-9 score of 4, indicative of minimal depression. During the PHQ-9 interview, Resident #4 reported she had little interest or pleasure in doing things 2 to 6 days (several days) and was feeling down, depressed or hopeless for several days. The same MDS assessment, under section G, revealed Resident #4 required supervision assistance for transfers, dressing, eating, and limited assistance for hygiene. Resident #4's Brief Interview for Mental Status (BIMS) (cognition assessment) score was a 15 out of 15, indicating she was cognitively intact. Progress Notes dated 12/21/15 at 3:57 PM, indicated the SW documented Resident #4 had been feeling down and had lost interest in doing things. The Nurse Practitioner (NP) note from mental health services dated 1/9/16, indicated Resident #4 was seen for anxiety. The same note indicated a history of arthritis, depression, and chronic [MEDICAL CONDITION]. The same assessment revealed Resident #4 was alert and orientated to person, place and time. Under assessment and plan, [MEDICATION NAME] 20 mg was to be continued daily; encourage socialization, activity; continue to identify and use new coping techniques. The same note under anxiety disorder plan included to encourage relaxation exercises. The same note under disposition included behavioral management planning; order/referral for Psychological Services-Evaluation, Therapy and Testing as deemed appropriate; Refer to PCP (primary care physician) to address pain as possible etiology for behavior/mood symptoms; Follow up in 2 months. In an interview in the conference room on 5/19/16 at approximately 1:45 PM, the Director of Nursing (DON) B and the Social Worker (SW) E stated that the physician was not notified of the above NP recommendations. Social Worker E stated in the same interview that she didn't feel a Psychiatric evaluation was necessary and did not make any changes to Resident's #4 care plans. SW E also stated resident had not been seen for any follow-up by mental health services. According to Resident #4's Progress Notes created by the social worker, dated 1/25/16 at 10:03 AM, Resident #4's family informed her of her that her nephew passed away that morning and resident became tearful and cried. There were no changes to Resident #4's care plan to reflect any grief support. On 5/19/16 at 11:25 AM, Social Worker E stated she did not feel it was necessary to bring in mental health services for an evaluation or counseling following Resident #4's loss of her nephew, and that she had planned to visit Resident #4 and encourage activities. SW E stated she was not licensed to provide counseling services, that she did not document follow up grief support visits with Resident #4, and that she did not update Resident #4's care plan at that time. The mental health Nurse Practitioner's recommendations made on 1/9/16, prior to Resident #4's nephew's death were again not implemented. Resident #4's Progress Notes, dated 3/4/16 at 7:57 AM, Resident was found on the floor with her left leg rotated out away from her body and was transferred by ambulance to the hospital. Progress Notes dated 3/15/16 at 10:02 PM indicated Resident #4 returned to the facility. The most recent comprehensive MDS assessment dated [DATE], revealed Resident #4 had a PHQ-9 score of 10, indicative of moderate depression. Resident #4 revealed in the PHQ-9 interview that she had little interest or pleasure in doing things in the last 12 to 14 days (nearly every day); was feeling down, depressed or hopeless nearly every day; feeling tired or having little energy for 7 to 11 days (half or more of the days). The same MDS revealed Resident #4 required extensive assist for transfers, eating, and hygiene. Resident #4's Progress Notes dated 3/18/16 at 11:07 AM, revealed resident had a decline in her ability to participate in group activities. Resident #4's Progress Notes dated 3/21/16 at 2:43 PM, indicated documentation by the SW that resident had been feeling down, had a loss of interest in activities, loss of energy and had a poor appetite; SW quoted resident as stating I wish God would take me home. Progress Notes dated 5/5/16 indicated Resident #4 was admitted to hospice care. Dietary Progress Notes dated 5/6/16 revealed Resident #4's intake of solids remained poor, less than 30% and presented with a 11% weight loss in 63 days. Resident #4's Progress Notes created by the social worker, dated 5/17/16, indicated the [DIAGNOSES REDACTED]. The same note indicated her PHQ-9 score was still a score of 10, the SW note indicated she would continue to monitor. The note did not reflect any plans for additional interventions for continuing depression. Resident #4's Care Plan for Depression with a start date of 2/16/12 revealed goals that Resident #4 would continue to accept medication, and would not exhibit behaviors/decline in functioning. This goal was initiated on 1/15/15 and the goals had not changed since despite increased symptoms of depression and a decline in functioning. The approaches to the Depression Care Plan had not been changed or updated since 2/16/12. Application of the Reasonable Person Concept would indicate that anyone with worsening symptoms of depression would want treatment to improve their quality of life. Resident #4 had no significant treatment for [REDACTED]. ( )