Every finding on record at Aspen Meadows Health and Rehabilitation Center

Based on interview and record review, the facility failed to develop a baseline care plan within 48 hours after admission to ensure pain management needs were met, including medications ordered for pain for a resident receiving rehabilitative services following hip replacement surgery, for 1 (#9) of 12 sampled residents. Findings include:During an interview on 8/12/26 at 11:19 a.m., resident #9 stated she had been concerned with the pain management that was provided to her during her stay at the facility, which started the day of her arrival to the facility. Resident #9 stated she had been in the facility for services following hip surgery. Resident #9 stated she felt her concerns about her pain levels were not taken seriously by nursing staff when she was requesting medications for managing her pain.During an interview on 8/13/26 at 2:29 p.m., staff member A stated resident care plans were started on a resident's admission to the facility. Staff member A stated both the nurse admitting a resident and nursing management would add to a resident's care plan. Staff member A stated the baseline care plan had the minimum amount of information based on the nurse's initial assessment. Staff member A stated the nurse who admitted resident #9 must have forgotten to click on a part of the admission assessment that would have brought the pain information into the care plan. Staff member A stated the nurses completing the admission assessments would need to be reminded to make sure to click the pain assessment information.Review of resident #9's medication administration record, showed an admission date of 7/17/26. Resident #9 had two orders for opioid pain medications as needed and a scheduled dose of Lyrica 100 mg to be taken three times a day. The opioid pain medications included:- Oxycodone 10 mg to be taken three times as needed.- Oxycodone 5 mg (take 1-2 tabs or 5-10 mg) every four hours as needed for pain.Review of resident #9's admission nursing evaluation, dated 7/17/26, showed resident #9 was evaluated for pain and was experiencing both acute and chronic pain related to her conditions of chronic back pain, neuropathy, and left total hip pain following hip replacement surgery. Resident #9's areas of pain included her back, left hip, and bilateral lower extremities. Resident #9's use of non-medication aids for pain included warm blankets and ice to the surgical site on her left hip. Review of resident #9's baseline care plan, initiated 7/17/26, showed a problem, Establish baseline plan of care, with three goals, which included:- Wound Healing surgical left hip;- discharge: Return Home; and,- Work with Therapy to regain strength [sic] Resident #9's baseline care plan did not have goals or interventions associated with resident #9's acute or chronic pain management needs or interventions to alleviate pain. The baseline care plan did not provide information related to non-pharmacological pain management or include monitoring for signs or symptoms related to the use of high-risk opioid medications.Review of a facility policy titled, Baseline Plan of Care, updated 7/25, showed: . 1. The facility develops the baseline plan of care for each resident, within 48 hours of admission.2. The baseline plan of care includes information regarding care and services sufficient to promote safe delivery of care. The baseline plan of care consists of the following:a. Physician orders . f. Initial goals .

Based on interview and record review, the facility failed to implement person-centered pain management approaches to address goals and preferences, for 1 (#9) of 6 residents sampled for pain. The deficient practice caused resident #9 increased discomfort because the facility did not have doses of scheduled medications for pain to administer, and provided the lowest available dose of as-needed opioid pain medications for pain relief following hip replacement surgery, when resident #9 requested the highest available dose. Findings include:During an interview on 8/12/26 at 11:22 a.m., resident #9 stated she was admitted for rehabilitation following hip surgery and had long-standing and chronic and nerve pain treated with Lyrica and opioid medications. Resident #9 stated nursing staff did not adequately address her pain when she requested scheduled or as-needed medication. Resident #9 stated staff member C told her Lyrica had not been included with her hospital discharge orders and that staff were contacting the provider and pharmacy to obtain it. Resident #9 stated she felt staff did not take her reports of pain seriously. She also stated she received oxycodone 5 mg on multiple occasions when she had requested the available 10 mg dose. Resident #9 stated staff member B provided Flexeril while Lyrica was unavailable, but she reported that Flexeril was ineffective and made her feel strange. Resident #9 stated she, . did not feel her pain was controlled at all during her stay in the facility.During an interview on 8/13/26 at 9:28 a.m., staff member D stated she was responsible for reviewing physician orders for new admissions and double-checking opioid orders when clarification was needed. Staff member D stated the hospital provider was responsible for sending discharge orders to the facility pharmacy. She stated the pharmacy did not receive resident #9's Lyrica order on admission and that nursing staff contacted the on-call provider for an order. Staff member D stated order clarifications should be documented.During an attempted interview on 8/13/26 at 11:31 a.m., a voicemail was left for staff member B who provided care for resident #9 on 7/17/26 through 7/20/26. Staff member B did not return the phone call before the end of the survey. During an interview on 8/13/26 at 12:40 p.m., staff member C stated she contacted the on-call provider and pharmacy regarding resident #9's Lyrica during the weekend of 7/18/26. Staff member C stated she administered as-needed opioid medication when resident #9 requested it and started with the lowest dose. She stated the on-call provider only ordered temporary and limited doses of Lyrica from facility stock.During an interview on 8/13/26 at 2:19 p.m., staff member A stated resident #9 received pain medication during her stay. Staff member A stated the hospital did not send the Lyrica order to the facility pharmacy and that nursing staff contacted the on-call provider for a temporary order. Staff member A stated nurses used their judgment when selecting the as-needed opioid dose. She stated resident #9's progress notes showed she was able to sleep and that the PAINAD scale could be used to assess pain while a resident was sleeping. Staff member A stated she would have to check with the resident's provider about Flexeril being given only a few times by staff member B.Review of resident #9's admission nursing evaluation, dated 7/17/26, showed she was assessed as having acute and chronic pain related to chronic back pain, neuropathy, and left hip pain following surgery. Pain was identified in the back, left hip, and bilateral lower extremities. Identified non-pharmacological interventions included warm blankets and ice to the left hip surgical site.Review of resident #9's medication orders showed an admission date of 7/17/26 and diagnoses including aftercare following joint replacement surgery, presence of a left artificial hip joint, other chronic pain, and unspecified inflammatory spondylopathy. On 7/17/26, oxycodone 10 mg by mouth every eight hours as needed was ordered for hip fracture. On 7/18/26, oxycodone 5 mg by mouth every four hours as needed was ordered for breakthrough pain.Review of resident #9's baseline care plan, dated 7/17/26, failed to identify resident-specific pain management goals, preferences, or interventions related to her acute and chronic pain following left hip surgery. The plan did not identify interventions for staff to follow when resident #9 reported pain or when pain interfered with sleep, rehabilitation, or daily activities.Review of a nursing progress note by staff member C, dated 7/18/26 at 12:11 p.m., showed resident #9 expressed concern about her oxycodone order and the availability of Lyrica. The note showed resident #9 was upset that she had to request an additional 5 mg of oxycodone and reported that she did not have her Lyrica. The pharmacy reported that no Lyrica prescription was available to fill.Review of resident #9's Oxycodone narcotic logs showed resident #9 received Oxycodone 10 mg doses on 5 of the 14 opportunities to receive it from 7/17 through 7/21/26. The documentation did not consistently show resident #9's pain rating before or after the administration of the as-needed medication, the medication's effectiveness, or the clinical rationale for selecting the lower opioid dose when resident #9 reported ongoing pain.Review of resident #9's medication administration records showed the Lyrica 100 mg was to be given three times a day, medication administration documentation showed:- 2 doses administered on 7/18/26; 1 was not given.- 1 dose administered on 7/19/26; 2 doses were not given.- 2 doses administered on 7/20/26; 1 dose was not given. - 3 scheduled doses administered on 7/21/26.Although staff contacted the on-call provider for temporary orders for the Lyrica, the medical record did not consistently show resident #9's pain level while the Lyrica was unavailable, or the effectiveness of alternative interventions provided for pain management. Review of resident #9's nursing pain assessment, dated 7/21/26, showed she reported pain during the previous five days that occurred Almost constantly. She reported that pain frequently interfered with sleep, rehabilitation therapy, and daily activities. She rated her worst pain as 10 on a 0-10 scale and described it as Very severe, horrible. The staff response identified daily indicators of pain.Review of resident #9's pain assessment, medication administration records, nursing progress notes, and care plan did not demonstrate consistent documentation of resident #9's pain before and after administration of as-needed medication, the effectiveness of interventions, or individualized interventions based on her stated goals and preferences. The record also did not consistently show how staff responded when resident #9 reported that medication was ineffective or when pain continued to interfere with sleep, rehabilitation, and daily activities.Review of a facility policy titled, Pain Management, updated 5/26, showed: Policy Statement: It is the policy of this center that residents receive care to attain and maintain the highest quality of care and life. Residents are evaluated for pain upon admission. Subsequent pain evaluations are completed in conjunction with the Resident Assessment Instrument (RAI) process and PRN. 2) The resident is evaluated every shift for signs and symptoms of pain, receiving pain management according to the plan of care and/or physician order. Data for the evaluation of pain management is collected from the Medication Administration Record (MAR), nursing progress notes and through the daily clinical meeting/review process.4) An appropriate pain scale is selected for use based upon resident ability and needs. Examples may include. Numeric 1-10, Verbal Descriptor Scale. and the PAINAD (Pain Assessment in Advanced Dementia). 5) For residents using PRN pain medication, a 0-10 pain scale is used to document levels of pain both before and after receiving pain medication.6) If it is determined that pain is not controlled to the resident's satisfaction, the medical provider is consulted, and the resident remains on alert charting.7) The care plan may include non-pharmacological interventions that the resident finds helpful for pain management. Non-pharmacological interventions are implemented as requested by the resident or ordered by the physician. a) Note - nonpharmacological interventions are not required to be implemented before attempting to give ordered pain medication.i) The residents' right to participate in directing the plan of care will be observed. A resident may request pain medication and choose to forego implementation of non-pharmacological interventions.ii) A resident may state that non-pharmacological interventions are ineffective, and request only pharmacological intervention be implemented, and their request is honored. [sic] Review of a facility policy titled, Medication Administration, updated 1/26, showed: . 1. Medications are administered in accordance with written orders of the prescriber. If a dose seems excessive considering the patient's age and condition, or a medication order seems to be unrelated to the resident's current diagnosis or condition, the nurse calls the provider pharmacy for clarification prior to the administration of the medication. If necessary, the nurse contacts the provider for clarification. This interaction with the pharmacy and the resulting order clarification are documented in the nursing notes and elsewhere in the medical records as appropriate . 14. Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule. Documentation:1. The individual who administers the medication dose records the administration on the resident's MAR immediately following the medication being given. 2. If a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time. the nurse shall document either in the Electronic Medication Administration Record or the paper MAR that the dose was withheld, refused, or given at other than scheduled time, and enter an explanatory note.7. Observe resident for medication actions/reactions and record in the nurse's notes as appropriate. Any noted adverse consequence should be reported to the prescriber and/or attending physician. [sic]

Based on interview and record review, the facility failed to identify, correct, and protect a resident who voiced neglect of care concerns, including when the neglect resulted in a lack of care by a staff member (NF7), and this failure contributed to psychosocial harm, for 1 (#47); and when grievances were brought forth, staff did not identify neglect included in the grievances, to neglect continued to occur. The system failure for the prevention of neglect of care contributed to the resident's ongoing anxiety, feelings of being unsafe, decline in mobility, lack of ADL care related to bowel and bladder, and ongoing skin concerns with the resident's ears, heels, and coccyx; out of 19 sampled residents. This failure also put other residents at risk of neglect due to the system failures and neglect not being addressed. Findings include:1. During an interview on 3/23/26 at 3:27 p.m., resident #47 stated he had complaints about a specific previous staff member, NF7, who would leave his call light on for hours, would not help resident #47 with ADL cares which resulted in resident #47 soiling his brief (bowel and bladder) from waiting so long. Resident #47 stated NF7 would then want resident #47 to ambulate to the restroom, but resident #47 stated he had already gone in his brief (was incontinent) and would refuse to ambulate to the restroom. Resident #47 stated NF7 would then encourage resident #47 to sign a refusal of care form. The lack of care and assistance was upsetting for the resident. A review of resident #47's admission MDS, submitted 8/22/25, showed the resident had a BIMs of 15; cognitively intact. The resident was dependent on staff for bowel and bladder care and assistance, and he had range of motion limitation on both upper and lower extremities. During an interview on 3/24/26 at 10:48 a.m., NF6 stated they were concerned about resident #47's care at the facility. NF6 stated resident #47 and NF6 had concerns about a specific previous staff member, NF7, who would leave resident #47's call light on for over an hour, which resulted in resident #47 soiling his brief. NF6 stated she overheard NF7 talk to resident #47 on the phone one night, and she said NF7 was very rude and he sounded angry with resident #47. NF6 stated she expressed these concerns in person, through phone calls, and through emails to staff members A and C. NF6 stated resident #47's mobility had declined in the facility, and he now needed two people in order to ambulate and stated, Just because you're a two person (assist), you should not have to wait two hours. NF6 stated resident #47 was ridiculed for not making it to the restroom after waiting for his call light to be answered, and stated I'm sorry, I can't hold my urine that long either.During an interview on 3/24/26 at 3:47 p.m., resident #47 stated, I hate to say this, I usually pee my pants. He stated he had asked for a commode in the past due to his decline in mobility and some additional concerns with his roommate. Resident #47 also stated, So I [expletive] my pants. Resident #47 stated he usually waited over 45 minutes for help, and stated he developed skin issues at the facility from sitting so long and not being cleaned up timely.During an interview on 3/24/26 at 4:12 p.m., staff member O stated that resident #47 used to have behaviors until he was moved to a different unit. Staff member O stated that sometimes he would have anxiety, which was from an accident prior to his admission, but he would also get nervous and display behaviors when staff would forget about him or fail to perform all of the required care.During an interview on 3/25/26 at 11:32 a.m., staff member Q stated NF7 worked at the facility from 3/4/25 until 3/16/26, with no previous disciplinary action.2. Resident #47's Skin Concerns: Please see F686 - Prevention of Pressure Ulcers for detail on skin concerns.During an interview on 3/25/26 at 2:04 p.m., staff member B stated the facility staff members should have been doing weekly skin assessments for resident #47. Staff member B stated she and the wound care staff were unaware of any ear or coccyx skin issues.Review of resident #47's physician orders failed to show wound orders for his left heel.During an interview and observation on 3/25/26 at 4:32 p.m., staff member P stated resident #47's skin was described as: his left heel had eschar, and it looked like it probably should be debrided. The resident's right heel was red and cracked, his coccyx was pink, his right rear ear was red, and his left rear ear was red and blanchable, but had a slightly slower capillary refill time of approximately four seconds. Staff member P stated to prevent skin issues on resident #47's heels, staff should float the heels. Resident #47 was sitting in a recliner with his feet raised a couple of inches off the ground. Staff member P looked in resident #47's cabinet and found Posey boots. Staff member P stated she had never seen the Posey boots on resident #47 before and stated she had no idea they were in his room. Staff member P also stated resident #47 had +2 pitting edema to both of his feet and ankles. Staff member P stated the edema felt like thick fluid, and it had developed while the resident was in the facility. Staff member P stated mobility and elevation would help with the resident's edema.3. Grievance Process: Please see F585 - Grievances for details on grievance concerns and the grievance system.During an interview on 3/25/26 at 11:22 a.m., staff member C stated a grievance should be made if a resident brought up a concern of neglect of care, ADLs not being done, or long call light wait times. Staff member C stated if there were any concerns brought forward by a resident or family member, a grievance would be filed. Staff member C stated they were unaware of any concerns brought forward from resident #47 or NF6, specifically. Review of resident #47's Care Conference, dated 2/24/26, showed, (Resident #47) reports that at night they are making him sign refusal sheets. Reports waiting 20-40 minutes for call light to be answered, and in the mean time he reports having an accident and when they come, they want him to go to bathroom, and he expresses that he is already wet so they can clean him when standing up. This issue is only at night per (resident #47). (Resident #47) reports that when he refuses to go to the bathroom they make him sign a refusal paper and he does not understand why. This document was signed by staff member C. Although staff member C signed the document showing the neglect of care concerns, a grievance was not filed and the neglect was not reported and investigated.During an interview on 3/25/26 at 4:15 p.m., resident #47 stated he told staff member C about the neglect and long call lights, and sitting in a soiled brief for hours and staff member C had brought this issue up to management. Resident #47 stated when NF7 was taking care of him, he had not felt safe as he would go for hours without being checked (12:00 a.m. to 4:00 a.m.), or his call light not answered in that time. Resident #47 stated, Oh boy, yes, that he was irritable and anxious, every time NF7 walked into the room. Resident #47 stated he waited as long as possible to push his call button if he knew NF7 was working that night. Resident #47 stated no staff members had asked him if he felt safe, what had happened those nights with NF7, what happened on nights without NF7, and how his concerns related to neglect of care impacted him physically, mentally, or psychosocially.During an interview on 3/26/26 at 9:19 a.m., staff member B stated no concerns from family or the resident were brought to their attention. Staff member B stated they did not report or investigate the alleged abuse or neglect for resident #47.

Based on observation, interview, and record review, the facility failed to ensure the system for pressure ulcer prevention was meeting the residents needs, and the processes used by staff for pressure ulcers did not effectively identify, assess, treat, monitor, or prevent pressure ulcers, which affected 4 (#s 47, 63, 78, and 82) of 28 sampled and supplemental residents. This failure placed the residents at risk for experiencing ongoing skin concerns or negative outcomes related to pressure ulcer development and treatment, stemming from staff not using protective measures to prevent pressure ulcers, not identifying pressure ulcers that developed (or are developing), not assessing or documenting pressure ulcers accurately, not implementing interventions to prevent pressure ulcers, and not updating resident care plans for pressure ulcer prevention. Findings include:1. Review of resident #78's nurse progress notes, dated 1/5/26, showed the resident was admitted with skin issues on the buttocks, both heels, and the right knee. Review of the nurse progress note, dated 1/6/26 at 1:57 p.m., showed resident #78 had one wound on her sacral area, one on her right knee, and blisters on both heels. Review of resident #78's nurse progress note, dated 1/11/26 at 11:26 p.m., showed the nurse was called to resident #78's room, and the notes showed, The resident had a silicone foam dressing on that was saturated with drainage. It has a very foul odor and is a brown yellow. Removed from coccyx and found a non-stage-able pressure ulcer on her coccyx measuring the following, 10cm x 5.5cm margin with slough noted in varying measurements from 0.5 cm to 1 cm surrounding black eschar measuring 8cm from 9 to 3 on the clock face x 4cm from 12 to 6on the clock face. There is a reddish pink blanch-able border around the entire area measuring 12cm x 8.5 cm respectfully. There is no wound care orders in the chart at this time. [sic] This was the first documented description of the pressure ulcer wound on the resident's coccyx by the facility staff. Review of resident #78's Weekly Skin Evaluation, dated 1/14/26, showed resident #78's coccyx wound. The wound was noted to have a large eschar cap, and the eschar was boggy and detached on one side. The wound was described as having copious amounts of foul-smelling serous drainage. The wound bed below the eschar cap is about 75% slough and 25% granulation tissue. The wound measured 4.9 (cm) centimeters in length, 8.5 centimeters in width and was 5.0 centimeters deep and was irregularly shaped. This assessment went on to describe this as the first date of observation of the pressure ulcer wound, even though it was identified nine days prior, on 1/11/26. The facility documentation failed to include the evaluation of resident #78's wounds on the left heel, the right outer ankle, and the front of the right knee until 1/14/26. The right heel was not evaluated during resident #78's stay at the facility (1/5/26 to 1/15/26). Review of resident #78's Care Conference Meeting form, with an effective date of 1/8/26, showed portions of the plan were signed on 1/8/26, and other sections were not completed until 1/15/26. The care conference failed to identify a concern with nutrition related to a resident being admitted with one pressure wound to the coccyx and bilateral heel blisters. During the care conference, the POA requested resident #78 have an air mattress due to the resident's coccyx pressure ulcers. Review of resident #78's care plan, with a revision date of 1/8/26, showed the care plan did not identify that pressure ulcers were a problem. Resident #78's care plan did not have any interventions related to pressure ulcers or nutritional interventions to address the healing and prevention of a large pressure ulcer, which was draining copious amounts of fluid. Review of resident #78's January 2026 treatment administration record showed no wound treatments were ordered until 1/13/26, when resident #78 had the following physician orders: - Clean and dress coccyx wound daily and as needed. The wound care was not documented as being done on 1/14/26 or on 1/15/26. - left heel DTI (deep tissue injury) cleanse wound and apply a protective foam dressing. Change the dressing daily and as needed. The treatment record did not have documentation to prove the wound care was completed after 1/13/26. - right lateral ankle wound care. Cleanse area apply treatments and place foam heel dressing secured with Tube grip. Change daily and as needed when soiled or nonintact. The January treatment record showed the treatment was not performed on 1/14/26 and 1/15/26. - Right shin wound care. Cleanse and apply treatment and dressings. Change daily and as needed for soiling or not intact. The treatment record showed this treatment was never completed. Resident #78's progress notes dated 1/15/26 at 7:00 p.m., showed the resident was sent to the emergency room per family request. During an interview on 3/24/26 at 11:14 a.m., NF4 said she spent a significant amount of time with the resident. NF4 said the facility staff did not change the dressings on the wound on resident #78. NF4 said the wound on the resident's coccyx got worse. NF4 said she took a picture of the wound because it was so disgusting and smelled gross. NF4 said she felt she needed to show resident #78's primary care provider the picture of the wounds so someone would do something to get resident #78 treatment. NF4 said the resident's primary doctor told her to have the facility call the ambulance and send resident #78 to the hospital for evaluation. NF4 said resident #78 was seen in the emergency room, and resident #78 had an operation to clean the wound the next day. 2. Review of resident #82's nurse progress note dated 3/9/26 at 7:11 p.m., showed the resident had an incision to the lower back. The progress notes showed a skin concern that the resident's coccyx was open, and possibly caused by pressure, and noted when the resident was admitted . A late entry note dated 3/9/26 at 9:40 p.m. showed resident #82 had a Stage 3 pressure ulcer to the coccyx from admission. Review of resident #82's Nutrition Evaluation Form dated 3/16/26 showed: - no to the question was there a pressure injury present - Other skin condition- coccyx wound care ordered, area opened. Surgical Spine incision. Review of resident #82's Weekly Skin Evaluation showed resident #82 was admitted to the facility on [DATE]. The form showed the date of the first observation of the wound was 3/9/26. The first documented measurements and description of the coccyx wound was made 14 days after admission, and it was on the weekly skin evaluation form. The coccyx wound measured 3.6 cm in length, 1.5 cm in width, and 0.2 cm deep. The form identified that the dietitian was not notified until 3/18/26. Review of resident #82's treatment record for March 2026 showed the wound care for the pressure ulcer and the surgical incision on the spine were ordered on 1/9/26. Wound care for neither the surgical incision nor the pressure ulcer was completed on 3/19/26 and 3/20/26, even when the physician ordered daily wound cleansing and dressing changes. Review of resident #82's care plan showed nutritional interventions were not added to the care plan for wound healing/prevention until 3/24/26. On 3/24/26, Proheal, a protein supplement, was added to the care plan to support wound healing fifteen days after the wound was identified. During an interview on 3/24/26 at 2:39 p.m., staff member N said she is physically at the facility about six hours a day, two days a week, usually Monday and Wednesday. Staff member N said her priority is vetting through the newly admitted residents and reviewing weights. Staff member N said the facility had skin and weight meetings. Staff member N said that the meeting was when the facility reviews all the resident wounds again and re-checks their weights. Staff member N said if a resident admits on a Thursday with dietary needs, the resident may not be assessed until next Monday. Staff member N said there was a delay at times, but she had fourteen days to do her assessments and update any nutritional plans. Staff member N said the fourteen-day delay would not be the best practice for any resident with a wound. During an interview of 3/25/26 at 8:56 a.m., staff member B said it may not be in the facility policy, but the facility practice is to do skin checks every seven days. During an interview on 3/25/26 at 1:45 p.m., staff member B said she is not sure why the nurses are not coding skin tears on the heels and coccyx correctly. Staff member B said the problem regarding wounds not being documented every seven days and on admission is because the computer system went through a change. Upon the resident's admission, the nurses must do an admission assessment. If a wound is identified, there is an admission skin evaluation that needs to be opened and completed as well. Staff member B said the admission skin evaluations are not always getting done. During an interview on 3/25/26 at 2:15 p.m., staff member B said the residents with wounds and weight loss are reviewed weekly. Staff member B said it is her and the dietitian at this time at the meetings, but the meetings will be more robust going forward. During an observation and interview on 3/26/26 at 10:30 a.m., staff member H was completing a wound treatment on resident #82's coccyx area. Staff member H said she had no formal wound training but worked for over a year in a wound care clinic. Staff member H said resident #82's wound was staged as a Stage III pressure ulcer. Staff member H said 100 percent of the wound bed was covered with a thick layer of yellow, tan colored slough. Staff member H said the wound edges are starting to have some epithelialization. Staff member H said the facility's practice is for the facility to handle the wounds for a few weeks, and if there is no change or the wound gets worse, the local clinic's wound nurse practitioner starts to follow the resident for assistance. When a wound is covered with a yellowish tan slough and according to the National Pressure Ulcer Advisory Panel the surveyor was unable to stage the wound due to the slough. 3. During an interview and observation on 3/24/26 at 10:06 a.m., resident #47 stated the back of his ears hurt. The oxygen tubing protectors had slid down and were no longer protecting his ears from the tubing. Resident #47's rear right ear was red where the tubing sits, while the rear left ear was very red and had a whitish substance in the crease. Resident #47 stated both of the backs of his ears hurt. Resident #47 stated the left ear hurt the most. During an interview on 3/25/26 at 2:04 p.m., staff member B stated the facility nursing staff should have been doing weekly skin assessments for resident #47. Staff member B stated she and the wound staff team had been aware of resident #47's heel concerns but were unaware of any ear or coccyx skin issues. Staff member B also stated resident #47 had a scab on his left heel. During an interview on 3/25/26 at 4:32 p.m., staff member P stated resident #47's skin looked like the following: his left heel had eschar and it looked like it probably should be debrided, his right heel was red and cracked, his coccyx was pink, his rear right ear was red, his rear left ear was red and blanchable, but had a slightly slower capillary refill time of four seconds. Staff member P stated staff member B knew about the skin issues of resident #47's heels, but stated I don't know if they ever told them about the (coccyx redness) or his heels. Review of resident #47's physician orders failed to show wound orders for his left heel. Review of resident #47's EHR failed to show any skin assessments were completed since his most recent re-admission on [DATE]. Review of resident #47's admission Nursing Evaluation, dated 2/18/26, showed, . skin appearance: warm, dry, and intact ., and . Does the resident present with a wound (s)? no [sic] was marked. 4. During an observation on 3/24/26 at 8:42 a.m., NF10 changed the dressing to the pressure ulcer on resident #63's coccyx. Review of resident #63's wound assessments, dated 1/7/26, 1/14/26, 2/11/26, and 3/11/26, showed the pressure ulcer on the resident's coccyx was gradually decreasing in size and was present on admission. Review of resident #63's Comprehensive MDS assessment, with an ARD of 11/30/25, showed the resident had no unhealed pressure ulcers present on admission to the facility. Review of resident #63's PPS Part A Discharge MDS assessment, with an ARD of 1/12/26, showed the resident had one unhealed pressure ulcer which was documented as a Stage IV and present on admission. Review of resident #63's Quarterly MDS assessment, with an ARD of 3/2/26, showed the resident had a Stage III pressure ulcer which was not present on admission. Review of resident #63's TAR, dated November 2025, failed to show any treatment for the resident's pressure ulcer on her coccyx. Review of resident #63's TAR, dated December of 2025, showed daily wound care to the pressure ulcer on the coccyx starting on 12/23/25. Wound care scheduled for 12/25/25 was not documented as completed. Review of resident #63's TAR, dated January of 2026, showed daily wound care from 1/1/26 through 1/22/26. Of the 22 days wound care was scheduled, 12 of the days failed to have documentation showing wound care was completed. Review of resident #63's TAR, dated February of 2026, failed to show any wound care was performed on the resident's coccyx pressure ulcer. Discrepancies in the documentation of the appearance (size and stage) and treatment was found with the wound assessment forms, the MDS documentation, and provision of daily wound care treatment. Review of a facility policy titled Skin Integrity updated January 2026 showed: .a resident having pressure ulcer/injury receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. 2. Upon admission, the licensed nurse (LN) establishes a plan of care based on risk factors or presence of wounds. 3. Ongoing evaluation continues weekly with the LN completing a full body skin audit. 4. For new skin impairments identified, the LN completes the following: a. Documents the skin impairment that includes measurements of location, size, color, presence of odor, exudate and presence of pain associated with the skin impairment. b. Surgical wounds, pressure injury, burns venous stasis ulcer, arterial ulcer, diabetic ulcers, blanchable redness on a bony prominence, and Moisture-Associated Skin Damage (MASD) is documented on the Weekly Skin Evaluation. are documented on the weekly skin evaluation form. d. Notifies the medical provider, and if needed, obtains a treatment order and documents on the TAR after order is implemented. e. Notifies the resident/representative of skin condition and treatment plan. f. Notifies the facility Registered Dietitian. g. Implements interventions and documents on the resident's care plan as appropriate. References 1. National Pressure Ulcer Advisory Panel, Prevention and Treatment of Pressure Ulcers: Clinical Guideline. [NAME], DC: National Pressure Ulcer Advisory Panel; 2009.

Based in interview and record review, the facility failed to ensure residents were free from significant medication errors for 1 (#4) of 3 sampled residents with insulin orders. The medication error of omission resulted in a deterioration of condition and an unplanned hospitalization for resident #4. Findings include:Review of resident #4's hospitalization, dated between 1/29/26 and 3/23/26 showed the following:- 1/29/26 - 2/20/26, hospitalized ,- 2/20/26 - 2/23/26, in facility, and- 2/23/26 - 2/26/26 hospitalized .Review of resident #4's insulin orders showed the following:- 1/23/26 - 1/29/26, Lantus insulin 10 units every evening, at bedtime,- 2/20/26 - 2/23/26, no order for Lantus insulin,- 2/26/26 - 3/10/26, Lantus insulin 10 units every morning.Review of resident #4's SNF admission orders from the hospital, dated 2/20/26, showed an order for Lantus insulin 10 units daily.Review of resident #4's admission orders in the EHR, dated 2/20/26, failed to show any Lantus insulin was ordered or given to the resident from 2/20/26 to 2/23/26.Review of resident #4's emergency department note, dated 2/23/26, showed, Patient is a [AGE] year-old male just recently discharged for (from) facility for encephalopathy as well as diabetic ketoacidosis. Patient was discharged several days ago apparently in good condition. He was found to be unresponsive today at the nursing facility. Brought in here obtunded.During an interview on 3/25/26 at 4:10 p.m., staff member B stated resident #4 should have been receiving Lantus insulin daily (2/20/26 to 2/26/26) as ordered at discharge from the hospital. Staff member B stated the Lantus order was missed and not entered into the EHR. The omission resulted in hyperglycemia and a change in mental status necessitating an unplanned hospitalization. Staff member B stated when a resident was discharged from an acute hospital setting, the medical provider from the hospital generally wrote the admission orders and any discrepancies were clarified with the nursing home provider.

Based on interview and record review, the facility failed to fully investigate allegations of abuse and neglect for 3 (#s 26, 47, and 77) of 28 sampled and supplemental residents. The deficient practice failed to ensure the facility identified all residents who may have been abused or neglected, in an attempt to prevent ongoing or future abuse or neglect. Finding include: 1. During an interview on 3/24/26 at 10:08 a.m., resident #26 stated NF8 had been nasty and pushy with her while helping her brush her teeth one night. Resident #26 stated she only had partial dentures and NF8 had told her she should not take so long brushing her teeth because she only had eight teeth. Resident #26 stated NF8 made me hurry up and did not give her the time she needed. Resident #26 stated, We all need help, and I don't even need a ton of help. During an interview on 3/24/26 at 4:40 p.m., staff member A stated they were looking for the staff interviews for resident #26's incident with NF8. Staff member A stated when NF8 was questioned about the incident with resident #26, he instead resigned from his position. Review of the Facility Reported Incident investigation failed to show staff interviews were completed. The importance of staff interviews for an incident in a long-term care facility ensures a more accurate and complete understanding to identify the root causes, improve care practices, and prevent reoccurrences. 2. During an interview on 3/23/26 at 3:27 p.m., resident #47 stated he had complaints about inadequate ADL care with NF7 due to long call light times and being left in a soiled brief for hours. Resident #47 stated he reported the concern to facility staff. During an interview on 3/26/26 at 9:19 a.m., staff member B stated they were unaware of any concerns from family or resident #47 regarding NF7. Staff member B stated they did not report the alleged abuse or neglect or investigate it. A request was made for resident #47's interdisciplinary team notes, root cause, reporting, and investigation for any concerns with staff member NF7 and resident #47. No documentation was provided by the end of the survey. 3. Review of a Facility-Reported Incident submitted to the State Survey Agency on 11/10/25, showed resident #77 alleged a certified nurse assistant came to the room, turned off the call light, and refused to provide requested personal care for resident #77. The facility interviewed the staff involved the night of the incident. The facility investigation did not include interviews from any other residents who may have been affected by staff not responding to care needs when call lights were turned off, and care was not provided. During an interview on 3/26/26 at 7:34 a.m., NF5 said it was the facility's MO (modus operandi) to turn off call lights and not provide the help while the staff was right there. NF5 said during the time she visited resident #77 she never saw the staff provide help when the call light was answered. NF5 said the staff told resident #77 they would be back to provide help but may not always return. NF5 said if the staff returned it may have been a few minutes to 30 minutes before resident #77 received the help she needed. NF5 said it was not just one certified nurse assistant, but many staff would turn off the call light and not provide help. On 3/25/26 at 11:00 a.m., the facility was requested to provide interviews from other residents regarding the allegation of neglect because of staff turning off call lights without providing care. By the end of survey on 3/26/26 at 1:15 p.m., the facility had not provided any further interviews or information.

Based on interview and record review, the facility failed to complete a baseline care plan that provided instructions needed to provide resident centered care for 3 (#s 11, 78 and 82) of 28 sampled and supplemental residents. The failure to have a baseline care plan placed the residents at risk of not being provided care to meet their basic needs. Findings include: 1. Baseline Care Plan Concernsa. Review of resident #11's electronic health records showed an admission date of 2/19/26. Resident #11 was admitted with diagnoses which included acute kidney failure, anemia, atrial fibrillation, chronic respiratory failure, hypertension, right femur fracture, morbid obesity and muscle weakness. Review of the nurse progress note dated 2/19/26 at 8:14 p.m., showed resident #11 had wound to coccyx reported stage I open. [sic]Review of resident #11's baseline care plan showed no care plan had been started to direct staff in caring for resident #11's wounds, pain management or caring for chronic medical conditions. A care plan was not initiated until 2/24/26 when advanced directives, oral dental health problems, loneliness, and discharge planning were added to the care plan. b. Review of resident #78's care plan showed she was admitted on [DATE] with diagnoses which included dysphagia, dementia, behaviors, history of falls and a urinary tract infection.A review of resident #78's nurse progress note dated 1/5/26 at 5:53 p.m., showed the resident had skin issues on the buttocks, both heels, and the right knee. The baseline care plan initiated on 1/5/29 did not identify pressure wounds or treatment for the wounds. c. Review of resident #82's physician Office/Clinic Notes showed the resident was admitted to the local hospital on 3/1/26 with a lumbar 4 compression fracture. The hospital surgically repaired the lumbar fracture.Review of resident #82's admission Nursing Evaluation initiated on 3/9/26 showed resident #82 had a Stage 3 pressure ulcer and the incision on the lower back had intact staples.Review of resident #82's baseline care plan, dated 3/9/26, did not identify wound management interventions. Resident #82's baseline care plan did not include pain management to control post operative pain.During an interview on 3/24/26 at 4:49 p.m., staff member B said the baseline care plan was triggered when the admitting nurse completed the admission nursing assessment. The baseline care plan was not completed until the nursing assessment was locked. When the nursing assessments were not locked the baseline care plan was not done. Staff member B said the baseline care plans are not always completed on time.

Based on interview and record review, the facility failed to provide education and information to the residents or responsible party on the risks and benefits of psychotropic medication, so they were able to make an informed decision, and the facility did not have documentation to show the resident/responsible party consented to the use of the medications, for 2 (#s 2 and 83) of 19 sampled residents. Findings include:1. Review of resident #83's Hospitalist History and Physical, dated 3/1/26, showed resident #83 had diagnoses which included mixed anxiety and depressive disorder. Review of resident #83's Medication Administration Record, dated March of 2026, showed Ativan, an antianxiety medication, was ordered on 3/11/26. The Ativan could have been given every eight hours as needed for anxiety. Review of resident #83's electronic health record, accessed on 3/26/26, failed to show a consent was provided to resident #83 educating him on the risks verses benefits of using a psychotropic medication. During an interview on 3/26/26 at 7:48 a.m., staff member B said resident #83 had not been provided with a consent for the Ativan. Resident #83 was not educated on the potential side effects and did not have the opportunity to sign a consent for the use of psychotropic medication. 2. During an interview on 3/26/26 at 10:17 a.m., staff member F stated the nurse was responsible for obtaining a psychotropic medication consent form from the resident or the resident's representative prior to a new medication being started. Staff member F stated she did not know why the psychotropic medication consent form for resident #2 was not obtained prior to the resident starting medications. Review of resident #2's medical provider note, dated 1/26/26, showed an order for sertraline 50 mg daily with a start date of 1/24/26, related to depression and anxiety disorder. Review of resident #2's medical provider note, dated 2/3/26, showed an ordered for mirtazapine 7.5 mg every evening related to a decreased appetite. Review of resident #2's medical record failed to show the resident or the resident's representative was provided education related to the use, risks, and benefits of the psychotropic medications in order to make an informed decision on the use of the medications. Review of a facility document titled, Psychoactive Medications, dated June 2025, showed: Policy Statement: It is the policy of this facility that the resident's medication regimen is free from unnecessary drugs and helps to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being. PROCEDURE: 1. Psychoactive drugs are drugs that affect the brain activity associated with mental processes and behavior. These drugs include: . b. Antidepressant c. Antianxiety . . 4. The risks/benefits of the drug use and informed consent is obtained from resident/resident representative prior to administration of any psychoactive medication initiation or dose increase.

Based on interview and record review, the facility failed to ensure the resident's right to have visitors of their choice for 1 (#53) of 28 sampled and supplemental residents. Specifically, the facility failed to allow resident #53's friend to visit her in the facility. Findings include:During an interview on 3/24/26 at 3:55 p.m., NF1 stated she had been a friend of resident #53 for many years prior to the resident being admitted to the facility. NF1 stated the first time she tried to visit, staff member B escorted her out of the building and was told if she tried to return, law enforcement would be called. NF1 stated she had been an employee of the facility approximately four years ago and was terminated due to an allegation of abuse towards a resident.During an interview on 3/26/26 at 8:48 a.m., NF2 stated he knew the facility was not allowing NF1 to visit resident #53. NF2 stated he was aware of the abuse allegation and was not worried about NF1 abusing resident #53. NF2 stated he wanted NF1 to be allowed to visit resident #53. NF2 stated the facility did not offer supervised visits or visits in a common area of the facility. NF2 was hesitant to bring up the visitation issue because he was concerned it might change the way resident #53 was treated by the facility.During an interview on 3/26/26 at 12:05 p.m., staff member B stated when an employee was terminated due to an abuse allegation, the employee was not allowed to return to the building for any reason. Staff member B stated the restriction was to protect all residents from abuse. Staff member B stated the facility did not consider the resident's history with the visitor when deciding to deny visitation.Review of the facility's policy titled, Visitation, dated March of 2025, showed residents have the right to receive visitors of their choice and at a time of their choosing. The policy also showed, The CENTER PROVIDES REASONABLE ACCOMMODATION FOR VISITATION . LIMITATIONS MAY INCLUDE BUT ARE NOT LIMITED TO: . 4. Denying access or providing limited and supervised access to an individual if that individual is suspected of abusing, exploiting, or coercing a resident until an investigation into the allegation has been completed or has been found to be abusing, exploiting, or coercing a resident.

Based on interview and record review, the facility failed to provide written notice of charges not covered when the resident was no longer receiving Medicare skilled services for 1 (#89) of 3 residents sampled for coverage notifications. Findings include: Review of the SNF ABN for resident #84, failed to show this notification was provided to the resident as required. During an interview on 3/24/26 at 2:45 p.m., staff member D stated she was responsible for completing the required notifications when a resident was no longer receiving Medicare A skilled services. Staff member D stated she should have completed the SNF ABN for resident #89. Staff member D stated she did not know why the form was not completed on 1/9/26 when the resident was discharged from skilled care. Staff member D stated the resident stayed for several more days while waiting for approval of his admission to a facility which contracted with the Veterans Administration. Staff member D stated the resident was charged the daily per diem rate until his discharge from the facility on 1/13/26. During an interview on 3/24/26 at 3:55 p.m., NF3 stated he believed resident #89 signed the paperwork associated with the end of skilled care services and the beginning of private pay services. NF3 stated he did not remember seeing anything in writing which explained the services charged after the end of Medicare skilled services.

Based on interview and record review, the facility failed to ensure a grievance was completed for an abuse and neglect allegation for 1 (#47); and failed to thoroughly investigate and document the findings for 1 (#53) of 28 sampled and supplemental residents. This deficient practice resulted in resident #47 reported feeling afraid and more anxious when NF7 would care for resident #47. Resident #47 also felt neglected in his care at the facility and feared retaliation for speaking up about NF7's care at the facility. The deficient practice affecting resident #53 increased the risk of discomfort from not repositioning the resident for comfort. Findings include:1. During an interview on 3/23/26 at 3:27 p.m., resident #47 stated he had complaints about a specific previous staff member, NF7, who would leave his call light on for hours and would not help with ADL cares which resulted in resident #47 experiencing bowel and bladder incontinence while waiting for his call light to be answered. Then once NF7 would respond to the needs of resident #47, resident #47 stated NF7 would force resident #47 to ambulate to the restroom instead of being cleaned up near his bed in the middle of the night. Resident #47 stated when he refused to ambulate to the restroom, NF7 would tell resident #47 to sign a refusal of care form. Resident #47 stated he reported the concern to staff member C. During an interview on 3/25/26 at 11:22 a.m., staff member C stated she was the grievance official and if there were any concerns a grievance would always be made to document the concern. Staff member C stated there were no concerns brought forth from family or resident #47 regarding a male CNA or NF7. Staff member C stated a grievance should be made if a resident brought up a concern of neglect of care, ADLs not being done, or long call light times. Review of [external] email from NF6 to staff member C, dated 2/15/26 at 6:49 p.m., showed: . Iam not happy at all with the care (resident #47) has received from the rest home side . (Resident #47) is afraid of him (NF7) due to how he acts I've been on (the) phone when he's flat told (resident #47) 'standing you up or moving you isn't in my job description' . BUT WE DO WANT TO FILE (a) GRIEVANCE . I would also like (NF7) away from (resident #47) . [sic] Review of resident #47's Care Conference, dated 2/24/26, showed, (Resident #47) reports that at night they are making him sign refusal sheets at night. Reports waiting 20-40 minutes for call light to be answered . This document was signed by staff member C. 2. During an observation and interview on 3/23/26 at 3:02 p.m., resident #22 was lying in bed wearing a hospital gown with his legs elevated on pillows. Resident #22 stated there was a night CNA who was rough and refused to reposition his legs. Resident #22 stated he had complained to the facility about the CNA's refusal to lift his legs; however, it was still happening. Review of a grievance submitted by resident #22, dated 10/31/25, showed the nature of the grievance was, male CNA will not readjust my legs to make me more comfortable. [sic] The investigative findings, dated 11/4/25, failed to show any investigation of the portion of the grievance involving a specific night CNA. The findings failed to show there was any attempt to identify the staff member involved or clarify what care was being refused. During an interview on 3/26/26 at 8:10 a.m., staff member E stated she was responsible for investigating the grievance submitted by resident #22 on 10/31/25. Staff member E was not able to recall any of the details associated with the investigation. When asked why she did not attempt to identify the accused CNA, she stated it was a recurrent complaint made by resident #22. Staff member E stated she believed the refusal to reposition the resident's legs for comfort was the result of a miscommunication between the resident and the CNA. Staff member E stated resident #22 requested to have his legs straightened which was not possible due to contractures of both legs. Staff member E stated she encouraged resident #22 to be more specific about what repositioning he was requesting. When asked why this explanation was not documented on the grievance form, staff member E was not able to provide an answer. Review of resident #22's Annual MDS Assessment, with an ARD of 10/14/25, showed the resident had impaired mobility to both upper and lower extremities. The assessment also showed the resident was dependent for all ADLs except eating. The resident required partial or moderate assistance with eating. Review of a facility policy, titled Grievance Procedure Policy, dated 11/16, showed, . 6. Grievances are resolved immediately, when possible, by the individual receiving the grievance. The individual receiving the grievance fills out a Grievance Form. 8. If the grievance involves abuse, neglect, exploitation, or misappropriation . an investigation begins .

Based on interview and record review, the facility failed to timely report an abuse and neglect allegation to the State Survey Agency for 1 (#47) of 19 sampled residents. Findings include:During an interview on 3/23/26 at 3:27 p.m., resident #47 stated he had complaints of about a specific previous staff member, NF7, who would leave his call light on for hours, would not help with ADL cares which resulted in resident #47 soiling his brief (bowel and bladder) from waiting so long, and NF7 would encourage resident #47 to sign refusal of care form. Resident #47 stated NF7 would then want resident #47 to ambulate to the restroom, but resident #47 stated he had already gone in his brief. During an interview on 3/26/26 at 9:19 a.m., staff member B stated no care concerns from family or the resident were brought to their attention. Staff member B stated they did not report the alleged abuse or neglect of care. Refer to F600 - Abuse and Neglect on the lack of identification of neglect for the resident. A request was made for documentation for resident #47's interdisciplinary team notes, any root causes identified, reporting, and investigation for any concerns with staff member NF7 and resident #47. No documentation was provided by the end of the survey.

Based on interviews and record reviews the facility failed to provide written documentation to the resident and/or the resident's representative upon transfer. The resident or representative was not provided with documentation showing the reason for transfer and the opportunity to enact a bed hold for 1 (#78); and the facility failed to send a copy of the notice of hospital transfer to the local facility Ombudsman for 2 (#s 47 and 78) of 28 sampled and supplemental residents. This deficient practice affected the resident's ability to ensure the transfer was appropriate and did not allow the resident or representative to request the facility to hold their bed. The deficient practice prevented the Ombudsman from tracking transfers. Findings include:1. During an interview on 3/25/26 at 2:21 p.m., NF9 stated she was not notified for resident #47's hospitalization on 2/11/26. During a follow-up interview on 3/25/26 at 3:58 p.m., NF9 stated she did not have any hospitalization notifications for January, February, or March 2026 (until the current date of 3/25/26). Review of resident #47's electronic medical record showed the facility failed to include the discharge transfer notification. A request was made for resident #47 and 78's hospitalization transfer notice to the Ombudsman. No documentation was provided by the end of the survey. 2. During an interview on 3/24/26 at 11:14 a.m., NF4 said resident #78 was transferred to the local hospital emergency room. NF4 said resident #78 was sent for evaluation and treatment due to deterioration of the resident's wounds. NF4 said the facility did not inform her about a bed hold and no paperwork was given to her regarding resident #78's transfer. During an interview on 3/25/26 at 4:13 p.m., staff member B said the transfer notice and bed holds were typically done by the nurses caring for the resident, or by the nurse managers. The delivery of the notice depended upon what staff was available. Staff member B said the social worker completed a report and sent the information about discharges to the facility's Ombudsman. Staff member B said the report was sent to the Ombudsman monthly. Staff member B said the social service designee was not sending the transfer notices to the local Ombudsman. During an interview on 3/26/26 at 8:15 a.m., staff member C said she did not submit information to the facility Ombudsman for resident #78. Staff member C said she submitted information regarding discharged residents to the Ombudsman but was not aware she was to submit information regarding hospitalized residents. Review of the facility policy titled Transfer and Discharge, updated May 2025, showed, - 5. When the transfer or discharge is initiated, the resident received written notice using the Resident Notice of Transfer or Discharge which includes the following items. - 6. The facility sends a copy of the notice to the State Long-Term Care Ombudsman.

Based on observation, interview, and record review, the facility failed to ensure a resident assessment was completed accurately for 2 (#s 2 and 24) of 19 sampled residents. Findings include:1. During an observation and interview on 3/24/26 at 11:34 a.m., resident #24 was oriented to her surroundings, able to converse, and answer questions appropriately. Review of resident #24's Comprehensive MDS, with an ARD of 2/7/26, showed the resident interview should have been completed. The MDS failed to show a BIMS had been completed during the look-back period. All of the questions in the section were answered as not assessed or no information. Review of resident #24's Quarterly MDS, with an ARD of 12/18/25, showed a BIMS of 15, which correlated with intact cognition. During an interview on 3/26/26 at 8:24 a.m., staff member F stated she was responsible for completing all MDS assessments. When asked why resident #24 did not have a BIMS completed on her Comprehensive MDS assessment, staff member F stated, I just missed it. 2. During an interview on 3/24/26 at 3:59 p.m., staff member C stated that resident #2's PASRR level one was completed on 8/15/25, which showed that a level two was not indicated. A verbal request was made to staff member C for the level one assessment for resident #2 as it was not in the resident's electronic medical record. During an interview on 3/26/26 at 8:50 a.m., staff member C stated that resident #2's PASRR level one was completed on 8/15/25, and she misread the document. Staff member C stated that a PASRR level two was completed on 8/22/25, but she had not received the recommendation, but had since learned she would need to check a secure web portal to get the information. During an interview on 3/26/26 at 10:17 a.m., staff member F stated resident #2's Comprehensive MDS assessment did not reflect that the resident's PASRR level one was completed on 8/15/25 and level two was completed on 8/22/25. Staff member F stated she reviewed resident #2's electronic medical record at the time of the comprehensive assessment and the documentation in which a PASRR had been completed, and it was not in the resident's medical record, and she would not have known one was done. Review of resident #2's electronic medical record did not show documentation of a PASRR level one or two was completed for the resident on 8/15/25 or 8/22/25. Review of resident #2's PASRR's documents, dated 8/15/25 and 8/22/25, requested from the facility showed a level one PASRR had been completed on 8/15/25 and the resident qualified for a level two screening which was completed on 8/22/25 with recommended services for the resident posted to a secure web portal on 8/25/25. Review of resident #2's Comprehensive MDS assessment, with an ARD of 12/30/25, section A, showed the facility indicated the resident was not considered by the state level two PASRR process to have serious mental illness and or intellectual disability or a related condition by answering no.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive care plan for 1 (#63) of 19 sampled residents. Findings include: During an observation on 3/25/26 at 10:15 a.m., resident #63's dressing to the pressure ulcer on the resident's coccyx was changed by NF10. The wound was almost healed with no drainage or odor. NF10 placed a small hydrocolloid dressing to the wound. Review of resident #63's PPS Part A Discharge MDS assessment, with an ARD of 1/12/26, showed the resident had a Stage IV pressure ulcer which had been present on admission [DATE]). Review of resident #63's care plan, dated 3/5/26, showed a problem statement of, The resident has risk for impaired skin integrity r/t (related to) fragile skin d/t (due to) limited mobility . She has a coccyx wound stage III since admission. with an initiation date of 3/5/26 and a revision date of 3/23/26. There was nothing related to a pressure ulcer on the care plan until 3/5/25, approximately three months after admission to the facility.

Based on observation, interview, and record review, the facility failed to accurately document the ADL services offered for 2 (#s 47 and 51), failed to offer a washcloth in the morning for 2 (#s 47 and 51), failed to offer mouthwash for 1 (#47), and failed to provide ADL assistance for a dependent resident for 1 (#22) of 19 sampled residents. Findings include: 1. During an observation and interview on 3/23/26 at 3:24 p.m., resident #22 was lying in bed wearing a hospital gown. Resident #22 also had several days growth of facial hair. Resident #22 stated he did not always get help with meals, has only had sponge baths the past several weeks (no showers) and needs a shave. Resident #22 stated his hand function varied from day-to-day, and the amount of assistance needed changed. Review of resident #22's Comprehensive MDS assessment, with an ARD of 10/14/25, showed the resident was dependent for all ADLs, except eating. The resident only required partial to moderate assistance with eating. Review of the facility's grievance log showed resident #22 had submitted a grievance on 10/31/25. The grievance submitted on 10/31/25 showed, She (unidentified night nurse) will not assist me with the urinal. I cannot do this myself. and male CNA will not readjust my legs to make me more comfortable. [sic] 2. During an observation and interview on 3/24/26 at 3:47 p.m., resident #47 stated he did not receive the care he deserved. Resident #47 stated he had not been offered mouthwash or a warm washcloth to wash his face for that morning or day yet. No mouthwash was in resident #47's room. Resident #47 had previously voiced concerns related to oral care and being offered a washcloth 3/23/26 at 3:27 p.m. Review of resident #47's Comprehensive MDS, with an ARD of 2/24/26, showed dependent for oral hygiene and upper and lower body dressing. Review of resident #47's PPS Part A Discharge MDS, with an ARD of 3/11/26, showed a BIMS of 13, cognitively intact. Review of resident #47's EHR showed the task oral hygiene: clean teeth/dentures and put dentures in/out of mouth. On 3/23/26 at 10:03 a.m., the resident was shown to need most help from staff to complete this task. During an interview on 3/24/26 at 4:12 p.m., staff member O stated resident #47 did not have teeth but that he would usually refuse to use a brush or a sponge (his mouth with a toothette sponge) if she offered. Staff member O stated she had never offered resident #47 mouthwash. Review of resident #47's EHR showed the task personal hygiene: comb hair, shave, apply makeup, wash face/hands. On 3/23/26, the documentation showed personal hygiene was offered at 10:03 a.m. to do most of the activity by staff. On 3/24/26, the documentation showed personal hygiene was offered at 3:37 p.m. During an interview on 3/26/26 at 10:25 a.m., staff member B stated that morning cares should be completed in a timely manner in the morning. 3. During an interview on 3/23/26 at 3:41 p.m., resident #51 stated she was able to wash her face, brush her teeth, and comb her hair, mostly all by herself. Resident #51 stated there were never any washcloths available for her to use unless she specifically asked staff to get her some. Review of resident #51's EHR showed the task personal hygiene: comb hair, shave, apply makeup, wash face/hands. On 3/23/26 at 10:05 a.m., the documentation showed staff did most of the activity for resident #51. During an observation and interview on 3/24/26 at 3:40 p.m., resident #51 stated there were no washcloths available for her to use for the day, yet. No washcloths were observed in resident #51's room. During an interview on 3/24/26 at 4:12 p.m., staff member O stated resident #51 was able to wash her face, brush her teeth, and comb her hair independently. Staff member O stated she had never given resident #51 a wash cloth daily as she was generally independent with cares.

Based on interview and record review, the facility failed to ensure an antibiotic medication order had an adequate indication for 1 (#19) of 19 sampled residents. Findings include:Review of resident #19's medication list, accessed on 3/24/26 at 9:11 a.m., showed the resident had an order for Macrobid capsule 100 mg, dated 1/7/26, give one capsule daily for prophylactic. The original order did not contain an appropriate indication for use.Review of resident #19's provider progress notes, since admission on [DATE], failed to show any history of chronic infections or any bladder disorders. A request for documentation of the medical necessity for Macrobid was made on 3/24/26 at 2:05 p.m. Review of resident #19's provider orders, dated 3/24/26 at 3:34 p.m., showed an order for Macrobid 100 mg, give one capsule every other day for a history of urinary tract infections. During an interview on 3/25/26 at 11:10 a.m., staff member B stated she had received a pharmacy recommendation regarding the use of Macrobid, which was dated 3/12/26. Staff member B stated she had forgotten to forward the recommendation to the Medical Director. Staff member B could not explain why the original order (dated 1/7/26) did not contain an appropriate indication.

Based on interview and record review, the facility failed to ensure pneumonia and Covid-19 (coronavirus-19) vaccines were offered per CDC recommendations for 3 (#s 23, 51, and 55) of 28 sampled and supplemental residents. Findings include:During an interview on 3/25/26 at 3:49 p.m., resident #23 stated he did not want the Covid-19 vaccine, but stated no one had ever offered him one or had him sign a declination form.During an interview on 3/25/26 at 1:13 p.m., resident #51 stated she would like a Covid-19 vaccine and stated no staff members had asked her if she wanted one.Review of request sheet #6 showed a request for the following vaccines (or declinations):-resident #51's Covid-19 vaccination-resident #55's Covid-19 and pneumonia vaccine-resident #23's Covid-19 vaccinationNo documentation was provided by the end of survey.During an interview 3/26/26 at 9:03 a.m., staff member B stated there were some vaccines which had been missed due to staff member B prioritizing numerous tasks and responsibilities. Staff member B stated another staff member had left in the past leaving staff member B with the task.

Based on interview and record review, the facility failed to schedule sufficient staff to ensure call lights were answered timely for 3 (#s 1, 2, and 3) of 7 sampled residents, and staff were using mechanical lifts with the appropriate number of staff for 1 (#5) of 7 sampled residents. This deficient practice had the potential to negatively impact all residents who use a call light by causing incontinent episodes and increases the risk of injury for all residents who need a mechanical lift for transfers. Findings include: 1. During an interview on 9/9/25 at 7:32 a.m., staff member D stated, I think the facility is understaffed 80 percent of the time. We (staff) try to get all our tasks done but some days it is hard. The facility is always trying to get people to pick up extra shifts. During an interview on 9/9/25 at 9:31 a.m., resident #1 stated, I do not feel as though the facility has enough staff. I don't always get the care I need due to the staff being too busy. The call lights are not always answered promptly. It takes a while to get help sometimes.During an interview on 9/9/25 at 9:35 a.m., resident #2 stated, I don't think there is enough staff to assist all of us (residents). Sometimes it takes 30 to 40 minutes to get the call light answered. That is a long time when you need to use the bathroom. During an interview on 9/9/25 at 9:37 a.m., resident #3 stated, There isn't enough staff, it is slow to get the call light answered most of the time. It takes 20 minutes or longer most times. During an interview on 9/9/25 at 3:25 p.m., staff member A stated she did not specifically have a policy on call lights. Staff member A stated It is the expectation of the facility staff that on most occasions, call lights are to be answered in at least 15 minutes. Staff member A stated that the facility has offered incentive bonuses for individuals who pick up extra shifts. Staff member A stated it is hard to find people who want to work. The facility covers employee call-offs and unfilled shifts with travel agency staff. During an interview on 9/10/25 at 7:19 a.m., staff member B stated, I have worked in other facilities, and I do not think this facility has enough staff for the acuity of the residents. Staff member B stated, the on-call person sends text messages all the time to see if we (staff) can pick up extra shifts. The facility has offered bonuses to staff to pick up shifts. Review of a facility document titled Call Light Response Audit, showed: . 8/3/25 - room [ROOM NUMBER]-2 - Time Light Turned ON: 0900 (9:00 a.m.) - Time Light Turned OFF: 0935 (9:35 a.m.) (35 minutes) .room [ROOM NUMBER]-1 - Time Light Turned ON: 0915 (9:15 a.m.) - Time Light Turned OFF: 0945 (9:45 a.m.) (30 minutes),room [ROOM NUMBER]-1 - Time Light Turned ON: 0917 (9:17 a.m.) - Time Light Turned OFF: 0935 (9:35 a.m.) (18 minutes) .room [ROOM NUMBER] - Time Light Turned ON: 0931 (9:31 a.m.) - Time Light Turned OFF: 0955 (9:55 a.m.) (24 minutes),8/30/25 - room [ROOM NUMBER] - Time Light Turned ON: 1:02 (1:02 a.m.) - Time Light Turned OFF: 1:23 (1:23 a.m.) (21 minutes) .A facility policy on call lights was requested on 9/8/25 at 3:52 p.m., no call light policy was received from the facility by the end of the survey.2. During an interview on 9/9/25 at 7:32 a.m., staff member D stated, It takes two staff members to use the lifts. I do use them (lifts) by myself when we are short-staffed or when I cannot get assistance. I know I'm not supposed to, but I do.During an interview on 9/9/25 at 7:43 a.m., staff member C stated, All lifts (mechanical) are a two-person transfer. I will do a lift transfer by myself when I can't get someone to assist me. I know we (staff) aren't supposed to but what else can we do? We don't want to make the residents wait longer than they need to. During an interview on 9/9/25 at 9:20 a.m., resident #5 stated, . Sometimes there is only one staff member to assist me with transfers. At other times there are two.Review of resident #5's care plan with a revision date of 5/14/25 showed: Transfer: Transfer between bed and chair or wheelchair: dependent assist of two . Transfers: Hoyer .During an interview on 9/9/25 at 3:25 p.m., staff member A stated she thought it would take two people to use a lift and stated, I will look for a policy on lifts. During an interview on 9/10/25 at 7:24 a.m., staff member A stated, I cannot find a policy on lifts and have reviewed the manuals and cannot find where it says how many people it should take to use them. Staff member A said she had watched a video about the lift they have, and in the video, it showed one person using the Hoyer lift. Staff member A stated she would still require two people to use the Hoyer lifts as she feels it is safest. A facility policy on lift use was requested on 9/8/25 at 3:52 p.m., and no lift use policy was received from the facility by the end of the survey.

Based on observation, interview, and record review, the facility failed to ensure a resident who had medications left at bedside was assessed, and a physician's order was obtained for the safe self-administration of medications, for 1 (#5) of 7 sampled residents. Findings include:During an observation and interview, on 9/9/25 at 7:14 a.m., staff member E prepared resident #5's medication and put them into a medication cup. Staff member E opened resident #5's door and placed the medications in the resident's room on the bedside table. Staff member E stated, She's (resident #5) sleeping, I leave them in there for her to take when she wakes up, most of the time she won't take them in front of me and says she will take them when she is ready to take them.During an interview on 9/9/25 at 9:20 a.m., resident #5 stated, Staff often leave my medication in my room for me to take when I'm ready to take them. Sometimes they will watch me take them, but not always.During an interview on 9/9/25 at 3:25 p.m., staff member A stated it was not okay to leave medications at the bedside for residents unless they had been assessed for the self-administration of medications.Review of resident #5's electronic medical record failed to show a physician's order for the self-administration of medications and failed to show that a safety assessment had been completed to determine if resident #5 was safe to self-administer her own medications.Review of a facility document titled Medication Administration: Self-Administration by Resident, dated January 2023, showed: Policy: Residents who desire to self-administer medications are permitted to do so with a prescriber's order and if the nursing care center's interdisciplinary team has determined that the practice would be safe and the medications are appropriate and safe for self-administration.Procedures: 1. If the resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of the resident's cognitive, physical, and visual ability to carry out this responsibility, during the care planning process. [sic]

Based on observation, interview, and record review, the facility failed to provide wound care as ordered by the provider; and failed to implement and document physician ordered interventions intended to mitigate worsening of a pressure ulcer, for 1 (#14) of 3 sampled residents with pressure wounds. These deficient practices contributed to the worsening of a pressure ulcer from nearly healed to a Stage III ulcer on the resident's heel. Findings include: 1. Pressure ulcer dressing changes not done as ordered Review of resident #14's provider orders, dated 8/23/24, showed the dressing change was, LEFT HEEL: cleanse ulcer with vashe wash, . pack with silver alginate rope, cover with opti-foam dressing. one time a day every Mon, Wed, Fri. [sic] Review of resident #14's provider progress note, dated 9/18/24, showed the resident's left heel ulcer had worsened with increased sloughing of yellow green tissue. The note also showed, Continued to emphasize to [resident #14 First Name] regarding the importance of offloading this ulcer to support wound healing. Educated that these types of ulcers are significantly pressure and weight related. Educated that without strict guidance to above, will likely never heal . Prevalon boot for offloading when supine and sitting. Review of resident #14's TAR, dated September of 2024, showed no dressing change was signed off as completed on 9/20/24. Review of resident #14's provider order, dated 9/25/24, showed, LEFT HEEL: Cleanse stage III with Vashe wash, pat dry, . apply foam to wound bed . cover all foam with transparent dressing. Wound vac to run continuously at 125mmHG. [sic] Review of resident #14's TAR, dated September of 2024, showed no dressing change was signed off as completed on 9/27/24. During an observation on 10/21/24 at 8:50 a.m., resident #14 was lying in bed and had a bulky Coban (special tape) dressing on his left heel with a date of 10/16 on it. Review of resident #14's provider order, dated 10/17/24, showed the dressing change was, LEFT HEEL: Cleanse wound and periwound with Vashe wound solution, apply gentian violet to peri wound, add metronidazole powder and silver alginate rope to wound bed, cover with ABD pad. one time a day every Mon, Wed, Fri for stage III. [sic] Review of resident #14's TAR, dated October of 2024, showed the dressing change on 10/18/24 was documented as completed by staff member F. During an interview on 10/21/24 at 9:32 a.m., staff member F stated she documented the completion of the dressing change on 10/18/24. But, did not actually do the dressing change. Staff member F stated the wound care nurse was there on that day and did the dressing change. During an interview on 10/21/24 at 9:55 a.m., staff member G stated she was responsible for wound care. But, she was only in the facility for a short time on Friday (10/18/24), but did not work. Staff member G stated it was the responsibility of the floor nurse to do their own treatments (dressing changes) when the wound nurse is not available. 2. Use of heel protector boots and a bolster pillow used for pressure ulcer prevention. During an observation and interview on 10/14/24 at 1:57 p.m., resident #14 was heard yelling Help from his room. Resident #14 was sitting up in his wheelchair and was not wearing the heel protector boot on his right foot. The resident's left foot had the heel protector boot on. However, his left foot had slipped off the footrest and was wedged between the footrests on his wheelchair. Resident #14 stated he was in pain and needed to go back to bed. Resident #14 stated he had been up in his wheelchair since about 10:30 (a.m.). During an observation and interview on 10/21/24 at 8:50 a.m., resident #14 was lying on his back in bed with his eyes closed and the head of the bed elevated. Resident #14 had a blue bolster pillow measuring approximately six inches thick and 18 inches wide place under both of his legs, and centered at his knees. There were also two regular bed pillows on top of the bolster pillow. When asked why he did not have the heel boots on, the resident stated, They say they don't have time. During an interview on 10/21/24 at 11:00 a.m., NF2 said she tried to attend #14's wound clinic appointments. NF2 stated she had been complaining to the facility staff for months about the improper placement of the bolster pillow, under the knees rather than under the calves, and the use of heel protector boots on both feet. NF2 stated she was told, by the wound clinic provider, the purpose of the bolster pillow was to allow the resident's heels to float and thereby minimize pressure. NF2 stated the wound clinic provider had ordered the heel protector boots to be on both feet at all times, except when ambulating. NF2 stated when she asked the facility staff about the heel protector boots, she was told resident #14 refused to have them on. During an interview on 10/21/24 at 3:15 p.m., staff member C stated she was not able to find documentation of the order for, or the consistent use of, the heel protector boots and the bolster pillow. Staff member C stated there were some refusals documented, but it was not documented consistently. Review of resident #14's nursing progress notes, dated between 8/21/24 and 10/17/24, showed the heel protector boots were refused by the resident on 8/21/24, 9/18/24, 9/23/24, 9/24/24, 9/26/24, and 10/17/24. Review of resident #14's nursing progress notes, dated between 8/20/24 and 10/16/24, showed the resident's heels were floated on 8/20/24, 8/21/24, 9/18/24 at 1:51 p.m., and the presence of a pressure ulcer was found on the resident's left heel. No other documentation of the use of heel protector boots was found in the EHR.

Based on observation, interview, and record review, the facility failed to anticipate the needs for 2 (#s 9 and 30) of 2 sampled resident, resulting in a fall with significant injury; and failed to identify potential faults in a wander guard system, which allowed a moderately cognitively impaired resident, 1 (#56) of 1 sampled resident, to elope from the facility. Findings include: 1. Review of a facility reported incident, dated 3/11/23, showed resident #9 was found on the floor, behind the door, to her room. She was lying sideways with her walker on the floor next to her. Resident #9 was in the facility for rehabilitation for a fall that occurred at home, resulting in a fractured hip. During an observation and interview on 3/27/23 at 9:04 a.m., resident #9 was lying on her bed with an ice pack and sling applied to her shoulder. Resident #9 appeared to be confused, asking where she was, and how long she had been in the facility. A review of resident #9's care plan showed she was admitted to the facility on [DATE], after a hip fracture from a fall at home. The care plan showed resident #9 required limited/extensive assistance of one for transferring, bed mobility, and toilet use. Resident #9 had been diagnosed with dementia. During an interview on 3/29/23 at 4:46 p.m., staff member I stated resident #9 had dementia and did not understand how to utilize the call light to ask for help. Staff member I stated she did not feel resident #9 would be able to understand a touch call light. During an interview on 3/30/23 at 7:40 a.m., staff member B stated the facility put the usual precautions into place for resident #9 as they would for anyone at risk for falls, including providing a call light and non-slip socks. The facility failed to implement an individualized care plan for resident #9 that would address her dementia and inability to understand how to use a call light, the need for frequent toileting such as every two hours and frequent checks. During record review, resident #9's EMR showed that she was found on the floor and unable to tell the nurse what happened because of her dementia. Resident #9 had no obvious injuries but was complaining of pain in her upper left arm. After being transported to her bed via mechanical lift, the staff obtained permission to send her to the emergency department where she was diagnosed with a fractured left shoulder. During an observation and interview on 3/30/23 at 8:48 a.m., resident #9 was heard telling staff member K she did not want to do any more because she was worn out. Staff member K stated resident #9 needed to be given significant motivation to get up and start moving. During an interview on 3/30/23 at 9:01 a.m., staff member J stated resident #9 did not want to get out of bed since the fall when she fractured her shoulder. Staff member J was not certain if it was related to the pain from resident #9's hip, back, and shoulder, or from fear of falling again. Staff member J stated resident #9 had become more incontinent since the fall. 40068 2. During an interview on 3/27/23 at 4:11 p.m., resident #30 stated she occasionally needed help getting off the toilet. Resident #30 stated she is often left on the toilet with no help for a long period of time. During an interview on 3/29/23 at 9:37 a.m., resident #30 stated she had a fall in June 2022 and broke her back. She stated she was in the bathroom waiting and she attempted to reach up and grab a roll of toilet paper. She slipped and hit her back on the front of the toilet and landed on the floor. During an interview on 3/29/23 at 10:36 a.m., staff member A stated resident #30 had a fall in June of 2022 and broke her back. Staff member A stated resident #30 had a BIMS score of 15 (cognitively intact) so she should not need any help in the bathroom. Staff member A stated if resident #30 did need help she should know to wait for help and not try to do it herself. Review of a facility incident on 6/24/22 showed, [Resident #30] had ambulated herself to the bathroom. The nurse heard her fall and found [Resident #30] on the floor in front of the toilet. [Resident #30] had attempted to transfer herself. The nurse checked her skin and discovered an abrasion to her lower/middle back. [Resident #30] stated that her back hurt. Neuro checks started, vital signs obtained, ROM intact, and skin evaluation conducted. Provider and healthcare POA were notified of the event. [Resident #30] was transferred to the hospital for further evaluation . Findings: [Resident #30] fell in her bathroom while transferring self from the toilet. She hit her back on the toilet and was provided first aide by facility staff. She complained of back pain and was sent to the hospital for evaluation per providers instruction. Due to the fall, [Resident #30] had a T12 fracture. She returned to the facility on [DATE]. [Resident #30] doesn't exhibit signs or symptoms of distress from the fall. She will continue PT and OT services. She is cognitively aware and staff to continue to remind her to request assistance with transfers. Provider and POA notification were made. Care plan updated and staff to monitor for changes in condition. [sic] Review of resident #30's Admission MDS, with an ARD date of 6/7/22, showed, under section I; toilet use extensive assist, one person physical assist. 32997 3. During an observation on 3/27/23 at 4:22 p.m., resident #56 was lying on his side in bed. The resident appeared to be sleeping. Resident #56 had what appeared to be a wander guard alarm, on his lower right leg, above his ankle. Review of resident #56's care plan, revised on 10/20/22, showed the resident was an elopement risk, and he was to wear a wander guard on his right ankle. Review of a facility reported incident and investigation, dated 7/15/22, showed resident #56 had eloped from the facility. The resident was found on a busy street by the maintenance staff. During an interview on 3/30/23 at 9:13 a.m., staff member I said she knew resident #56, and assisted him frequently. Staff member I said she knew resident #56 was an elopement risk, and had been since he was admitted to the facility. Staff member I said all of the exit doors on the units were alarmed, and could be heard anywhere in the facility. Staff member I said all the exit doors had a 15 second delay on them, and after the 15 seconds had passed a resident with a wander guard could exit the building. Staff member I said a new alarm was installed at the main entrance of the facility around the end of July last year. Staff member I stated, Residents with wander guards cannot leave through the main entrance anymore without someone turning the alarm off.

Based on observation, interview, and record review, the facility failed to ensure a resident had water or fluids readily available and within reach of the resident, specifically if the resident could not get water or fluid on their own, and the facility staff failed to follow the hydration policy for ensuring water availability for 2 (#s 12 and 24) of 2 sampled residents. Resident #42 was sent to the ER and found to be dehydrated. Findings include: 1. During an initial observation on 3/27/23 at 3:51 p.m., resident #42's personal water cup was on his side table, and the cup was empty. The facility provided water cup was across the room, next to his bed, and out of reach of the resident. During an observation and interview on 3/28/23 at 2:26 p.m., resident #42's personal water cup was on the bedside table, and empty. The facility provided water cup was across the room, next to his bed. The cup had the same level of fluid (500mL) as 3/27/23, it appeared untouched and had not been moved. Resident #42 stated, They haven't filled it (personal water cup next to him) since the night . During an observation and interview on 3/28/23 at 3:58 p.m., staff member L was passing waters on the unit to rooms 109 to 116. When asked when water pass usually occurred, staff member L stated, Usually once every shift, but I see that they haven't gotten water so I'm doing it now for my people, and again later. When asked who would fill the waters on resident #42's hall, staff member L stated, The CNA for The hall should be checking on his residents, and would see they don't have water. During observation on 3/29/23 at 7:19 a.m., the facility provided water cup was across the room next to resident #42's bed, with the same level of fluid as previous days. It appeared to be untouched. Resident #42 was sleeping in his recliner. His personal water mug was nearly empty. During an observation and interview on 3/29/23 at 9:08 a.m., resident #42 was in his recliner, and his personal water cup was nearly empty. A facility water cup was in the same spot, with approximately 500 mL of water next to his bed. The cup appeared to be untouched. Resident #42 stated, he had not received water, . no water since last night. During an observation on 3/29/23 at 9:12 a.m., staff member C was at nurse's station, directing the staff to go out and do a water pass, immediately. During an interview on 3/29/23 at 9:31 a.m., staff member G stated, Water is passed (to the residents) after breakfast and before we leave at two, if we have time. Residents have to ask for water if they need it between then. During an interview on 3/29/23 at 9:35 a.m., staff member Q stated water pass was at breakfast and bedtime. During an interview on 3/29/23 at 11:45 a.m., staff member D stated, They (staff) should be passing water a couple of times a day, and (staff) should really offer (fluid) every time they are in the room, guess we should add it to their pocket sheets and ISP (section in EMR for CNA documentation) CNA tasks. When asked about resident #42 specifically, staff member D stated, I know he had not been drinking or eating while his wife is in the hospital, and he doesn't like water in general. They (staff) should be going in and cueing him frequently throughout the day, on hydration. During an interview on 3/29/23 at 2:14 p.m., resident #42 stated, No water since I got up so whatever your doing isn't helping. Review of an Emergency Department Report, dated 2/14/23, showed, resident #42 was sent to the emergency room for generalized weakness, shortness of breath and hypotension. Resident #42 reported to the physician . he has not been drinking much fluid and feels like his mouth is dry, and he could be dehydrated. Labs reflected a worsening creatinine level that the physician believed was related to the dehydration. Resident #42 received IV fluids in the emergency room and was sent back to facility. The physician noted, . I suspect his acute kidney injury will improve with this as well as aggressive hydration at home. The Final Impression noted an, acute dehydration, acute kidney injury, hypotension-resolved with fluids, Plan noted as repeat labs next week, nursing home to schedule follow-up with cardiology, nursing to encourage PO fluid intake, nursing to report any changes. Review of a facility document, provided by staff member D, titled Water Pass, not dated, showed, Water is passed twice daily and as needed. Review of a facility inservice training document, titled Fluids and Hydration Inservice Training, updated February 2013, was not dated, and did not show a time when the training occurred or who presented the information. The inservice showed: - a. Offer fluids frequently throughout the day (at med passes, before and after personal care, at activities, before bedtime). - b. Provide early morning beverage carts, provide mid-day hydration carts, or evening beverage carts. e. Monitor at risk residents for physical signs of dehydration. The information did not show how individualized resident needs for hydration would be addressed, specifically if a resident was high risk. 2. During an observation and interview on 3/29/23 at 1:20 p.m., resident #21's facility water cup was sitting an on over-bed table, across the room from the resident. There was an electric wheelchair sitting in the middle of room. Resident #21 stated the lack of receiving fluids has .not gotten any better since I complained, most of the time . I just have to go down to nurses station and get it (fluid) myself or at least tell them at the station that I need it. They (staff) don't bring it (fluids) if I use this thing (call button). Review of a GRIEVANCE FORM, filed by resident #21, dated 3/10/23, which was investigated on 3/14/23, showed, . staff don't pick up his tray or get him ice water, Action taken: . staff get resident ice water when it is asked for, not after. Review of resident #21's care plan, with a revision date of 3/7/23, showed resident #21's transfer status as, .is able to move between surfaces with setup help and supervised assist.

Based on observation, interview, and record review, the non-smoking facility, failed to thoroughly assess, monitor, supervise, and implement constructive interventions for a resident who was a non-compliant and unsafe smoker, for 1 (#36), and the resident had a history of smoking in the facility, on facility grounds, eloped while smoking or attempting to smoke, had a second degree facial burn from smoking in his room with his oxygen on in May 2021, refused to allow the facility to assist and secure his smoking materials (lighter, cigarettes, and matches). The facility neither had a safe designated smoking area, nor enforced the policy for smoking. These cumulative failures increased the imminent risk of injury for resident #36 and others residing at the facility; and the facility failed to ensure an effective system was in place for residents who eloped or were at risk of eloping, for 2 (#s 24 and 36) of 2 sampled residents, and the facility did not monitor, supervise, re-evaluate safety interventions when necessary, or implement ample safety interventions, for the residents. On 3/29/22 at 4:49 p.m., the facility Administrator was notified that an Immediate Jeopardy existed in the area of F689: Free of Accident Hazards /supervision/devices, for smoking. The severity and Scope identified for the Immediate Jeopardy was identified to be at the level of J, and upon removal of immediacy, lowered to a G. Findings include: A. Smoking and Elopement During an observation on 3/29/22 at 7:50 a.m., resident #36 was observed on the sidewalk with his four wheeled walker, smoking. Resident #36 proceeded to walk through the front doors of the facility, enter the code to unlock the second set of entrance doors, and returned to his room in the skilled nursing facility. During an observation on 3/29/22 at 8:07 a.m., resident #36 did not check in with staff at the front desk when reentering the building after smoking, and did not secure his smoking materials with the staff. During an observation and interview on 3/29/22 at 9:26 a.m., resident #36 was walking back into the building, wearing thin clothes, and it was heavily sleeting outside. He stated he had gone for a smoke, and during the interview stated he had no intention of stopping smoking. He stated he kept his smoking materials on his person, and he had [NAME] holes all over his room at the facility. During an interview on 3/29/22 at 2:00 p.m., staff members A and B stated, the facility was non-smoking, but resident #36 attempted to smoke. Resident #36 was cognitive enough to be educated and he had no need of skilled nursing services. He was still at the facility until his disability kicked in in February. His goal was to live in an apartment. Resident #36 used oxygen, but facility staff were not sure how much he actually used it anymore, other than possibly to sleep. He did not take the oxygen with him outside. The facility told him he could not smoke and then he eloped by pushing the window screen out, climbing out the window, and walking to the store for beer and cigarettes. Resident #36 would sign himself out to smoke off property. This was the intervention after he was caught smoking in his room and burning himself. Resident #36 kept his smoking supplies on his person or in a lock box provided but this was not verified as he did not let anyone in his room. During an interview on 3/29/22 at 2:05 p.m., staff member S stated Yes, resident #36 smoked. Staff member S had not had any training related to the facility smoking policy, resident #36's smoking or sign out process, and was not aware of any prior smoking injuries of resident #36. During an interview on 3/29/22 at 2:07 p.m., staff member R stated Yes, resident #36 smoked. He would go out to the sidewalk past the parking lot. He signed out and then back in when he was done, and he had his cigarettes and matches. The facility policy was the residents had to be off the property (if smoking). Staff member R stated he was not trained on the smoking policy and not aware of any prior smoking injuries of resident #36. Staff member R stated, I believe he's safe if management is letting him [smoke]. During an interview on 3/29/22 at 2:10 p.m., staff member E stated resident #36 smoked off the property. Staff member E stated resident #36's smoking routine consisted of him telling us he was going out to smoke, alone. His supplies were in a lock box in his room. The nurse manager and resident #36 had a key. The policy was the facility was non-smoking. Staff member E stated there was no training for staff related to resident smokers but she had been trained at another facility. She stated resident #36 had an injury about a year ago, and he was sneaking out of his room and got burned when smoking. Staff member E stated if they [management] were allowing him to smoke, he was deemed safe. Staff member E stated there were weekly skin assessments for resident #36, and there had been no issues. During an observation on 3/30/22 at 11:36 a.m., resident #36 was smoking across the street from the front of the facility, by himself, without a smoking blanket, fire extinguisher, and not in the designated smoking area. A staff member was standing on the corner of the parking lot watching resident #36 from down and across the street. During an observation on 3/30/22 at 1:49 p.m., staff member C, asked where resident #36 was. The assigned staff member, who was the designated 1:1 for the resident, was staff member Q. Staff member Q was observed feeding another resident in the dining room. Staff member Q told staff member C resident #36 left in his truck at 1:30 p.m. When he left, there was a time set for smoking, so he got upset and left. Staff member Q was unsure of where resident #36 went. Staff member C asked if she notified anyone, and she stated she told staff member F. During an observation on 3/30/22 at 2:00 p.m., resident #36 was not in his room. The room was wall to wall belongings with a clear path out to the door. The bed was pushed against the wall and below the window. The room smelled heavily of old cigarette smoke. At the nurses station resident #36's sign out book showed the last sign out time as 1:30 p.m., but the sign out sheet did not have the correct date documented, or a return time. During an observation on 3/30/22 at 2:01 p.m., staff member Q was sent to the lobby by staff member F to wait for 1:1 supervision of resident #36. During an interview and observation on 3/30/22 at 2:02 p.m., staff member C was asked for the sign out for resident #36, since he had not returned to the facility. The form with check-in/out times was not dated accurately, so it was unclear if the documented time was accurate. During an interview on 3/30/22 at 2:04 p.m., staff member F stated resident #36 usually started smoking early in the day. Even before staff member F got to work in the mornings. Staff member F stated this, while he was trying to decipher when the times on the sign-out sheet started, for the current day. The date was not listed on the sign out sheet/binder. Staff member F signed the sign out sheet for the 1:30 p.m. sign-out of resident #36, even though that was the only nurse initials on any sign out sheet in the binder, and not when the resident actually signed out. During an interview on 3/30/22 at 2:06 p.m., staff member T stated resident #36 had the door code for the front door of the facility, so he would just walk in and out. Normally residents and visitors would check in with her when entering and exiting the building. The last time she saw resident #36 was when she was arriving to work in the parking lot. Resident #36 was out smoking, and a staff member was standing away from him, observing him. She had not seen him come through the front door of the facility, otherwise, but she wasn't always [NAME] the door. The only other exits were the assisted living door, or the staff entrance where the staff smoked, which was at the back of the facility. During an interview on 3/30/22 at 2:13 p.m., staff member A stated resident #36 just got in his truck and left the facility grounds. During an interview on 3/30/22 at 2:29 p.m., staff member Q stated, she was told when she arrived on her shift she would be resident #36's 1:1. She was to sit in $36's room with him, and go with him on the property. She was not told what area was designated for his smoking, any specific times for smoking, or if anything needed to be documented. Staff member Q stated resident #36 had left the building around 12:40 p.m., and he did not say where he was going. Resident #36 seemed upset with a talk management had about smoking rules. Staff member Q was to sit at the front door and wait until resident #36 arrived back to continue the 1:1 assignment. Staff member Q stated she would stand at the sidewalk on the facility property, as the resident smoked across the street. He would continue to smoke until he re-crossed the street and tossed the butts on the property before walking back in the facility. Staff member Q stated resident #36 had smoked since he was admitted , and when he was newer, he had gotten burned smoking in his room. During an interview on 3/30/22 at 3:41 p.m., staff member T stated resident #36 got back to the facility, an hour ago. Review of resident #36's current physician orders did not show any order for resident #36 to leave the facility on his own. Review of resident #36's nursing progress notes showed: - 5/29/21 Noted burn on lip and nose. - 5/30/21 Resident admitted to smoking. Forgot to take off oxygen canula and had been smoking in his room in the facility. Resident sent to ER and returned on 5/31/22 with treatments for 2nd degree [CONDITION(S)] on his face. - 6/4/21 Resident #36 eloped through his room window to go get cigarettes when under 15 minutes checks. - 6/5/21 Resident told a CNA to steal cigarettes for him. - 6/7/21 Resident met with the Executive Director, stated he would act like a prisoner because that was how he was treated for smoking in his room out the window. Resident was hanging out of his window to smoke. - 6/15/21 Executive Director said he can go on supervised walks and could not smoke nor could staff accompany him to smoke. - 6/24/21 Resident room smelled of smoke and his head was out the window. - 6/27/21 Popped screen off his window again. - 6/29/21-6/30/21 Resident put a fan in his window. - 8/4/21 Resident smoking in room. - 8/9/21 Resident smoking in room. -11/21/21 Resident found outside the front door of the facility smoking. Resident was given non-smoking reminder by a staff member. - 12/16/21 Resident reported boo [NAME] on blister on his thumb and scrapes on leg that were the same size and shape. Resident stated he got them when his truck caught on fire, and he slid off the hood. - 12/22/21 Filled his room with boxes of belongings. - 3/1/22 Care conference with the the facility staff and resident stated his room was a fire hazard. - 3/5/22 Resident came in from smoking with low oxygen saturation. Review of resident #36's smoking evaluations, dated 3/23/22 and 6/2/21, showed a lack of conclusion for the resident's risk and intervention needs related to safely smoking. Review of resident #36's MOCA assessment showed a score of 23/30. A normal score was equal to or greater than 26/30. This assessment is designed to show cognitive functioning including: orientation, visiospacial awareness, memory, attention, and executive functioning of a person's brain. Review of resident #36's assessment lists from 3/1/21- 3/23/22 showed weekly skin assessments were not completed every week. Review of resident #36's Care Plan, last updated 11/29/21, showed: - For smoking, there was a problem area added on 5/30/21 showing, Resident is an active smoker, has been caught smoking in the building. The goal was last updated on 11/29/21 as, Resident will not bring smoking materials into building, will not smoke here, especially while on oxygen therapy. The interventions were last updated 6/8/21 as, Nursing has offered getting provider to order patch or other safe nicotine therapy. Resident declines nicotine therapy and Resident has stated he will no longer smoke in his room. -For the elopement problem area added on 6/8/21, the plan showed, The resident is an elopement risk/wanderer crawls out window r/t impaired safety awareness. Under interventions the care plan showed, Assess for fall risk. Frequent checks daily. No other updates or interventions were in place related to the resident leaving the building and property for smoking or without alerting staff. Review of resident assessments showed on 6/4/21 a pre-elopement and at elopement assessments were completed. No other elopement risk assessments were conducted during resident #36's admission or added to the care plan. Review of the facility policy, Resident Smoking Safety, updated 8/2019, showed: - Smoking is only done supervised, and not allowed in the building. - Appropriate interventions are care planned and implemented based on the results of the Smoking Safety Evaluation. - If a resident wants to smoke independently off grounds, the Center does not knowingly allow this to occur without supervision. a. Smoking materials are provided to residents for/during center supervised smoking only. If a resident requests to go on LOA and requests smoking materials, the Center declines the request. The resident, if able, may purchase their own smoking materials while off grounds but must relinquish them upon return to the Center. - A portable Fire Extinguisher, rated Class A, is stored in the designated smoking area. - A fire blanket is stored in the designated smoking area. - Ashtrays of non-combustible material and safe design shall be provided in all smoking areas . -Metal containers with self closing cover devices shall be readily available in all smoking areas . -Residents who smoke remain at least 25 feet away from oxygen in use. -Residents who use oxygen are instructed to remove the mask or cannula, shut off the oxygen supply, and wait for the oxygen to dissipate for a minimum of five minutes prior to smoking. -When there is potential or identified conflict between the residents right to smoke and/or the residents continued smoking while using oxygen and/or the risk of harm to self or others, a re-evaluation of the residents smoking is completed. Residents safety outweighs the residents right to smoke. B. Elopement During an interview on 3/30/22 at 9:54 a.m., NF3, stated resident #24 had an elopement recently. He had a very tough deal and spends most of his time in his room. His pain management was poor and it increased his behaviors. During an interview on 3/30/22 at 2:11 p.m., staff member T stated, she was new and had not been a part of a drill for elopement or missing residents. She had online training modules that went over elopement during orientation. The facility had a few residents with wanderguard bracelets, and the doors to the skilled nursing and assisted living entrances were alarmed if a resident wearing a bracelet would get within range. During an interview on 3/30/22 at 2:39 p.m., staff member Q stated, there were residents who wander and some had wanderguard bracelets on. Nurses checked the bracelets to ensure they were working and for the placement. There was a resident who eloped recently, but she was not working when it happened. If a resident was an elopement risk it would have been on the care plan, and staff would try to redirect or use interventions for a resident exit seeking, or start a missing resident search if they couldn't find a resident. During an interview on 3/31/22 at 9:20 a.m., staff member B stated, resident #24 eloped the month before, in February 2022. He was wearing a wanderguard and had gone through the assisted living doors. A neighboring building resident noticed resident #24 in their parking lot and walked him back to the skilled nursing facility entrance. Staff member B stated resident #24 was not harmed upon assessment, and the responsible party and physician notifications were done including a progress note for the incident. Resident #24 had dementia and would wander aimlessly through the halls. When anxious and agitated he would exit seek, usually looking for his friend or son, both with the same name. Staff were to redirect and offer snacks as he needed the calories since his disease process was declining. Review of a facility reported incident for resident #24's elopement showed, the event happened on 2/15/22 at 6:20 p.m., resident was seen wandering the halls in his wheelchair by nursing an undetermined amount of time prior to being returned to the facility front doors by a neighboring facility resident. Review of resident #24's care plan showed for elopement: - The problem area, [Resident #24] is an elopement risk/wanderer attempting to find car and go to bank r/t History of attempts to leave facility unattended. Resident wanders aimlessly. This was initiated on 11/11/20 and revised on 3/3/21. Interventions initiated on 11/11/20 and revised on 11/18/21 were, Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers: and WANDER ALERT: walker/wheelchair #F04F1D right ankle # Model [sic] - Another problem area added on 2/21/22 showed: [Resident #24] has an actual elopement R/T Alzheimer's DISEASE, UNSPECIFIED, UNSPECIFIED DEMENTIA WITH BEHAVIORAL DISTURBANCE. The interventions were entered on 2/21/22 and showed, Check on me frequently during the day when I am up in my wheelchair and Distract me from wandering by offering pleasant diversions, structured activities, food, conversation, television, book [sic] The Care Plan did not address the root cause of how resident #24 eloped from the facility. Review of resident #24's progress notes showed: - 2/16/22 At approx. 1810h [6:10 p.m.], this nurse was given report that a staff member answered the front door to view an unknown person from [neighboring facility] accompanying res. Was told that the resident was found in the [neighboring facility] parking lot next door and brought back. He was dressed in a shirt, blue jeans, socks and shoes, sitting in his w/c. 'I went outside, I don't know why . I knew it was wrong.' Physical assessments yielded no skin redness/trauma. Res is poor historian and unable to explain how or why he left the building or even who assisted in returning him to the facility. Res was last seen propelling self in his w/c in the hallways of the SNF when the nurse was on her rounds. A CNA reported that she heard the ALF alarm sounding and as she was occupied in the restroom, she was unable to reset the alarm 'after about 5 mins'. She reported that no one was observed in the hallway leading into the ALF unit. Wanderguard in place around right ankle. tested positively for alarm and is in active mode. The responsible party and on-call provider were notified. - 2/17/22 Residents wonder guard is on his left ankle, he continues to circle the halls from timbers to tlc occasionally checking doors at the end of the halls. I have had to go get him 6 times on assisted living on my shift, he sets the alarms off, I redirected him back to out unit . [sic] - 3/22/22 Resident open the door at the end of hall 3, and began to exit, redirected resident. [sic]

Based on observation, interview, and record review, the facility failed to ensure repositioning for a dependent resident, which lead to skin breakdown and made the resident feel helpless and lousy, for 1 (#51) of 1 sampled resident. Findings include: During an observation and interview, on 3/30/22 at 3:40 p.m., staff member E performed wound care and a dressing change to the sacrum and buttocks area on resident #51. An open wound, which looked to be 1 cm in size, was noted inferior to resident #51's sacrum. Staff member E stated, That wasn't there yesterday, it was just a reddened area. During an interview on 3/29/22 at 9:18 a.m., resident #51 stated she had turned in a grievance for care not being provided to her. She stated she felt helpless and lousy because she cannot even turn herself over if they (staff) are not going to help her. During an interview on 3/30/22 at 3:28 p.m., staff member L stated resident #51's grievance was for not being repositioned. Staff member L stated she handed it over to the director of nursing, and the resolution was care in pairs which just always means two staff members. Staff member L stated staff would know because it is in resident #51's care plan and on the report sheet. Staff member L stated nursing management was responsible for ensuring the resident was repositioned. During an interview on 3/30/22 at 3:36 p.m., staff member M stated resident #51 was cares in pairs for bathroom needs, but she was not sure how often staff were to reposition her. During an interview on 3/30/22 at 3:54 p.m., staff member B stated he was not sure about the resolution of resident #51's grievance, he just knew she had one. During an interview on 3/30/22 staff member A stated the facility did not have CNA repositioning or monitoring documentation for resident #51, so there was not a way to ensure it was being completed, but it was being added. Review of resident #51's grievance, dated 3/7/22, showed: - She was, not getting repositioned every 2 hours, not getting 2 hour check and changes . [sic] - Action taken: cares in pairs . having staff keep notes of when/what was done with patient. [sic] Review of resident #51's ADL care plan, dated 3/8/22, showed: - I require staff to perform cares in pairs. - At risk for skin: I have a pressure reducing W/C cushion. - At risk for skin: I have a pressure reducing mattress. - .I require mechanical lift with 2 assist to move between surfaces. - .I require one assist with my toileting. - .I require one assist with my dressing/undressing. - .I require one assist with my oral care. - .I require one assist with my personal hygiene. - .I require one assist with my showering/bathing. - .I require one assist with my dressing/undressing. - .I wear glasses assist me with my impaired visual acuity. - .I am able to eat meals with supervision. - Monitor/document/report prn any changes, any potential improvement, reasons for self-care deficit, expected course, declines in function. Review of resident #51's Daily Skilled Evaluation, dated 3/30/22, showed: - A2. Has there been a change in condition since the last evaluation? It was marked yes. - A2a. Describe the change in condition: open area on coccyx, and blister on upper right thigh. Review of resident #51's Admission Evaluation, dated 3/2/22, showed no skin impairment to the coccyx area. Review of resident #51's Weekly Skin Evaluation, showed: - On 3/8/22, a first observation of a non-pressure wound to the right front iliac crest. - On 3/15/22, a non-pressure ulcer to the right abdominal fold (Pannus fold) was unchanged. - No wounds to the coccyx area were noted on her weekly skin evaluations. Resident #51's CNA Repositioning Documentation was requested on 3/31/22. No documentation was provided by the facility.

On 11/10/21 at 5:40 p.m., the facility administrative and corporate personnel were notified that an Immediate Jeopardy existed in the area of F686 - The Prevention of Pressure Ulcers. Severity and Scope identified for the Immediate Jeopardy was identified to be at the level of K, and upon removal of immediacy, lowered to H. Based on observation, interview, and record review, the facility failed to identify, assess, monitor, and treat a Stage two ulcer that progressed to a Stage four ulcer for 1 (#1) resident; failed to prevent a pressure ulcer to the right heel for 1 (#2); and failed to prevent new and worseing pressure ulcers for 1 (#3) of 8 residents reviewed for pressure ulcers. This deficient practice lead to a worsening ulcer and need for surgical intervention in a local hospital, and was a contributing factor listed on resident #1's death certificate; and contributed to the worsening and increase in the number of pressure ulcers for #2 and #3. Findings include: 1. Review of Resident #1's face sheet showed she was readmitted to the facility on [DATE]. Review of the facility document titled, Admission-Readmission Nursing Evaluation - V7, dated 08/23/21, showed resident #1 had a coccygeal pressure ulcer, Stage II. Review of facility documents titled, Progress Notes, between the dates of 8/23/21 and 9/8/21, showed the following documentation regarding the condition of resident #1's skin as related to the Stage II coccygeal ulcer: 8/23/21 - Coccyx Stage 2 pressure injury . 8/24/21 - Coccyx Stage 2 pressure injury, . 8/25/21 - Coccyx Stage 2 pressure injury, . 8/26/21 - resident does not have other non-surgical skin conditions 8/27/21 - Coccyx Stage 2 pressure injury, . 8/28/21 - Coccyx Stage 2 pressure injury, . 8/29/21 - Coccyx Stage 2 pressure injury, . 8/30/21 - Coccyx Stage 2 pressure injury, . 8/31/21 - resident does not have other non-surgical skin conditions 9/1/21 - resident does not have other non-surgical skin conditions 9/2/21 - Coccyx Stage 2 pressure injury, . 9/3/21 - Coccyx Stage 2 pressure injury, . 9/4/21 - Coccyx Stage 2 pressure injury, . 9/5/21 - resident does not have other non-surgical skin conditions 9/6/21 - resident does not have other non-surgical skin conditions 9/8/21 - Coccyx Stage 2 pressure injury, . Review of the facility document titled, eINTERACT Transfer Form V5, dated 9/9/21, showed resident #1 was discharged to the hospital with, Coccyx Stage 2 pressure injury . Review of the Family Nurse Practitioner note, dated 08/30/21, showed, No concerns with skin. Review of the facility document titled, PT Evaluation and Plan of Treatment, for the certification period 8/24/21 - 9/22/21, showed resident #1 required the following assistance for Functional Mobility: - Bed Mobility; roll left and right = dependent - Sit to lying = dependent - Lying to sitting on side of bed = dependent - Self care raw score = 0 (lowest score) - Assessment Summary, .Upon PT evaluation she has significant impairments to strength of all exremities . [sic]. Review of four pictures, provided by NF1 in a report to the Certification Bureau, of resident #1's wounds present on admission to the hospital on 9/9/21, showed resident #1 had three open wounds on the coccygeal area and either buttock cheek. These pictures showed full thickness wounds, with one wound appearing necrotic and Unstageable. Surrounding the wounds were areas of excoriation. No wound diagnosis, or measurements, or written descriptions of the wounds were provided with the pictures. Review of resident #1's skin and ADL care plans, showed they were last updated on 07/23/21, which was prior to the 8/23/21 admission, and showed resident #1 required extensive assist with ambulation/mobility, dressing, grooming, used a pressure reducing mattress, and a w/c cushion. She required extensive assist with toileting, transfers, and was incontinent. Under potential/actual impairment to skin integrity, also last updated 07/23/21, it showed the staff were to monitor/document location, size and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . to MD. The Stage II coccyxgeal ulcer was not added to resident #1's care plan when it was identified on the 08/23/21 admission assessment. Review of Resident #1's most recent MDS, with an ARD of 8/23/21, was an entry tracking record and did not assess possible pressure ulcers. A 14-Day Admission MDS had not been completed. Review of resident #1's Braden Scale For Predicting Pressure Sore Risk, dated 08/23/21, showed resident #1 scored a 14 and was at moderate risk for pressure sores. Requests were made throughout the survey on 11/9/21 at 6:40 p.m., 11/10/21 at 11:30 a.m. and 4:45 p.m., and 11/10/21 at 4:45 p.m., for documentation of wound assessments, including size, measurements (length, width, depth), exudate, color, odor, physician and family notification of the wound, and orders for wound dressings and care. No further documentation was provided for resident #1's coccxygeal wound, with the exception of one dressing change. Review of the facility document titled, Weekly Skin Report, dated 8/25/21, for resident #1, showed, 3 open areas on Buttocks, cleansed and covered [with] DermaBlue and [MEDICATION(S)] gentle. This document was the only identified assessment and treatment after resident #1's admission on 8/23/21, provided by the facility. During an interview and record review, on 11/09/21 at 11:30 a.m., staff member E said she did not remember resident #1. She said if the admission nurse identified an ulcer on a resident when they were admitted for services, they would send her a note, or she may be notified of the wound orally. Staff member E said it would be up to the nurse [the nurse conducting the skin assessment] to notify the physician of the wound. Staff member E searched in the EHR and said there was no information regarding the Stage II ulcer listed under the skin and wound catagory. She said the (physician) would write the orders for how to treat a wound. Staff member E said she did not know if there were standing orders for treating wounds before orders were received from the physician. She said on most admissions she would have worked with an admissions nurse who was no longer with the facility. The nurse would have written a note in the SBAR [electronic] system to notify the physician of a wound, and then the physician would look at the wound and provide orders to treat the wound. Staff member E said normally orders to treat a wound would show up on the TAR. During an interivew by phone, on 11/10/21 at 1:07 p.m., the FNP said she did not feel she was aware of, or had been notified, by the staff, patient, or hospital, regarding resident #1's coccygeal pressure ulcer. She would usually be notified by receiving a note, or staff would tell her. She did not assess the wound. The FNP said she was the only provider for the facility and if she was aware of a wound she would look at the wound, but she did not feel it was an expectation for her to conduct a full skin assessment with each visit. She said she tried to get the nurses to write an SBAR note to cover notification. During an interview and review of resident #1's care plan, on 11/09/21 at 2:09 p.m., staff member D said that she had not added resident #1's pressure ulcer to the MDS. She said the care plan would be developed based on what was added to the MDS. She said the ulcer had been missed, and I missed that. She said that another nurse should have put the wound on the care plan, but this didn't happen. Staff member D said, at the end of August (2021) We had three to four nurses leave and I have been on the floor, and it was the facility policy that every time staff updated the MDS they were supposed to go through and make sure everything put in the MDS was on the care plan. During a phone call on 11/09/21 at 8:15 a.m., NF1 said she felt the facility was understaffed when her mom was a resident there. She said the family was never notified by the facility regarding a pressure wound for resident #1. She said the wound required surgeries to address the wound and the surgeries were too much for her mother. She said the [hospital] said it [the wound] was the worst they had every seen. NF1 said her mother had four surgeries when she got to the hospital. She said the facility called and said her mother was going to the hospital for low oxygen levels. NF1 said after the surgeries, her mother never left the hospital. NF1 said her mother didn't have any treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . It was like someone saw it and it got brushed under the rug. NF1 said resident #1 was not mobile and had her arm in a sling due to just having had a pacemaker placed. NF1 felt all the surgeries had broken resident #1's spirit and that resident #1 had spent three days crying in the hospital when this happened. During an interview on 11/10/21 at 9:03 a.m., staff member B said the facility process was that the ulcer would be picked up in clinical [meeting] and pushed off to the RCM. He said resident #1's ulcer was discovered about the time the RCM left at the end of August. Staff member B said, I know it was taken care of, but we just totally missed the documentation of what was done with the ulcer. I will just have to swallow my pride on that. He said, We just lost that tool of getting all her assessments and parts of the process completed, like notify in the doctor. She fell right into that crack.There is nothing documented. We have searched and searched. We have a new team rehired. He said the expectation was for the wound nurse to be measuring the wounds at least weekly, and to document. At this point I need to find an IPAD that may have more information about wounds but I don't know if there is more information. If orders are not on point-click-care, then its not there. It is my subjective opionion that the documentation has fallen through the crack. I would expect the nurse to have a dressing change order before doing one. Review of [hospital] clinical records, dated 9/9/21 through 10/17/21 showed resident #1 had an, Infected sacral pressure ulcer with tracking. This needs to be cleaned out and debrided in the operating room for control. This might require more than one surgical intervention for optimal management. On admission a Stage IV coccygeal ulcer was reported . extensive subcutaneous [CONDITION(S)] compromising the perirectal area . taken to OR on 9/11 for incision and drainage where extensive nectrotic tissue was reported compromising soft tissue, buttocks, and perirectal area. The patient was returned to the OR on multiple occasions . Resident #1 received procedures in the OR for the sacral ulcer on 9/11/21, 9/12/21, 9/13/21, and 9/14/21. She was diagnosed with elevated white blood cell counts and multiple infectious agents. Resident #1 passed away 9/17/21. Review of resident #1's death certificate, dated 10/17/21, listed a sacral pressure wound as a contributing factor in her death. Review of the facility policy, Skin Integrity, last revised May 2019, showed, . 5. Ongoing evaluation continues weekly with the LN completing a full body skin audit. Completion of the skin audit is documented on the Treatment Administration Record (TAR) with their initials, and either a - or +. a. The - indicates no skin impairment present. b. The + indicates skin impairment present. 6. For skin impairment identified with admission (abrasion, bruise, burn, excoriation, pressure sore, rash, skin tear, surgical wound, etc.), the LN completes the following: a. Documents skin impairment that includes measurements of size, color, presence of odor, exudates, and presence of pain associated with the skin impairment in Nurse's Notes and on the Weekly Wound Evaluation. b. Notifies the Physician and, if needed, obtains a Treatment Order and documents on the Treatment Administration Record (TAR) after order is implemented. c. Notifies Responsible Party/Family Member of skin condition and treatment plan. d. Evaluates environment, mobility equipment, functional and cognitive ability, medications, and labs to identify interventions to promote healing/resolution or skin impairment. e. Implements interventions and documents on the resident's care plan and Care Directive. 7. If skin impairment is noted after admission (in addition to the above steps, the LN: a. Initiates Alert Charting. b. Completes (and documents) notifications to the physician and Resident representative. c. Completes Braden Scale and evaluates current interventions for necessary revision. d. Implements new interventions as needed. Documents on the resident's care plan and Care Directive. e. Notifies Food and Nutrition Services Manager (FANS) and/or Registered Dietitian of new Pressure Score, worsening wound condition for nutritional needs evaluation. f. Notifies Director of Nursing Services (DNS) of Skin Impairments that indicate a potential significant change in condition (Stage I or greater Pressure Ulcer, surgical wound dehiscence, hematoma, or bruise on an area of the body not usually vulnerable to trauma (e.g. head, breasts, inner thighs). g. The DNA and/or designee complete a comprehensive review of the resident's medical record to evaluate if the Pressure Ulcer was avoidable or unavoidable. This evaluation is documented in the Nurse's notes. 8. Non-Healing Wounds/Pressure Ulcers/[CONDITION(S)] are reviewed at the Nutrition Hydration Skin Committee meeting. 9. Wounds are evaluated weekly by Center clinicians. Arterial, Pressure, Stasis, and Venous Ulcers, significant surgical wounds, and [CONDITION(S)] are evaluated, measured, and findings documented in the medical record. This evaluation includes pain associated with the wound during wound care. If a wound condition fails to improve after 2 weeks of treatment or the condition of the wound deteriorates, the Physician and Resident's Representative are notified. If a new treatment order is obtained the LN: a. Re-evaluates POC and resident's condition (e.g. off-loading pressure from skin impairment area, nutritional intake, blood sugars, and lab values). 10. Significant abrasions and bruises are evaluated weekly by the LN (excoriations, rashes, skin tears, etc.) and documented in the medical record. 11. Evaluate resident's compliance with POC. When the resident chooses to not have specified treatments or interventions implemented, the Center discusses the following with the resident and documents in the medical record: a. The POC. b. Risk factors and why the treatment is important to healing. c. If able, the resident is provided instruction regarding shifting his/her weight while seated in chair/wheelchair. d. Education and guidance is provided to residents/representative for those with pressure ulcers affecting the sacrum or coccyx, emphasizing that time spent sitting should be limited to 3 times daily for periods of 60 minutes or less. e. Education and guidance is provided to resident/representative for those with pressure ulcers affecting the ischium, emphasizing that sitting in a fully erect posture while in bed or chair, should be avoided. f. Discussed with resident's responsible party if resident does not make sound choices. g. Notifies the Medical Doctor (MD) of choice. h. Update the comprehensive care plan to include resident' choice to decline treatments. 12. If allowed, the LN removes devices/braces/splints/dressings (and associated wrappings) 2 times per week and as needed (PRN). Risks and benefits of non-removal are discussed with the resident and MD. One of these times will be scheduled and completed with the weekly head to toe skin check. The LN examines the skin under the device and document findings on the TAR with their initials and either a - or + a. - indicates no skin impairment. (If no impairment noted, the nurse reapplies the device. b. + indicates skin impairment. (Proceed back to Step #7.) 2. During an observation on 11/10/21, resident #2's wound on the right heel was open and draining sanguineous fluid; there was a new area observed next to the open area, that was approximately the size of a dime, black in color, and unstageable. Review of resident #2's Nursing Progress Notes, in the EHR, showed the following: 7/21/21 - Approx. 0300h, CNA reported to this nurse upon assisting Res to bathroom, she observed swelling/sponginess on her right heel, color of skin a dark gray, approx. 3 in. diameter . 7/21/21 - Skin/Wound Note, Went in to look at right heel, it is not open but looks like a black and blue deep tissue . 7/22/21 - Note yesterday the Wound Nurse saw and assessed wound, labelled it a DTI versus stage 1 heel injury . 7/23/21 - Skin/Wound Note, Res has a DTI on back of right foot/heel, with a blood blister type intact roof Placed silver alginate over wound and covered with [MEDICATION(S)] and kerlix . 7/26/21 - Orders . apply pressure relieving boot to right heel at all times . 8/5/21 - Wound on heel continues to heal . 8/10/21 - Wound on heel continues to heal . 8/11/21 - Orders . eval and treat one time a day . 8/13/21 - Skin/Wound Note, residents right heel is still painful to her. heel has eschar so cleansed wound with wound wash and applied honey and covered with [MEDICATION(S)] and kerlix . 8/18/21 - Skin/Wound Note, residents right heel is still painful to her. heel has eschar so cleansed wound with wound wash and applied honey and covered with [MEDICATION(S)] and kerlix . 8/19/21 - Wound on right heel continues to heal . Dressing is clean, dry and intact . 8/20/21 - wound to right heel was cleaned, thera honey applied and covered with foam dressing . 8/21/21 - Dressing to right heal wound changed . was cleaned and thera honey applied with opti foam dressing . 8/24/21 - Wound to right heel continues to heal .Dressing is clean, dry and intact . 8/28/21 - Re-dressed right heal with therahoney, heel cup, and kerlix . 9/3/21 - Orders, Cleanse R heel, apply collagen (honey if debridement needed), cover with heel cup then kerlix one time a day every Mon, Wed, Fri done by wound nurse. 9/12/21 - Wound on residents right heel continues to heal . 9/21/21 - Wound on residents heel continues to heal . 10/22/21 - Orders, Apply pressure relieving boot to right heel at all times . 11/8/21 - Skin/Wound Note, . Heel cleansed with wound wash collagen applied then border gauze as the heel cup and kerlix might be easier to remove. 11/9/21 - Orders, Apply pressure relieving boot at all times . [sic]. Review of resident #2's care plan, provided on 11/9/21 at 2:27 p.m., showed a revision date of 8/12/21, under the problem area it showed actual impairment to skin integrity of the right heel. The intervention portion included heelpad over dressing, float heels when in bed, identify/document causative factors and eliminate/resolve where possible, monitor/document location, size, and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . to MD. The goal showed resident will maintain or develop clean and intact skin by review date. The care plan for resident #2, provided by the facility, had not been updated/revised with the current plan of care for the right heel to include the current dressing and wound treatment management. Review of resident #2's Quarterly MDS, with an ARD 9/13/21, showed the following documentation in section M for Skin Conditions: M0100 A. Resident has a Stage 1 or greater, a scar over bony prominence, or a non-removable dressing/device - check mark M0150 Risk for Pressure Ulcers 1- yes M0210 Unhealed Pressure Ulcer(s) 1- yes M0300 Current Number of Unhealed Pressure Ulcers at Each Stage- A. Number of Stage 1 pressure ulcer - 1 Review of resident #2's Braden Scale assessments for 7/22/21 and 9/10/21, showed a score of 18, which meant at risk for skin impairment. Review of the facility forms, titled Weekly Skin Report, were provided for 7/19/21, 8/6/21, 8/13/21, and 8/18/21. None of the forms reflected the stage of the wound to the right heel for resident #2. Forms dated 8/6/21 and 8/13/21 noted resident #2's wound was caused in the facility. No further Weekly Skin Reports after 8/18/21 were provided regarding the wound to resident #2's right heel. Review of the Skin and Wound Evaluations for resident #2 provided included the following: 8/6/21 - . ST 1 pressure, right heel, acquired in house, with eschar to wound bed, progress is deteriorating, measures 5.1cm (centimeters) x 2.7cm x 2.4cm, no exudate, attached edge, dark reddish brown . 8/13/21- . ST 1 pressure, right heel, acquired in house, progress stable, measured at 3.6cm x 2.4cm x 2.2cm . There were no other measurements provided during the survey for resident #2's right heel wound. Review of the facility Nutrition Hydration Skin Committee Review Forms provided for 9/9/21 and 10/11/21 showed in section 8a, Pressure Ulcer stage comments, ST 11 . for resident #2's right heel wound. During an interview on 11/9/21 at 3:50 p.m., staff member C stated the facility has a clinical meeting and Stand-Up meeting every morning that he attends when working. He stated during the clinical meeting the team goes through every chart for documentation from the previous day. Staff member C stated there would not be an instance where documentation was missed for an open wound or anything. Staff member C stated if documentation was missed, the staff member would be notified that day to document a late entry. Resident #2 did not have daily documentation in the medical record for the wound to her right heel. The facility failed to consistently assess and document the worsening of a pressure ulcer injury to the right heel of resident #2. The facility documentation of the wound showed it as ST I (Stage 1) and other documentation as ST 11 (Stage II) during the same time frames. 3. Resident #3 was admitted to the facility on [DATE]. The facility failed to heal a heel wound and prevent additional pressure injuries for resident #3. Hospital discharge records showed one heel wound. Currently resident #3 has three wounds: the original heel wound is Unstageable necrotic, a second heel wound, was documented as purple upon admission, and is a Stage II, the sacrum wound, was documented the day after admission as an excoriation on the buttock on both sides, is Stage II/III, on both sides and is open and draining sanguineous fluid. Documented on the Admission MDS, were three pressure areas, the resident currently has four pressure areas. Resident #3's wounds were observed on 11/10/21 at 11:35 a.m., with staff member D. Resident #3 was lying flat on his back upon entry to the room. The resident's left buttock had an open area approximately the size of a quarter. The right buttock had a ST 11 wound. The right heel had a darkened black/purple area approximately 0.5 cm which was open to air. The residents's left heel had a large dark area purple/brownish, dry eschar. The resident's left heel was Unstageable. The left buttock was a ST 11, the right buttock had a ST 11, and the right heel had a scab, which was Unstageable. Review of resident #3's Nursing Progress Notes, provided by facility, for the pressure ulcer wounds showed the following: 9/29/21 - . Lt heel is black, Rt heel is purple (heel protectors in place, Buttock excoriated & broken down on both sides, [MEDICATION(S)] in place . 10/2/21 - . sore buttocks, DTI to both heels, they are off loaded . 10/3/21 - . DTI to left and right heel. pressure sore to bottom . 10/6/21 - . Left heel black, Right heel purple and heel protectors in place. Buttock is excoriated broken down on both side of the buttock . 10/7/21 - . pressure ulcer to buttocks, barrier cream and [MEDICATION(S)] applied DTI to both heels. they are offloaded . 10/8/21 - . Left heel is black, Right heel purple and heel protectors in place. Buttock is excoriated broken down on both sides of the buttock . 10/9/21 - . pressure ulcer to buttock . 10/21/21 - . Left heel is unstageable, right heel is purple and heel protectors are in place, Buttocks are excoriated broken down on both sides of the buttocks. Moderate amount of drainage . 11/10/21 - . Lt buttock has area approx. quarter skin that is pink with healing loose skin. Rt buttock has healing ST 2 wound with irregular edges . Rt heel has healing DTI .Theres is small dark area approx. 0.5cm of dark purple area at 12 o'clock area. Wound is OTA . Lt heel shows DTI area . dark area purple/brownish dry eschar. Wound is unstageable . [sic]. Review of the Skin/Wound Notes provided for resident #3 showed: 10/4/21 - Skin/Wound Note . fridat October 1st. the pressure ulcer on his left heel looked like a DTI it is black. lotioned well and put on foam boots to off load .[sic] Review of resident #3's care plan, provided on 11/9/21 at 2:27 p.m., showed a revision date of 10/8/21. Under the problem area the plan showed actual impairment to skin integrity. The intervention portion included pressure relieving mattress, keep skin clean and dry, monitor/document location, size, and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . to MD. The goal showed resident will have no complications through the review date. The care plan provided by the facility for resident #3 did not show updates/revisions for the current interventions for wounds to his coccyx and bilateral heel wounds. Review resident #3's Admission MDS, with an ARD of 10/5/21, section M for skin conditions, showed the resident was at risk for pressure ulcers, had one unhealed pressure ulcer, one ST 1 and 11 pressure ulcer, one St 11 pressure ulcer was present on admission, and one Unstageable pressure ulcer, and one Unstageable pressure ulcer present on admission. Review of resident #3's Braden Scale Assessments, dated 11/10/21, showed a score of 13, moderate risk, and on an 11/11/21 assessment, it showed a score of 12, high risk. Review of resident #3's Weekly Skin Evaluation, dated 11/10/21, showed the following documentation: Left buttock - open area approx quarter size with skin that is pink with healing loose skin . pressure ulcer . pressure ulcer ST 11 ., Right buttock - healing ST 11 with irregular shapes . length 6, width 5, depth 0.2, irregular shaped, 0.2 -0.3 at top of wound ., Left heel - DTI area dark purple/brownish dry eschar. Wound is unstageable & OTA ., length 5.6, width 5.9, depth 0, shape is round, over heel & extending to back of heel ., . Right heel - healing DTI with some loose healing sin & pink wound bed . length 2.5, width 2.5, depth 0, shape round quarter size . pressure ulcer . Review of resident #3's Nutrition Hydration Skin Committee documentation, dated 10/11/21 and 10/28/21, showed, . Sacral Stage 11, heels bilat are unopened DTI, black eschar under skin . During an interview on 11/9/21 at 4:25 p.m, staff member P stated she does a skin assessment upon admission. She stated if there is a skin problem she will note it in the medical record, and notify the nurses, then leave a note for the wound nurse, staff member E. During an interview on 11/10/21 at 11:35 a.m., staff member D stated resident #3 was admitted to the facility with abrasions to his coccyx. After staff member D changed the dressings to resident #3s wounds, on 11/10/21 at 11:35 a.m., she stated, resident #3 has a ST 1, ST 11, one deep tissue injury, and one Unstageable pressure ulcer.

Based on interview and record review, the facility neglected to provide goods and services to prevent the worsening of a Stage II coccygeal pressure ulcer to a Stage IV pressure ulcer for 1 (#1) of 8 residents reviewed for pressure ulcers.This deficient practice and neglect lead to the worsening of the Stage II pressure ulcer to a Stage IV, which required surgical interventions, and sacral ulcer was listed as contributing to the death of the resident. Finding include: Review of resident #1's face sheet showed she was readmitted to the facility on [DATE]. Review of the facility document titled, Admission-Readmission Nursing Evaluation - V7, dated 08/23/21, showed resident #1 had a coccygeal pressure ulcer, Stage II. Review of the facility document titled, eINTERACT Transfer Form V5, dated 9/9/21, showed resident #1 was discharged to the hospital with, . Coccyx Stage 2 pressure injury . Requests were made throughout the survey for documentation of resident #1's wound assessments, including size, measurements (length, width, depth), exudate, color, odor, physician and family notification of the wound, physician treatment orders for wound dressings and care, and an updated care plan that reflected the existence of the Stage II ulcer. No further documentation was provided for resident #1's coccygeal wound, with the exception of one dressing change, and a prior care plan that had not been updated. Review of the facility document titled, Weekly Skin Report, dated 8/25/21, showed, 3 open areas on Buttocks, cleansed and covered [with] DermaBlue and [MEDICATION(S)] gentle. This document was the only identified assessment and treatment after resident #1's admission on 8/23/21, provided by the facility. Review of [hospital] clinical records, dated 9/9/21 through 10/17/21 showed resident #1 was admitted to the hospital with an, Infected sacral pressure ulcer with tracking. This needs to be cleaned out and debrided in the operating room for control. This might require more than one surgical intervention for optimal management. On admission a Stage IV coccygeal ulcer was reported . extensive subcutaneous [CONDITION(S)] compromising the perirectal area . taken to OR on 9/11 for incision and drainage where extensive necrotic tissue was reported compromising soft tissue, buttocks, and perirectal area. The patient was returned to the OR on multiple occasions . Resident #1 received procedures in the OR for the sacral ulcer on 9/11/21, 9/12/21, 9/13/21, and 9/14/21. She was diagnosed with elevated white blood cell counts and multiple infectious agents. Resident #1 passed away 9/17/21. Review of Resident #1's death certificate, dated 10/17/21, listed sacral pressure wound as a contributing factor in her death. During an interview on 11/10/21 at 9:03 a.m., staff member B said I know it was taken care of, but we just totally missed the documentation of what was done with the ulcer. I will just have to swallow my pride on that. He said, We just lost that tool of getting all her assessments and parts of the process completed, like notifying the doctor. She fell right into that crack. There is nothing documented. We have searched and searched.

Based on observation, interview, and record review, the facility failed to maintain enough staffing to effectively manage the care needs of the residents which lead to a lack of up-to-date care planning, failure to notify physician/family of a resident change of status, neglect of resident care needs, worsening pressure ulcers, failure to identify pressure ulcers, failure to provide treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] #6) of 15 sampled residents. Findings include: Findings include: During a phone call from NF1 on 11/09/21 at 8:15 a.m., NF1 felt the facility was understaffed when her mom [resident #1] was there. She said, They were hard to get a-hold of on the phone. At that time, you could call in and arrange for a time to visit, but you couldn't get a-hold of them to make that arrangement. Sometimes five days would go by when you couldn't get a-hold of anyone. I don't know what was going on there, I really don't. She [resident #1] passed away on the 17th. The wound care [at the hospital] and the amount of damage was just too much for her. [Local hospital] said it was the worst they had every seen. We were never notified [by the facility] or contacted this was going on. My brother and sister were notified about other things, but not the ulcer. We didn't find out about it until she was at the [local hospital]. She had four surgeries when she got to the hospital. I had been compulsively calling them for days. They called and said she [resident #1] had low oxygen levels and was going to the hospital. Her oxygen level was normal at the hospital, but her blood counts were up. She had four surgeries after that and she never left the hospital. She didn't have any treatment that I know of at the facility. There was documentation of the cleaning of the incision of the pacemaker site. It was like someone saw it [stage II coccyx ulcer] and it got brushed under the rug. During an interview on 11/09/21 at 2:09 p.m., staff member D said, At the end of August (2021) we had three or four nurses leave and I have been on the floor [working.] During an interview on 11/10/21 at 9:03 a.m., staff member B said, regarding resident #1's Stage II coccyx ulcer, The process was that it would be picked up in clinical and pushed off to the RCM. That was about the time my RCM left at the end of August. I know it was taken care of, but we just totally missed the documentation of what was done with the ulcer. I would just have to swallow my pride on that. We just lost that tool of getting all her assessments and parts of the process completed, like notify in the doctor. She fell right into that crack. There is nothing documented. We have searched and searched. We have a new team rehired. Between [staff member D] and I we did clinical's, we ended up doing a lot of floor work. We had three of our team members step down. Within the last week of August all three of Managers quit, and I lost a night nurse to surgery, so now it's [staff member D] and I and [staff member E] picking up the shifts. We lost another nurse to COVID on nights. We've had a few nurses from agency that we have hired and then they will call back and say they got another job. We had to fire a nurse for drug diversion a couple of weeks ago. About half the time, still, some of the team has had to work on the floor to cover the shifts. We always have at least the minimum CNAs. We have some people that will come in part time. Our activities director left and we are down an Activities director now. During an interview on 11/9/21 at 9:50 a.m., resident #12 and resident #13 each stated showers did not happen as scheduled or less than once a week due to staffing issues; often the shower aide is working the floor instead of giving showers. During an interview on 11/9/21 at 10:00 a.m., resident #15 stated showers happened less than scheduled due to staffing issues. During an interview on 11/9/21 at 9:50 a.m., resident #12 and resident #13 each stated call lights were not answered very quickly. During an interview on 11/9/21 at 9:55 a.m., resident #14 stated call lights were not answered very quickly. During an interview on 11/9/21 at 10:00 a.m., resident #15 stated call lights were not answered quickly. Resident Council Notes showed complaints relating to not enough resident showers in two out of three months of meetings. The Grievance Log and grievances showed resident #6 filed a grievance stating she had not received a shower in 12 days. Four residents each stated showers did not happen as scheduled or less than once a week due to staffing issues; often the shower aide is working the floor instead of giving showers. A review of the resident shower records were unreliable as dates and information was inconsistent and missing. A review of the staffing schedules showed management staff working as nurses or CNAs. During an interview on 11/9/21 at 9:35 a.m., staff member L stated the residents are supposed to get at least one shower a week. She stated she had worked at the facility for several months, and the facility usually only had two CNAs on the 100 unit. Staff member L stated that two CNAs are not enough to provide the daily care and assistance the residents needed. During an interview on 11/10/21 at 7:20 a.m., resident #11 stated he understood the lack of staff at the facility, and that staff did not say anything to him when he did not get his shower/bath as scheduled. Resident #11 stated it made him feel terrible when he was unable to get his showers. Record review showed resident #11 did not receive or refuse showers for the following days: 7/29/21 through 8/11/21, 14 days; 8/13/21 through 8/24/21, 12 days; and, 9/11/21 through 9/22/21, 12 days. During an interview on 11/10/21 at 7:30 a.m., staff member K stated that she gets pulled to the floor one or two times a week when short staffed. Staff member K stated she had been pulled from showers to work the floor on Tuesday and Wednesday that week due to staffing, and would probably have to work the floor the rest of the week due to staffing.

Based on observation, interview, and record review, the facility failed to ensure the resident received the necessary care for pressure ulcer prevention, to include failing to assess, evaluate, treat, and monitor an avoidable pressure ulcer, which worsened to an Unstageable pressure ulcer, upon the resident's return from the hospital, for 1 (#72) of 29 sampled residents. Findings include: During an interview on 6/12/19 at 9:41 a.m., staff member BB stated she had just assessed resident #72's pressure ulcer was healing very good, it was scabbed over, and measured the same. During an interview on 6/13/19 at 9:03 a.m., staff member T stated she was not sure how resident #72's pressure ulcer occurred. Staff member T stated typically the facility, on admission, assess the risk for a pressure sore by utilizing the Braden Scale. Staff member T stated if a pressure sore is found the facility contacts the provider, registered dietician, and notifies the responsible parties. The facility will then monitor the pressure sore weekly through skin assessments, nutritional meetings, and monitoring the appropriateness of the treatment. Staff member T stated resident #72's pressure ulcer was improving and was receptive to the current treatment. Interventions used for resident #72 were the Braden Scale that scored a 21, weekly monitoring, and nutritional interventions. During an interview on 6/13/19 at 10:45 a.m., staff member C stated the cause of the pressure ulcer to resident #72's right ankle was, difficult to say and could have been due to the resident taking a steroid. During an observation on 6/13/19 at 10:59 a.m., resident #72 had on her right lateral malleolus a 1.5 cm x 1.5 cm rounded Stage III pressure ulcer. The wound bed had white/yellow slough on the left proximal edge of the ulcer. The center of the wound was open with a red center at a Stage III. There was no dressing on the wound. Review of resident #72's Care Plan, dated 4/25/19, showed, potential or actual risk for impairment to skin integrity The interventions listed were pressure relieving/reducing cushion on wheelchair, relieving/reducing mattress, keeping skin dry and clean, treat per orders, weekly treatment documentation, and obtain blood work. Review of resident #72's Care Plan, dated 5/16/19, showed, resident #72 had a pressure ulcer to right lateral ankle. The interventions were listed as, administer medications as ordered, administer treatments as ordered, assess/record/monitor wound healing, pressure relief boot to right ankle while in bed, and resident refuses nutrition interventions. Review of resident #72's Braden Scale for Predicting Pressure Sore Risk, showed the following: - On 3/14/19, and admission to the facility, the resident scored a 17 and was at risk for a pressure sore, - On 4/18/19 the resident scored a 20 and not at risk for a pressure sore, - On 4/29/19 the resident was readmitted from the hospital, a readmission assessment of the resident scored a 19 and was not at risk for a pressure sore. - On 5/6/19 the resident scored a 19 and was not at risk for a pressure ulcer. Review of resident #72's MDS, with the following reference dates, showed: - On 3/21/19 the resident was at risk for developing a pressure ulcer, - On 4/23/19 the resident was at risk for developing a pressure ulcer, - On 5/6/19 the resident was at risk for developing a pressure ulcer. NO was marked for the question does resident have one or more unhealed pressure ulcer at a Stage 1 or higher. Determination of pressure ulcer risk b. formal assessment instrument and tool (e.g., Braden, Norton, or other) and clinical assessment. Review of resident #72's Progress Notes, showed the following: - On 4/29/19, showed an admission assessment was done on resident #72. - On 5/7/19, showed, unstageable ulcer on right malleolus, foam dressing applied. To be evaluated by wound care nurse for possible debridement. - On 5/8/19, the provider was notified. Wound care: Stage 2; Assessed wound on right lateral malleolus; no debridement needed at this time. Cleansed with wound cleanser and [MEDICATION NAME] placed with occlusive dressing applied. Measures: 1cm x 1cm x .1. Scant serous drainage noted. Peri-wound bed has small rolled edges but is pink in color. - On 5/16/19, Received orders for dressing change. Dressing change done. 1 cm circle area over R-ankle bone, inside area covered with serosanguinous drainage, outer edge of wound red 2 cm non-blanchable darker reddened area 4 cm oblong area. - On 5/17/19, Wound is unstageable at this time provider was notified and new orders were implemented. Review of resident #72's (Hospital) Discharge Instructions, dated 4/29/19, showed: Other: ankle Right, Lateral Unknown 4/28/19 Scabbed Percentage: 75% Skin Surrounding Wound: Red Wound Bed Description: Scabbed Wound Edges: unattached Wound onset/date: 4/28/19 Wound Present Pre-Hospital: yes Wound Care Treatment: CTM, painful. (sic) Review of resident #72's Order Summary Report, dated 5/1/19, showed, no order for monitoring or wound care to the right ankle. Review of resident #72's MAR and TAR, for (MONTH) 2019, showed the following: - On 5/6/19 resident #72 was started on weekly skin audits. - On 5/8/19 and 5/9/19 were blank and no dressing changes were documented until 5/18/19 for the right ankle pressure sore. - No assessment, evaluation, monitoring, or treatment was initiated from 4/29/19 to 5/6/19 for resident #72's right ankle pressure sore.

Based on observation, interview, and record review, the facility failed to have sufficient staffing to provide the necessary care and services, to prevent the development of a new penile wound which resulted in pain for 1 (#44); failed to ensure a catheter bag was drained daily for 1 (#44); failed to empty urinals and a full trash bin which made the resident feel undervalued for 1 (#62); and failed to provide routine showers which resulted in residents feeling dirty and affected their psychosocial well-being for 6 (#s 3, 5, 6, 37, 44, and 52) of 35 sampled and supplemental residents. Five of the sixteen residents (#s 5, 10, 45, 51, and 52) of the Group Meeting stated the facility did not have enough staff to provide regular showers for the residents, and sixteen of the sixteen residents in the Group Meeting unanimously agreed the facility did not have enough staff to provide care for the residents. Findings include: 1. Penile Wound During an interview and observation on 6/10/19 at 4:03 p.m., resident #44 stated he had some pain down there gesturing to his penis. He stated he had a catheter, and the staff did not always help him with his catheter care. He stated he would put his call light on and it would take over an hour for someone to help him. He said he would ask staff for something, and they would tell him they would be right back, and they would never come back. He said he would take himself to the bathroom instead of waiting for the staff. Review of resident #44's Braden Score, dated 4/1/19: showed the resident was scored at 15, classified as high risk for pressure ulcer development. Review of resident #44's Braden Score, dated 6/12/19: showed the resident was scored at 16, classified as high risk for pressure ulcer development. A review of resident #44's Care Plan, revised on 3/18/19, showed, Problem: (resident #44) has an ADL self-care performance deficit r/t requires assistance with ADL related to . incontinence, Foley . Skin Inspection: requires skin inspection, arterial/venous ulcers BLE, Foley catheter and bowel incontinence. Observe for redness, open areas, scratches, cuts, bruises and report changes to the Nurse. Peri-care with episodes of incontinence. A review of resident #44's (MONTH) 2019, and (MONTH) 2019, TARs, showed an order for [REDACTED]. A review of resident #44's (MONTH) 2019 TAR, showed the following dates when the weekly skin check was not completed: - 5/3/19 - 5/10/19 - 5/24/19 A review of resident #44's (MONTH) 2019 TAR, showed there were no new skin impairments noted on 6/7/19. A review of resident #44's progress notes, and alert chart charting from 6/7/19 to 6/12/19, failed to show the penile wound was noted by nursing staff. During an interview on 6/11/19 at 9:32 a.m., staff member K stated peri-care for resident #44 should be completed every shift, and as needed. She stated anything that looked different with his skin, the nurse should be immediately notified. She stated she had not noticed anything different with resident #44's penis, but had not had time to perform peri-care on the resident during her current shift. During an observation and interview on 6/12/19 at 10:09 a.m., resident #44 had his catheter tubing tied off to the left side of his penis. The tubing was secured to his left thigh, which created tension on his penis. The foreskin was retracted and under the catheter tubing was a 3 cm in length, by 1 cm wide sore. There was red frank blood on the catheter tubing which smeared on the resident's penis when the catheter tubing was removed. The sore was open and was bright red in appearance. During an interview on 6/12/19 at 10:20 a.m., staff member Q stated it was the expectation the aides performed peri-care for the residents every shift, and as needed. She stated she had not performed peri-care for the resident for her shift, and was not aware of any open sores on the resident's penis. She stated if anything was abnormal during peri-care for the resident, they would immediately notify the nurse. During an interview on 6/12/19 at 10:29 a.m., staff member [NAME] stated the resident had a lot of yeast in is groin and problems in the past with his penis and catheter. She stated she had noted the resident had an open area under the catheter tubing which was bleeding. She stated she contributed that to the pressure from the catheter tubing on the penis. During an interview on 6/12/19 at 10:30 a.m., staff member S stated she was not aware resident #44 had an open sore on his penis. She stated during her assessment she noted the resident had frank fresh bleeding at the urinary meatus. She stated she felt the sore was related to the pressure from the catheter tubing on his penis. She stated the resident had a yeast infection which contributed to skin break down, and may have developed a sore under the tubing related to yeast. She stated she had placed orders in the TAR for the nurses to ensure there was pressure relief of the tubing off the irritated area, and complete daily wound checks. During an interview on 6/13/19 at 7:48 a.m., staff member T stated she had checked resident #44 that morning to assess his penis and to ensure staff performed peri-care. She stated staff had performed the peri-care, did not note any frank red bleeding, and did not note any open areas on his penis except for an area of excoriation. During an interview and observation on 6/13/19 at 10:14 p.m., staff members B and T noted the resident had a 3 cm by 1 cm open area on the left side of his penis. There was white/yellow slough in the wound bed, which the staff stated was from the barrier cream. The edge around the wound bed was bright red, and inflamed. Staff member B stated she was not sure what contributed to the open area, if it was due to maceration or excoriation. She stated she did not feel it was related to pressure. Staff member B stated it was the expectation the aides performed peri-care every shift and as needed. She stated they were to report to the nurse with any new skin changes. She said this skin area was not identified by the nursing staff until 6/12/19 during the surveyor observation. 2. Empty Leg Bag During an observation on 6/10/19 at 4:30 p.m., resident #44 had 300 ml of clear yellow urine in his leg bag, attached to his left leg. During an interview and observation on 6/11/19 at 10:00 a.m., resident #44 stated no one came in and emptied his leg bag the previous night, and now his left leg felt heavy. The resident lifted up his pant leg and revealed the leg bag attached to his left leg. The leg bag was full to 750 ml of light yellow urine. The leg bag showed a maximum amount of 800 ml allowance. During an observation on 6/11/19 at 10:00 a.m., staff member J stated it was not an expectation that staff check and empty a resident's catheter bag every shift, only as needed. She stated staff should note output every shift. During an interview on 6/11/19 at 10:32 a.m., staff member K stated she had not had time to check with resident #44 to see if his leg bag needed to be emptied that morning. She stated it was also the expectation that the night shift should empty the leg bag on their shift. She stated she started her shift at 6:00 a.m. 3. Empty Urinals and Trash Bin During an observation 6/12/19 at 3:26 p.m., resident #62 had two urinals attached to an over-flowing trash bin. The first urinal was filled with over 1000 ml of urine. The second urinal had 600 ml of urine. The urinals were open without lids. The trash bin was over-flowing with trash and napkins, and there was a package of rounded processed meat in a Ziploc bag on the ground next to the trash, with several pieces of tissues and papers on the floor. Staff member M stated to resident #62, the staff need to come and empty his trash bin and urinal. Resident #62 agreed. During an interview on 6/12/19 at 3:49 p.m., staff member M stated it was the expectation for staff to empty urinals when they were full, and check on them at least once a shift. She stated anyone can empty a urinal. She stated the trash bins should be emptied as needed and any staff can empty the trash bin for a resident. During an interview on 6/13/19 at 9:00 a.m., resident #62 stated staff did not empty his urinal very often. He stated he did not feel the facility had enough staff to answer call lights or empty his urinals and trash bins. He stated he usually had to empty his own urinals by himself. He stated he had to empty three urinals that morning, because staff did not come in to check on him. He stated two urinals were completely full, and the third was partially full. He stated it made him feel like the staff did not care about him enough to take out his trash or empty his urinals. He stated he quit asking the staff for help because when he did, they would say they would be right back but would not return. He said it really bothered him when his mom came to visit, and she had to empty his urinals for him. He said it was very embarrassing, and upsetting for him when his mom had to empty the urinals. He stated She should not have to do that. During an interview on 6/13/19 at 9:12 a.m., staff member X stated the resident was on her assigned hall for the day. She would forget to check on resident #62's urinals every day, especially when it was busy. She said unless she went into his room to assist the resident, she might not remember to check to empty the urinal. She stated the resident's urinal should be emptied when it was half full or as needed, and output documented as needed. She stated she would not know how much output to document if the resident emptied his own urinal. She stated it should be the expectation of staff to empty the urinal for the resident. Staff member X stated trash bins should be emptied when they are full. If a trash bin was noticeably full, it should be emptied by any staff. 4. Missed Showers a. During the resident group meeting on 6/11/19 at 2:10 p.m., concerns were voiced related to showers/bathing, and the following was found: - Resident #5 stated, Not enough staff, especially weekends and 2 p.m. to 10 p.m., shift. There had been times when there had been only two CNAs for the whole facility. - All residents in attendance (16) unanimously agreed with resident #5's statement. - Resident #5 stated, One staff that was working at night told me, 'We might not be able to get you up in the morning, because I am the only one working, day shift will have to do that'. Resident #5 stated, Call offs on weekends, the same people call off all the time. - Resident #5 stated, Never know when we are going to get our next shower, sometimes it is seven to ten days. Resident #s 45, 51, and 52 agreed with this statement. Resident #5 stated, I worry about infection and I am wondering when the next one (shower) is. - Resident #42 stated, It's (not knowing when next shower will be) stressful. - Resident #10 stated, When I don't get a shower, I may not feel like participating in group activities, don't want to be around other people. It's a mental health thing. b. During an observation and interview on 6/12/19 at 11:05 a.m., resident #3 was sitting in her chair wearing a faded white nightgown with a faint blue pattern, it had several red stains on the front, and the top was held together with a safety pin. She stated she was not sure she would get my shower today or not, and you never know when you will get one. She stated she should get a shower because she had a doctor's appointment this afternoon for her foot wound. There was an appointment card attached to the doorframe of resident #3's room for an appointment on 6/12/19 at 3:00 p.m., and it showed the resident needed to leave by 2:00 p.m. During an interview on 6/12/19 at 11:21 a.m., staff member O stated the CNAs should provide two showers per shift when there was not a bath aide scheduled. She stated that was most of the time. Staff member O stated it was hard to complete two showers per shift, because she was scheduled two halls by herself with at least 23-25 residents. The residents were mostly extensive assist needing help from other staff members. During an observation and interview on 6/12/19 at 1:45 p.m., resident #3 was sitting in her chair wearing the same faded white nightgown with a faint blue pattern, it had several red stains on the front, and the top was held together with a safety pin. She stated she was not sure if she was making it to her appointment today and was still waiting for someone to shower her. When the time of day was pointed out, resident #3 stated she guessed she was not getting to her appointment then because she was not ready. Review of resident #3's shower schedule showed resident #3 was scheduled to receive showers on Wednesday and Saturday. Review of resident #3's shower logs, from (MONTH) 2019 through (MONTH) 2019, showed the resident did not receive a shower for the following dates: - 1/1/19 to 1/12/19; 12 days without a shower, with 1 refusal. - 1/14/19 to 1/21/19; 8 days without a shower. - 1/23/19 to 2/12/19; 21 days without a shower, with 1 refusal. - 2/14/19 to 2/20/19; 7 days without a shower. - 2/22/19 to 3/12/19; 19 days without a shower. - 3/14/19 to 4/17/19; 35 days without a shower, with 1 refusal. - 4/19/19 to 5/19/19; 31 days without a shower. - 5/21/19 to 5/30/19; 10 days without a shower. - 6/1/19 to 6/8/19; 8 days without a shower. Review of resident #3's Podiatry Physician Note, dated 5/24/19, showed, resident was to shower for the appointment on 5/28/19. The resident did not receive a shower on 5/28/19. Review of resident #3's Physician Notes, dated 5/30/19, showed, resident to shower on 6/3/19 before her appointment. The resident did not recieve a shower on 6/3/19. Resident #3 was scheduled to have a shower on 6/12/19 and had a physician appointment scheduled for after the shower. The resident did not recieve the scheduled shower before her appointment, and declined to attend the appointment. c. During an interview and observation on 6/10/19 at 4:03 p.m., resident #44 stated he could not remember the last time he had a shower. He said he would wash up in the sink every day. He stated he did not feel there was enough staff to help everyone at the facility so he was fine with washing himself. The resident was sitting in his room, in his wheelchair, his hair was cut short and he was shaved, except under his chin and neck he had long beard hair. The resident stated he shaved himself, but was not aware he missed his chin and neck. The resident smelled slightly of stale body odor. During an observation on 6/11/19 at 10:35 a.m., resident #44 was in his room, in his wheelchair, he was wearing the same clothes from the day before, his chin and neck hair had not been removed and he smelled slightly of stale body odor. During an observation on 6/12/19 at 2:00 p.m., resident #44 was in his room, in his wheelchair, he was wearing the same clothes as 6/10/19, his chin and neck hair had not been shaved and he smelled of stale body odor. A review of resident #44's shower schedule showed resident #44 was to receive a shower on Tuesday and Friday evenings. A review of resident #44's shower logs from (MONTH) 2019 to (MONTH) 2019 showed the resident did not receive a shower on the following dates: - 1/19/19 to 1/28/19; 10 days without a shower. - 2/14/19 to 3/11/19; 25 days without a shower. - 3/20/19 to 4/12/19; 24 days without a shower. - 4/24/19 to 5/13/19; 26 days without a shower. - There were no showers provided for resident for the month of June. During an interview on 6/11/19 at 8:15 a.m., staff member D stated the residents should receive their showers as scheduled. Sometimes they only get a shower once a week. She stated if they had a bath aide it was easier to provide showers to the residents but that often did not happen. She stated the bath aide was usually pulled to provide resident care. d. During an observation and interview on 6/10/19 at 3:30 p.m., resident #6 was sitting in her room, in her wheelchair. Her hair was mashed to the left side of her head and it was not washed or brushed. The resident had a slight stale smell of body odor. She stated she had not been provided a shower in over a month. She said she felt dirty, and that the staff did not care about her. She said she just stayed in her room. During an observation and interview on 6/10/19 at 3:30 p.m., resident #6 was sitting in her room. Her hair was unkempt. Her hair was mashed down in the back and on the left side of her head. She had been assisted out of bed after a nap and was not offered to have someone brush her hair. She stated it was over one month since she had a shower, and that made her feel dirty. During an observation and interview on 6/11/19 at 8:00 p.m., resident #6 was in bed laying on her left side. Her hair was messy and she had a slight smell of body odor. She stated she still had not gotten a shower. She stated it hurt her feelings when staff did not make an effort to give her a shower. She said she did not think there was enough staff to help her get a shower every week, so she quit asking for one. A review of resident #6's shower schedule showed resident #6 was to receive a shower on Wednesday and Saturday mornings. A review of resident #6's shower logs from (MONTH) 2019 to (MONTH) 2019 showed the resident did not receive a shower on the following dates: - 1/2/19 to 1/10/19; 9 days without a shower. - 2/9/19 to 3/5/19; 30 days without a shower. - 3/14/19 to 3/26/19; 13 days without a shower. - 4/8/19 to 4/19/19; 12 days without a shower. - 4/28/19 to 5/7/19; 10 days without a shower. - 5/16/19 to 6/11/19; 27 days without a shower. e. During the group interview on 6/11/19 at 2:05 p.m., resident #5 stated there was not enough staff to help the residents, and they don't get showers. He stated if someone comes in and offers you a shower, you better take that opportunity because you don't know when they will offer you another shower. He stated showers were important not only for your mental health, but physical health as well. The resident stated he felt missing showers made him feel bad, and did not want to be around people. He stated the facility is shorthanded, and he has waited as long as three weeks for a shower, and if they had more help they could get showers. A review of resident #5's shower schedule showed resident #5 was to receive a shower on Monday and Thursday evenings. A review of resident #5's shower logs from (MONTH) 2019 to (MONTH) 2019 showed the resident did not receive a shower on the following dates: - 1/5/19 to 1/13/19; 9 days without a shower. - 1/28/19 to 2/4/19; 8 days without a shower. - 2/6/19 to 2/14/19; 9 days without a shower. - 2/16/19 to 2/25/19; 10 days without a shower. - 2/27/19 to 3/11/19; 13 days without a shower. - 3/20/19 to 3/31/19; 12 days without a shower. - 4/9/19 to 4/21/19; 13 days without a shower. - 4/23/19 to 5/2/19; 10 days without a shower. - 5/4/19 to 5/12/19; 9 days without a shower. - 5/14/19 to 6/4/19; 22 days without a shower. f. During an interview on 6/10/19 at 4:45 p.m., resident #37 stated she gets her hair done at the beauty salon, but preferred to have a bath twice a week. She was told by staff that they did not have enough staff to give her a bath twice a week, so they can only give her one once a week. She stated she did not like waiting much longer than a week for a bath because she started to feel dirty and uncomfortable. She stated she did not feel there were enough staff to help all the residents and showers were always done last. A review of resident #37's shower schedule showed resident #37 was to receive a shower Tuesday and Friday mornings. A review of resident #37's shower logs from (MONTH) 2019 to (MONTH) 2019 showed the resident did not receive a shower on the following dates: - 2/2/19 to 2/11/19; 10 days without a shower. - 2/13/19 to 2/25/19; 13 days without a shower. - 3/27/19 to 4/8/19; 13 days without a shower. - 4/10/19 to 4/25/19; 16 days without a shower. During an interview on 6/11/19 at 9:32 a.m., staff member K stated when there was enough aides on the hall, we can have a bath aide to complete the resident showers. She stated when there were not enough staff, the bath aides must provide resident care, and each aide was responsible for giving the residents their showers. She stated this had been frequent when there was not enough aides to complete showers for all the scheduled residents. During an interview on 6/11/19 at 5:06 p.m., staff member Y was tearful and stated the facility had her working today from 5:45 a.m., until 10:00 p.m. She stated she did not get any breaks, and ate lunch while she worked. She stated she has worked shifts in the past from 2:00 p.m. until 6:00 a.m. She said she often worked seven days a week, with no days off. She stated she did not mind the work because the residents were worth it. She said she did try to schedule enough staff to complete all resident cares, but at times there was not enough staff to schedule for a full shift. She stated she could not always staff a bath aide, because resident care needed to come first, and unfortunately because of that, showers were not always provided. The staff member stated the facility wanted her to staff nine CNAs during the day and eight CNAs during the evening, but they could never get there. She stated weekends were the hardest days to schedule. g. During an observation and interview on 6/11/19 at 8:52 a.m., resident #52, an obese man, was sitting on his bed in his bedroom, his clothing was disheveled, wrinkled, on crooked, with skin showing. He had a strong body odor. Resident #52 stated the assistance he needed for showers were a one-person assist and for, one to three times per week, based on staffing but he was, lucky to get one shower a week. During an interview on 6/11/19 at 8:52 a.m., resident #52 stated the facility was, short staffed, especially at night, but not enough (staff) ever. He stated call lights were on for a long time, sometimes up to an hour, so it was difficult to get staff to answer your call light. Resident #52 stated there was only one CNA to assist all the people at mealtimes. Review of the facility's shower schedule showed the resident was scheduled for showers on Wednesday and Saturday evenings. Review of resident #52's Bathing Schedule(s) dated (MONTH) 2019 through (MONTH) 2019, reflected 12 showers completed in six months.

Based on observations, interviews, and record review, the facility failed to provide the necessary services and staffing to prevent the development and worsening of pressure ulcers for 3 (#s, 1, 2, and 3); failed to provide necessary services to prevent isolation and neglect for 1 (#1); failed to provide catheter care to prevent the potential for a UTI for 1 (#1); failed to provide routine care to a suprapubic catheter for 1 (#3); and failed to ensure necessary staffing to provide regularly scheduled showers for 4 (#s 1, 2, 3, and 4) of 6 sampled residents. The accumulative effect of this deficient practice resulted in harm with the development of pressure ulcers for resident #s 1, 2, and 3; and alternate negative outcomes identified included: pain for #2; resident #4 felt dirty, gross, and unclean; and resident #3 felt bad, unclean, and that no one cared about the resident. Findings include: 1. Pressure Ulcers A. During an observation on 8/20/18 at 11:15 a.m., resident #3 was laying on his back, with his head propped up, watching his computer, which was placed on his over the bed table. The resident had a strong musky odor, and his hair was oily with flakes of dandruff. During an interview on 8/20/18 at 11:15 a.m., resident #3 stated he had been in his bed for approximately one and half months, since his electric wheelchair quit working. He said he was told it would be fixed, but no one has come by to check on repairing his electric wheelchair. He stated he owns a manual wheelchair, but he did not know where it was. He stated he had asked staff to find his manual wheelchair for him, but nobody had brought it in for him. He stated he had difficulty moving and repositioning himself in his bed because of his upper extremity weakness, and his bilateral lower extremity amputation. He said he lays in the same position most of the day, because staff did not come in and help him reposition. He said had many skin impairments when he was admitted to the facility, and they had been improving when he had a Sand mattress. He stated since the facility changed him from the Sand mattress to his current mattress (air mattress), he had developed more skin problems. He stated his doctor had ordered for him to have wound care once a day, and that was not happening. He stated he also did not get regular showers, he preferred to be showered at least twice a week, but he was lucky to get one once a week. He stated he felt there was not enough staff to care for everyone. During an interview on 8/20/18 at 11:29 a.m., staff member O stated she was the only nurse to manage two medication carts. She stated she was expected to manage the care for 27 or more residents every shift. She stated there were days when she physically could not provide wound care for her assigned residents. She stated she felt she needed to prioritize her day, and passing medications came first, then if she still had time she would provide wound care. She stated she was not always able to get to the assigned skin assessments as well. The staff member stated she did not feel she had enough time to manage the care for all her assigned residents and was afraid she was going to hurt a resident because of the exaggerated workload. During an interview on 8/21/18 at 9:00 a.m., staff member O stated she did not have time to assess resident #3's skin the day before, and she would not be able to complete a skin assessment on the resident until 11:00 a.m. During an observation on 8/21/18 at 11:00 a.m., resident #3 was lying in bed on his back, with his head supported with pillows. He smelled of musk, his hair was oily with flakes of dandruff. While the resident was laying on his back, staff members O and R removed the front of the resident's brief. The brief had a foul odor and was saturated with a thick yellow and green drainage. The suprapubic site had a thick white and yellow string which pulled out of the suprapubic site when the brief was pulled back. The brief had a large amount of thick yellow, green and brown colored exudate build up, which came from the suprapubic site. The posterior side of the resident's penis appeared to have had a previous surgical repair, which showed the penis flayed open from the tip of urinary meatus down the shaft. The interior of the penis was exposed. The interior of the penis was bright red. Below the surgical opening, there was an approximately 12 cm by 5 cm oval shaped area of bright red, inflamed, macerated skin which was open and had sanguineous and purulent drainage which saturated the front of the resident's brief. The resident was then turned to his left side and his brief was removed entirely exposing his buttocks. The brief had a large amount of thick brown, green, and yellow, purulent drainage, which pulled away in thick strings from his buttocks, as the brief was removed. The wound had a strong odor. Two dressings were present, one on the right sacrum and one on the left sacrum, both dated 8/19/18. The resident's buttocks showed a large football sized area of discolored skin. On the resident's right sacrum were 2-3 open areas approximately 1 cm by 1 cm, round, the wound bed was filled with slough, and was unstageable. On the right sacrum were 2 open wounds, both approximately 1 cm by 1 cm, round, one covered with eschar and one covered with slough, both were unstageable. The resident also had a bright red, open area approximately 1.5 cm by 1 cm, round, on puckered skin on the sacrum. He also had an area of bright red macerated skin on is scrotum, which measured approximately 5 cm by 4 cm, oval shaped. The area on his scrotum was draining a sanguineous red fluid. The resident was covered with a bed sheet for privacy and offered a bath, which he accepted. On the resident's right shoulder was a patch of scaled skin, which had a 2.5 cm scratch, which was open and actively bleeding bright red blood. During an interview on 8/21/18 at 11:30 a.m., resident #3 stated he could not reposition himself and would lay for long periods on his back. He stated staff did not offer to come in and reposition him. He stated he felt his skin has had substantial breakdown since his mattresses were changed. He stated he had told the staff his concern regarding his mattress, and they did not follow up on his concerns for skin breakdown related to his new mattress. Review of resident #3's Braden Scale Assessment for Predicting Pressure Sore Risk, showed the resident was a very high risk for skin breakdown, with a score of 9. Review of resident #3's Physician Orders, dated 6/26/18, showed, Wound Treatment: Apply Hydroguard silicone cream, cover with gauze dressing Q-day. No tape necessary can be open to air when the gauze falls off. The wound order fails to identify the site for wound care. Review of resident #3's Physician Orders, dated 7/14/18, showed, Meplix dressing on both sacral sores Q 24 hours and PRN. The physician orders [REDACTED]. A review of the resident's MAR/TAR's for (MONTH) and (MONTH) of (YEAR), failed to show an order for [REDACTED]. Review of resident #3's Weekly Skin Evaluations showed the resident had a weekly skin assessment on the following dates, for the following wounds: - 7/19/18: showed: 1. left buttock pressure ulcer to left buttock scabbed over, no drainage. Measured 0.7 by 0.3 by 0, circular wound. 2. The right buttock pressure ulcer is scabbed over and no drainage noted, no pain. Measures 1 x 0.5 by 0, circular wound. 3. The pressure ulcer to the right buttock scabbed over no drainage noted, no pain. Measured 1.2 by 1.4 by 0, circular wound. - 7/25/18: showed: 1. Left buttock, small pressure ulcer to left buttock now resolved. 2. Left buttock, pressure ulcer to left buttock decreasing in size, scabbed over, minimal serous drainage noted, no odor, no complaint of pain. Measured 0.9 by 0.8 by 0, circular shaped wound. 3. Right buttock, pressure ulcer to right buttock decreasing in size, scabbed over, no drainage noted, no complaints of pain. Measured 1.2 by 0.5 by 0, circular shaped wound. -8/1/18: showed: 1. Left buttock, stage 2 pressure ulcer to left buttock red in color, moderate serous drainage noted, no complaints of pain. Measured 1.0 by 0.2 by 0, oblong wound shape. 2. Left buttock, stage 2 pressure ulcer to left buttock wound bed is light pink in color, minimal serous drainage noted. Measured 1.0 by 1.0 by 0, wound circular in shape. 3. Left buttock, stage 2 pressure ulcer to left buttock wound bed is light pink in color, minimal serous drainage noted. Measured 1.0 by 1.0 by 0, with a circular wound bed. -8/8/18: showed: 1. Left buttock, pressure ulcer to left buttock now resolved. 2. Left buttock, pressure ulcer to left buttock now resolved. Review of resident #8's Nutrition Hydration Skin Committee Review Form, dated 8/8/18, showed, Skin issue healed 8-8-18. The Skin Evaluation Notes and Nutrition Hydration Skin Committee Review Forms, failed to identify any skin breakdown on the resident's penis and scrotum. Review of resident #3's Skin Evaluation Notes, MAR/TAR, IDT Notes, Nutrition Notes, and Progress Notes, failed to show continued management and assessments for skin breakdown after 8/8/18. On 8/21/18, the resident was observed to have had open areas of skin breakdown to his penis, distal side of his scrotum, buttocks, and right shoulder. The facility failed to provide weekly skin assessments, daily wound care, and regular position changes for resident #3, which resulted in the development of sacral and coccyx pressure ulcers, open areas of maceration on his penis and distal scrotum. B. During an observation on 8/20/18 at 11:13 a.m., a strong odor of urine and BM could be smelled in the hallway, outside of resident #1's room. The resident was lying in bed on her right side. She was contracted into a semi-fetal position and was very rigid, with limited mobility. During an observation on 8/20/18 at 12:37 p.m., resident #1 was lying in the same position in her bed. The room had a strong odor of urine and BM. During an observation on 8/20/18 at 2:15 p.m., resident #1 was lying in the same position, on her right side. The room had a strong odor of urine and BM. During an interview on 8/20/18 at 2:20 p.m., staff member K stated she honestly had not had time to check on resident #1 since around 9:00 a.m. She stated it was the expectation to check on resident #1 every two hours or more, because she was completely bed ridden, and was close to death. She stated she thought the resident had a small wound on her back. She said she was not sure if it was supposed to be covered or not, because sometimes it did not have a dressing covering it, so she believed it was to be open to air. She stated she was the only CNA on resident #1's hall, and she had not even had time for a break or lunch since she came into work that morning at 6:00 a.m. She stated she frequently felt the facility was understaffed, and had to work without help on many different shifts. She stated she was afraid of hurting herself and the residents, because she has had to make many challenging transfers without assistance. Staff member K stated she would get another CNA, and go in and check resident #1. During an observation on 8/20/18 at 2:30 p.m., staff member K and H assisted resident #1, to change her soiled brief. When the staff pulled back the resident's top sheet, the resident was wearing a hospital gown, and brief. The bottom sheet was saturated with yellow, brown fluid from her thighs up her back. The BM had seeped out around her brief and was saturated into the sheep skin blanket which was wrapped around the resident's feet. When the staff removed the resident's brief, the resident had BM which extended from the top of her pubis around her back and up past her sacrum. The resident's catheter tube was saturated in BM up to the catheter hubs. After the staff had cleaned off the majority of the BM from the resident, there was a sacral pressure ulcer, which was open to the air, and it measured approximately 1.5 cm by 1.5 cm, it was open and the wound bed was cavernous, and was impacted with BM and slough. The pressure ulcer was not able to be staged. When the wound was wiped clean of the majority of BM, there remained a brown/yellow dried circle of BM around the wound. During an interview on 8/20/18 at 2:45 p.m., staff member Q stated the resident should be checked on at least every two hours to change her brief and change her positioning. She stated many times there was not enough staff to complete all the required cares for residents. She stated she did not get time for breaks. She stated she was not sure if the resident's wound should be covered with a dressing, because it doesn't have one most of the time. During an interview and observation on 8/20/18 at 2:40 p.m., staff member J stated she was not aware of resident #1's sacrum wound. She reviewed the MAR/TAR for resident #1 and stated there was no wound care orders for her to complete on the resident during her shift. She reviewed the MAR further and determined the wound care was to be provided by the night shift. She stated she would go in and assess resident #1's sacrum and place a dressing over the wound. She stated she felt overwhelmed many times with not having enough staff to complete all resident cares. She stated they used to have three nurses on the unit, two to pass meds, and one to provide treatments. She stated there has only been two nurses for about four months, and she wants to quit, because she can no longer put her license at risk. Review of resident #1's Braden Scale Assessment for Predicting Pressure Sore Risk, showed the resident was a very high risk for skin breakdown, with a score of 9. Review of resident #1's Physician Recapitulation Orders, dated 8/1/18 to 8/31/18, stated, Restrictions: (1) Turn every 2 hours to prevent skin breakdown . Review of resident #1's Physician Recapitulation Orders, dated 8/1/18 to 8/31/18, stated, Weekly skin audit one time a day every Thursday. Wound Care: Turn every 2 hours from side to side . (4) Sacral Breakdown, wach (sic) daily, opti foam. Review of the resident's MAR, dated (MONTH) (YEAR), showed the resident did not receive a weekly skin audit on the following date: - 8/16/18 Review of resident #1's MAR, dated (MONTH) (YEAR), stated, Santyl Ointment 250 units/gm ([MEDICATION NAME]). Apply to Sacrum topically one time a day related to pressure ulcer of sacral region, unspecified stage. Review of the dates of administration the resident did not receive the ordered ointment on the following dates for the month of August, (YEAR): - 8/6/18, 8/17/18, and 8/21/18. Review of resident #1's Weekly Skin Evaluations showed the resident received a skin assessment for the month of (MONTH) on the following dates: - 8/2/18, showed, stage 3 pressure ulcer to sacrum, wound bed covered in slough, maceration noted to edges. Skin surrounding wound is red in color and blanches easily. The wound measured 1.0 by 1.5 by 0.6, and was circular in shape. - 8/9/18, showed, sacrum stage three pressure ulcer to sacrum covered in slough with red wound edges, maceration noted, minimal SS drainage noted, decreasing in size. Wound measured 0.9 by 0.8 by 0.4, and was circular in shape. -There was no Weekly Skin Evaluation for the week of 8/16/18. The facility failed to provide weekly skin assessments, daily wound care, and regular position changes for resident #1, which resulted in a worsening of a Stage 3 pressure ulcer to unstageable. C. During an observation on 8/20/18 at 2:00 p.m., resident #2 was sitting in his wheelchair by the nurses station. He told staff member O that he his backside hurt and he wanted to lay down. Staff member O stated the CNA's were busy right now but would be there to lay him down before long. During an observation on 8/20/18 at 2:56 p.m., resident #2 was asleep in his wheelchair at the nurses station. During an observation on 8/20/18 at 5:46 p.m., resident #2 called out that he wanted to lay down in his bed. During an interview on 8/21/18 at 9:28 a.m., staff member L stated she had not yet seen the pressure ulcer on resident #2's sacrum. She stated the resident did complain of a lot of bottom pain. She stated his bottom starts to hurt from sitting in his wheelchair for too long. During an observation on 8/21/18 at 9:35 a.m., resident #2 had a new reddened area, which was non-bleachable, on his left sacrum. He had a dressing covering a wound on his right sacrum which was dated, 8/19/18. The wound to his right sacrum had an area which was approximately 3 cm by 5 cm, and it was open. The wound bed was red and raised in appearance and had about 25% slough covering the surface. During an interview on 8/21/18 at 9:35 a.m., the resident stated his bottom hurt if he sat in his wheelchair for too long. During an interview on 8/21/18 at 9:35 a.m., staff member L stated she was aware of the pressure ulcer on his right sacrum, but was not aware of the one on his left. She stated she would start an SBAR, measure the wound, and document the findings. She stated she would also notify the physician and family. Staff member L stated she did not know if the facility had a standing order for wound treatment until the physician can be notified. The staff member stated she was not able to get to all the wound care on her hall. She stated when she had to work two medication carts, she did not have time to complete all the wound care. She stated the facility used to have a third nurse on this wing, but not for the last four months. She stated she tried to prioritize her care provided to the resident's. She said she rarely gets a break during her 12 hour shift. Review of resident #2's Braden Scale Assessment for Predicting Pressure Sore Risk, showed the resident was a high risk for skin breakdown, with a score of 16. Review of resident #2's Physician Orders, started on 7/20/18, showed, Weekly skin audit every day shift, every Sunday. Review of resident #2's TAR's for (MONTH) (YEAR), and (MONTH) (YEAR), showed the resident did not receive a weekly skin check for the following dates: 7/1/18, 7/15/18, 7/22/18, 7/29/18, 8/5/18, 8/12/18 and 8/19/18. Review of Nursing Progress Notes, dated 8/19/18, stated, Direct care staff reported skin breakdown on (resident #2). He has a red area on his right buttock approximately 1 x 2 inches stage II. The center of this area is open with no drainage. This is likely caused from direct pressure as he usually lays on his back related to hip discomfort. Area cleaned and foam dressing applied. Encouraged to try to lay on his side rather than on his back. Review of resident #2's MAR's and TAR's for (MONTH) (YEAR), and August, (YEAR), failed to identify ordered wound care for the wound on the resident's right buttock, which was identified by staff on 8/19/18. The facility failed to provide weekly skin assessments, daily wound care, and provide aid when the resident wished to lay down and relieve the pressure on his bottom. These factors resulted in a new development of a Stage I pressure ulcer on the resident's left sacrum, and a worsening Stage II pressure ulcer which became larger in diameter. A review of the facility's policy, titled Skin Integrity, showed, In an effort to maintain the resident's optimal level of skin integrity and promote healing of skin ulcers/pressure ulcer/wounds, the Center has a systematic approach and monitoring process for evaluating and documenting skin integrity. In the event that a resident is admitted with or develops a skin ulcer/pressure ulcer/wound, care is provided to treat, heal, and prevent, if possible, further development of skin ulcer/pressure ulcers/wounds .4. The resident's skin is inspected daily with completion of ADL's (unless resident is independent in ADL completion). Changes in the resident's skin are reported to the Licensed Nurse (LN). Ongoing evaluation continues weekly with the LN completing a full body skin audit. Completion of the skin audit is documented on the Treatment Administration Record (TAR) with their initials, and either a '-' or '+'. a. '-' indicates no skin impairment present. b. '+' indicates skin impairment present. 6. New admissions are reviewed by the Nutrition Hydration Skin Committee meeting, for 4 weeks following admission. 7. For skin impairment identified with admission .a. document skin impairment that includes measurements of size, color, presence of odor, exudates, and presence of pain associated with the skin impairment in Nurse's Notes and on the Weekly Wound Evaluation. b. Notifies the physician and obtain a Treatment Order if needed, document on the TAR after implemented .10. Wounds are evaluated weekly by Center clinicians . 2. Isolation and Neglect During an observation on 8/20/18 at 11:13 a.m., a strong odor of urine and BM could be smelled in the hallway, outside of resident #1's room. Inside the room, the room was dark, resident #1 was lying on her right side, she was contracted into a semi-fetal position. The resident's hair was stringy with oil, and the pillow behind her head had a green pillow case which had a ring of oil saturated around the resident's head. The resident's eyes were open and the TV was on, the volume for her TV was inaudible. Resident #1's roommate was not in the room, but the roommate's TV was on, and the volume was turned up and could be heard on resident #1's side of the room. The resident had a tube feeding pump which was continually beeping, indicating the tube feeding was complete. The resident had a catheter bag which was laying on the floor under her bed. When asked questions, the resident could blink once for yes, and twice for no, but was not consistent in responses. During an observation on 8/20/18 at 12:37 p.m., resident #1 was lying in the same position in her bed, the tube feeding alarm was still beeping. The room was dark, and the TV was on without sound. The roommates TV was on and the volume was turned up. The room had a strong odor of urine and BM. During an observation on 8/20/18 at 2:15 p.m., resident #1 was lying in the same position, on her right side. The room was dark and the blinds were drawn. The resident's TV was on with the volume turned down, and the roommates TV was turned up, and the roommate was not in the room. The tube feeding alarm was still beeping, and the room had a strong odor of urine and BM. During an interview on 8/20/18 at 2:20 p.m., staff member K stated she honestly had not had time to check on resident #1 since around 9:00 a.m. She stated it was the expectation to check on resident #1 every two hours or more, because she was completely bed ridden, and was close to death. She stated she was the only CNA on resident #1's hall and she had not even had time for a break or lunch since she came into work that morning at 6:00 a.m. She stated she frequently felt the facility was understaffed, and had to work without help on many different shifts. She stated she was afraid of hurting herself and the residents, because she has had to make many challenging transfers without assistance. Staff member K stated she would get another CNA, and go in and check resident #1. During an observation on 8/20/18 at 2:30 p.m., staff member K and H changed resident #1's soiled brief. When the staff pulled back the resident's top sheet, the resident was wearing a hospital gown, and brief. The bottom sheet was saturated with yellow, brown fluid from her thighs up her back. The BM had seeped out around her brief and was saturated into the sheep skin blanket which was wrapped around the resident's feet. When the staff removed the resident's brief, the resident had BM which extended from the top of her pubis around her back and up past her sacrum. The resident's catheter tube was saturated in BM up to the Hub. After the staff had cleaned off the majority of the BM from the resident, there was a dime sized open to air pressure ulcer on coccyx. The wound was covered in BM, and there was BM in the wound bed. When the wound was wiped clean of the majority of BM, there remained a brown/yellow dried circle of BM around the wound. During this process the TV was still on with the volume off. The roommates TV was on and the volume was turned up, but the roommate was not in the room. Resident #1's tube feeding alarm was still beeping, and CNA's did not notify the nurse of the tube feeding alarm sounding. The alarm was still sounding when the staff finished their care of resident #1. During an interview on 8/20/18 at 2:55 p.m., staff member H stated the resident's tube feeding alarm sounded when her tube feeding was done running, and the nurse would need to change the tube feeding. She stated the resident should be checked on at least every two hours to change her briefs and change her positioning. During an observation on 8/21/18 at 8:45 a.m., resident #1 was lying in her bed on her left side. She had a bag of tube feeding solution hanging from the pump with a date and time of 8/20/18 at 3:30 p.m. The room had a strong odor of urine and BM, and it could be smelled in the hall outside of the resident's room. The resident's hair was oily and stringy, with dandruff. She was wearing a black neck pillow. The alarm on the resident's tube feeding was beeping. The resident's TV was on and the volume was down, and the volume of the resident's roommates TV was turned up. The roommate was not in the room. During an observation on 8/21/18 at 9:00 a.m., staff member Q stated it was the expectation to check and change the resident every two hours. She stated she routinely did not have time to check on resident #1 until after the morning meal pass, because she was alone on the hall, and had too many resident's to get up by herself. Staff member Q said she had not checked on resident #1 since she had started her shift at 6:00 a.m. She stated she believed the resident had her brief changed and was checked on by the night shift, around 5:00 a.m. She stated she would try to find another CNA to help her change resident #1. During an observation on 8/21/18 at 9:20 a.m., staff member Q and I provided resident cares to resident #1. The resident had a brief which was saturated in urine, even with a catheter in place. The urine had a strong odor. The resident had a dressing covering her coccyx wound, which was dated 8/20/18. The tube feeding had ended, and the alarm was beeping. The CNA's did not turn off the alarm while providing care or before they left the room. The resident was repositioned to her left side. During an interview on 8/22/18 at 8:00 a.m., NF1 stated she was worried about the care of resident #1. She stated she did not feel the resident was repositioned or checked for soiled depends. NFI stated she had complained to the facility, because she was worried the resident was not receiving regular baths. She stated she was not always able to come in and visit, but thought the facility was too short staffed to provide adequate care for all the residents. During an observation on 8/22/18 at 8:30 a.m., resident #1 was laying in bed on her right side. The alarm on her tube feeding was beeping and her TV was on, without volume. The date on the tube feeding bag indicated the bag was hung new on 8/20/18 at 3:30 p.m. The tube feeding had been hanging for over 24 hours. Review of resident #1's Progress Note, dated 8/19/18, showed, Daughter in to visit this pm. She is concerned that she feels like her mother has not had a shower or had her hair washed recently . The facility failed to provide the necessary services for resident #1. The facility failed to ensure the resident was free from excessive noise related to the alarm on her tube feeding, and the excess noise from the roommates TV. They failed to provide regular check and changes every two hours as ordered. 3. Lack of Catheter Care During an observation on 8/20/18 at 2:30 p.m., resident #1's catheter bag was lying on the floor under her bed. Staff member K picked it off the floor and placed it on the bed. Staff member K and H changed resident #1's soiled brief. The resident's catheter tube was saturated in BM up to the Hub. Staff member H reminded staff member K to clean the catheter tubing away from the resident. After staff member K finished cleaning the catheter tubing, the catheter tubing remained discolored a light-yellow color. During an interview on 8/20/18 at 2:30 p.m., staff members K and H stated they tried to clean the catheter tubing the best they could every time they changed the resident's briefs. During an observation on 8/21/18 at 9:20 a.m., staff member Q and I provided resident cares to resident #1. The resident had a brief which was saturated in urine, even with a catheter in place. The urine had a strong odor. The staff members failed to clean the catheter tubing during peri-care. During an interview on 8/21/18 at 9:20 a.m., staff members Q and I stated it would be important to provide catheter care during the resident cares to prevent infection. A review of resident #1's Physician Orders, and the MAR and TAR's for (MONTH) of (YEAR), failed to reflect an order for [REDACTED]. A review of resident #1's Nursing Progress Note, dated 8/19/18, showed, (Resident's) urine has an odor and is cloudy appearing. Will ask direct care staff to obtain urine specimen in the a.m. for analysis and C&S if indicated. A review of resident #1's Nursing Progress Notes and Physician order [REDACTED]. The facility failed to provide proper and routine catheter care to resident #1's catheter. The facility failed to establish an order on the MAR/TAR to provide services to care for the resident's catheter and prevent infection. The facility failed to obtain an order for [REDACTED]. 4. Lack of Care to a Suprapubic Catheter During an observation on 8/21/18 at 11:00 a.m., staff members O and R provided peri-care for resident #3. They removed the front of the resident's brief. The brief had a foul odor and was saturated with a thick yellow and green drainage. The suprapubic site had a thick white and yellow string which pulled out of the suprapubic site when the brief was pulled back. The brief had a large amount of thick yellow, green and brown colored exudate build up, which came from the suprapubic site. During an interview on 8/21/18 at 11:00 a.m., resident #3 stated he had his suprapubic catheter cleaned once a month. He stated it was only cleaned when it was changed. He stated the staff did not clean the site regularly between catheter changes. A review of resident #3's Physician Orders, dated (MONTH) (YEAR), stated, Change suprapubic catheter Q 30 days and PRN one time a day every day(s) related to encounter for surgical aftercare following surgery on the skin and subcutaneous tissue. A review of resident #3's physician orders, and treatment orders, failed to include regular care and cleaning procedures for the resident's catheter care. 5. Missed Showers for dependent resident's A. During an observation on 8/20/18 at 12:03 p.m., resident #4 was sitting in his wheelchair, he smelled lightly of musk and body odor, and had short cut hair which appeared oily with small flakes of dandruff. During an interview on 8/20/18 at 12:03 a.m., resident #4 stated he did not feel there was enough staff to provide the necessary care for all the residents. He stated it had been almost three weeks since he was given a shower. He said before he was admitted to this facility he would shower every day. He said he was told by the staff that he would not be offered a shower everyday due to staffing, and could have one twice a week. He stated when he was not provided a shower he felt dirty and gross. Review of resident #4's ADL-Bathing report for the month of (MONTH) (YEAR), s

Based on observation, interview, and record review, the facility failed to have sufficient staffing to provide the necessary care and services, to prevent and treat residents for pressure ulcers for 3 (#s 1, 2, and 3); failed to provide showers for 4 (1, 2, 3, and 4); failed to provide assistance for a dependent resident to prevent incontinence of urine for 2 (# 7 and 8); and failed to to provide meal service in timely manner for 6 (#s 3, 4, 5, 8, 9, and 10) of 13 sampled and supplemental residents; and failed to maintain a system for adequate nursing coverage, to ensure a charge nurse was available for the provision of nursing services, when the assigned charge nurse was required to leave the designated skilled nursing area of the facility, and would be unable to provide resident care. The accumulative effect of this deficient practice, put all residents at the facility at risk for not receiving care due to the lack of staff availability. Findings include: During an interview on 8/20/18 at 11:09 a.m., staff member O stated she was the only nurse available to manage two medication carts. She stated she had 29, residents who were extensive assist, to care for by herself. She stated she had multiple residents who needed wound care, and did not have time to provide that care. She stated she also had three residents with catheter care, a resident with a [MEDICAL CONDITION] and one with a tube feeding. She stated she had a resident who was on hospice and was approaching the end of life, and she had not had time to check on him. She stated there were times they did not have enough staff to get residents out of bed in the mornings, and many times residents who needed extensive assistance stayed in bed, and they would also miss meals at times. She stated on many different occasions, residents lay in soiled briefs for hours, until a CNA could help them. She stated the unit currently had two nurses, and three CNAs for 58 residents. They currently had three CNAs to provide care for 58 residents, of which approximately half of the residents required extensive 2-person assistance for their cares. She stated one of the CNAs was new that day, and was training. She said the night shift had only one nurse and one CNA, to care for 58 residents, of which, approximately half require an extensive two-person assistance. She stated when CNAs call off, their is no system in place to replace them, and many times they just work short. During an interview on 8/20/18 at 12:03 p.m., staff member J stated the staffing for the facility was not great. She said she had to go per diem because she could no longer handle the hours. She stated on many occasions over the last year, she was asked to work two shifts in a row, over 24 hours. She stated she was the only nurse to run two medication carts, and provide care to 27 residents. She stated she had two residents with a tube feeding, two with catheter care, and several with wound care. She stated she had a difficult time completing her assigned tasks for all 27 residents. She said she would miss wound care because she did not have time to complete it for the residents. She said there was currently three CNAs and one which was orienting, to provide care for 58 residents. She stated there was only one CNA per hall which had 2-person assist residents. She, the charge nurse, would do the best they could to replace call off's, but with all the other duties, this did not happen. She stated she was aware some residents remained soiled for long periods of time, and sometimes they did not get food delivered to their rooms. She stated she was fearful for the residents and has felt she was placed in an impossible situation. She stated on several occasions she would be pulled from her duties as a charge nurse for the unit to provide assessments or services for residents on the assisted living side of the building. She said that was frustrating because she barely had time to complete the care she was required to do for the residents of the nursing home. During an interview on 8/20/18 at 12:31 p.m., staff member G stated she was afraid for the residents. She stated the facility was understaffed and many residents were being left soiled for long periods of time, not helped out of bed, and taken to the dining room for meals. Many of the residents don't get their scheduled showers, and there are several residents who have developed new skin impairments, which have not been addressed. She stated there was only 3-4 CNAs scheduled to work the unit, and that was not enough to care for all the residents. She stated there were many times when there were only two CNAs to provide care for 58 residents. During an observation on 8/20/18 at 12:56 p.m., there were four CNAs working the unit, one of which was a trainee, and was being oriented by a CNA. During an interview on 8/20/18 at 2:16 p.m., staff member K stated she was the only CNA for an entire hall, the hall had several residents which were a two-person assist. She stated she could not get those residents up and they would just stay in bed. She stated she did not feel it was safe to help many of the residents because she was the only CNA for the entire hall with 16 residents, and other staff did not want to help her. During an interview on 8/20/18 at 2:30 p.m., staff member H stated she was afraid she was going to hurt a resident. She stated she has been the only CNA on two halls with over 20 residents, of which there are residents who are a two-person assist. She stated she did what she could, but there was many times when she could not answer call lights or change a soiled brief for over an hour. She stated she was aware there were residents who did not get their showers, or get up for meals, because there was not enough staff to help. She knew residents were developing new pressure ulcers because they are left for long periods in their chairs or in bed in the same position. During an interview on 8/20/18 at 2:40 p.m., staff member S stated the facility had replaced their DON and the Administrator on 8/20/18. He stated the facility was actively trying to recruit more CNAs and nurses. He stated the facility did not usually use travel nursing for staffing shortages. He stated there were employees who were certified nurses assistants, and could float over to help the floor staff when things were busy. He stated there was an activities aide, a human resource manager, a business office manager, and a receptionist, all who had their CNA license and could help when short. He stated these services were not scheduled, they were just available to help if needed. 1. Pressure Ulcers During observations, interviews, record reviews, the facility failed to ensure resident #s 1, 2, and 3, had adequate staffing to provide the required nursing services to prevent the development of, and worsening of pressure ulcers. Resident #1 developed five new Stage 2 pressure ulcers on his buttocks, and had also developed open areas of maceration on his penis and distal scrotum. Resident #2 developed a worsening pressure ulcer on her sacrum; and, resident #1 developed a new Stage 1 and a worsened Stage 2 pressure ulcer. These deficiencies were related to the insufficient staffing to provide the necessary services to prevent skin impairment (See F 600 for further detail). 2. Showers During observation, interviews, and record reviews, the facility failed to provide scheduled showers to maintain the residents highest-practicable well-being for four residents (#s 1, 2, 3, and 4) (See F 600). 3. Incontinence A. During an observation on 8/20/18 at 12:57 p.m., resident #8 was sitting in his wheelchair in the doorway of the assisted dining room. His food was sitting at his table, untouched. He told staff member P he had to go to the bathroom. The staff member told the resident he would need to wait for a CNA to come help him. During an observation on 8/20/18 at 1:15 p.m., resident #4 asked if someone was going to help resident #8 to the bathroom. Resident #8 stated, it's too late. A CNA entered the dining room and pushed the resident up to his table and started assisting him with his meal. B. During an observation on 8/20/18 at 5:00 p.m., resident #7 explained to staff member F that he was experiencing a lot of urgency with urinating, but when he tried to go, nothing would happen. He explained to staff member F that he needed to go to the bathroom and asked if someone could help him. The staff member told him he would have to wait because the CNAs were busy, and there wasn't one available right away to help him to the bathroom. The resident stayed by the nurses station and kept reminding staff member F that he needed to use the bathroom, and it was becoming more urgent. At 5:15 p.m., staff member F assisted the resident to his room and called in two CNAs to help transfer the resident. During an interview on 8/20/18 at 5:35 p.m., staff member F stated the resident was brought to his commode, and was not able to go once he was put on his commode. She stated the CNAs did need to change the resident's brief because it was soiled with urine. 4. Late Meal Service During an observation on 8/20/18 at 12:15 p.m., lunch was delivered to the assisted dining room. During an observation and interview on 8/20/18 at 12:30 p.m., staff member P brought meal trays to the tables for the residents in the assisted dining room. Four residents, #s 4, 8, 9, and 10, had a meal tray in front of them on the table, but they could not feed themselves without assistance. Staff member P stated she could not assist in feeding the residents, she was just there to ensure the residents' meals were correct before they were given their food. During the observation, several residents did not have anything offered to drink. There was fresh salad on the counter which was not offered to any of the residents. During an observation and interview on 8/20/18 at 1:04 staff members N entered the dining room to assist residents' 4, 8, 9, and 10, with their meal. Resident #4 stated he was hungry but wanted to make sure the older residents received their meals first. He stated he was raised to respect his elders and just wanted to make sure they were helped first. He stated this morning he waited over an hour and half with his food sitting on the table next to him, before someone came in to set up his meal so he could eat. He stated there were many residents that did not get their room tray either. The resident stated there was also many times when there wasn't a CNA in the assisted dining room at all, he stated we are not supposed to be left unattended, but it happed on many different occasions because they did not have enough staff. During an observation on 8/20/18 at 1:36 p.m., resident #s 4, 8, 9, and 10, were still seated at their tables, with food in front of them. There was no staff in the assisted dining room. During an observation and interview on 8/20/18 at 1:44 p.m., resident #5's food was still in the meal cart at the nurses station, it had not been brought to resident #5. During an interview resident #5 stated he was not hungry and, It's a good thing too, because no brought me my lunch. During an observation on 8/20/18 at 6:00 p.m., residents were waiting in the assisted dining room for dinner. The food cart was outside the dining room, next to the nurses station. During an observation on 8/20/18 at 6:15 p.m., staff member P passed out the meal trays to the residents in the dining room. Resident #4 asked for his assistive device so he could eat, and staff member P told him she could not help him, and he needed to wait for an aide. Staff member P finished passing the meal trays for the assisted dining room, several residents were able to feed themselves, but there were four residents, 4, 8, 9, and 10, who needed total assistance, their food was sitting in front of them, but there was no one available to help them eat. During an observation on 8/20/18 at 8:46 p.m., two CNAs entered the assisted dining room and started to assist resident #s 4, 8, 9, and 10 with their meals. The residents had to wait for 46 minutes with their food in front of them, and no one was available to help them eat. During an interview on 8/20/18 at 8:46 p.m., resident #4 stated it was the normal to wait for someone to come in and help them with their meals. During an interview on 8/21/18 at 7:30 a.m., staff member P stated she was embarrassed about how the meal services went the day before. She stated she could only pass out the food, and ensure it was the correct diet, but she could not help serve food. She stated residents will wait up to an hour at times waiting for staff to come in and help them eat. She stated the facility was understaffed. During an observation on 8/21/18 at 8:00 a.m., the kitchen brought down the meal cart for the unit. During an observation and interview on 8/21/18 at 8:42 a.m., resident #3 stated he had not been brought his morning meal tray yet. He stated he was hungry, but was used to waiting for the staff to bring him his meals. He stated many times he would get his food and it was cold. He stated he would not eat the food when it was cold. The resident stated he felt this was because the facility was short staffed. During an observation at 9:56 a.m., staff member Q brought resident #3 his breakfast meal tray. The resident waited two hours for his breakfast. 5. Inadequate Nursing Coverage During an observation and interview on 8/20/18 at 2:40 p.m., staff member J stated she was the charge nurse for the unit and was just asked to go to the assisted living center to check on a resident who was experiencing chest pain. She stated she was pulled from her duties as a charge nurse on the unit to complete assessments, or services for residents at the attached assisted living facility. The staff member stated she felt this put a huge strain on her to meet her already heavy workload at the nursing home, and then be pulled over to the assisted living facility in the middle of her shift to help over there. She stated it made her uncomfortable to leave her residents unattended to help over at the assisted living facility, but it was an expectation of her duties by the management. During an interview on 8/20/18 at 3:30 p.m., staff member S stated if the assisted living center needed a nurse to help with resident care, the staff from the nursing home could go over and help them. (See F 835 for more detail)

Based on observation, interview, and record review, the facility failed to adequately monitor a resident's weight decline to identify when weight changes became more significant, and the resident experienced a severe weight decline of over 12% in three months; failed to assess the resident adequately for contributing factors for weight decline; failed to identify, implement, and ensure the use of, interventions implemented for weight decline and prevention of further decline for 1 (#19) of 28 sampled residents. Findings include: On 4/18/18 at 1:49 p.m., the facility Executive Director, DD[NAME], and the Divisional Vice President were notified that an Immediate Jeopardy existed in the regulatory area of F692 - Nutrition, cited at the Severity and Scope of a J. The facility submitted an acceptable plan to remove the immediacy on 4/19/18 at 10:00 a.m. After the plan was accepted the Severity and Scope was reduced to a G. Findings Include: During an observation on 4/16/18 at 12:45 p.m., resident #19 was seated in the main dining room with three tablemate's. Resident #19 was eating meat loaf, mashed potatoes with gravy, and green peas. The resident had one cup and several glasses of liquid on her tray that were empty. A CNA was seated by the resident's table. Resident #19 was attempting to cut her meat loaf with her fork. She was having difficulty applying enough pressure to the edge of the fork to cut the meat loaf. The CNA did not offer resident #19 any assistance with the meal, although the resident needed physical assistance from staff. During an observation on 4/16/19 at 1:10 p.m., resident #19 was still in the dining room eating her meal. Resident #19's three tablemate's had completed their meals and left the table. Resident #19 was not eating, and the resident had not eaten all the food on her plate, but had consumed the liquids. A CNA was in the dining room. The CNA did not prompt resident #19 to continue eating the meal in an attempt to increase the resident's intake. Review of resident #19's nutrition note, dated 12/4/17, showed the assessment was not completed due to not having the current weight of the resident. Review of resident #19's FNP progress note, dated 12/8/17, showed the resident's Functional and Cognitive Status as: Functionally, needs assistance with mobility and meds. She is able to feed herself. Cognitively, has dementia but is alert and conversational today. No concerns for agitation or depression today. Documentation reviewed: Reviewed prior records, Aspen chart, Case discussed with: Aspen nursing. Listed under Impression and Plan, 10. Weight loss. Eats 50-75% of meals. Will order a nutrition consult. The FNP's progress note did not show the resident's weight loss to be unavoidable due to her functional or cognitive status. The document showed the resident needed assistance with meals, but did not show the overall level of assistance needed for meals. Review of resident #19's nutrition/dietary note, dated 12/11/17, showed the dietician had identified a weight loss of 10.2 pounds or 7.93% in six months, from (MONTH) (YEAR) to (MONTH) (YEAR). The dietician said the weight loss was not significant but it was trending down. The dietician said the resident was eating 50 to 75% of her meals. The dietician recommended nutritionally enhanced meals (NEMS) and added yogurt to resident #19's meal trays as an intervention to prevent further weight loss. During an observation on 4/17/18 at 8:45 a.m., resident #19 was eating french toast, a sausage patty, and mandarin orange sections. There was no yogurt on resident #19's tray. A CNA was seated by resident #19's table. The CNA did not assist resident #19 with her meal. Resident #19 ate approximately 50% of her breakfast, without encouragement of staff to consume more of the meal. During an observation and interview, on 4/18/18 at 8:44 a.m., resident #19 was eating her breakfast. Staff member D said she was not aware of resident #19 receiving any dietary supplements. Staff member D said if resident #19 ate less than 50% of her meal, she would offer the resident an alternative such as cereal, fruit, or a sandwich. There was no yogurt on the resident's breakfast tray. During an interview on 4/18/18 at 8:51 a.m., staff member E said she did not monitor the residents for weight loss. Staff member E said the registered dietician monitored the residents for weight loss. Staff member E stated the registered dietician was in the facility two to three times a week. During an interview on 4/18/18 at 8:54 a.m., staff member F said she reviewed all resident weights monthly. Staff member F said she had a report she could run monthly to see resident weight changes. Staff member F said she had just started using PCC (electronic health record) to review the resident(s) weights and weight reports in the last two months. Staff member F said she would notify the director of nursing and the physician if she had identified any resident with a weight loss. Staff member F said she had not recently identified any residents with a significant, severe, or insidious weight loss in the last several weeks. Staff member F said she had not been monitoring the weights for resident #19, although the resident had the prior weight loss identified, and the dietitian recommended the nutritionally enhanced meal plan for the loss. During an observation on 4/18/18 at 9:09 a.m., resident #19 was still eating breakfast. Her tablemate's had completed their meals and left the dining room. A CNA was seated away from the table. The resident had not consumed the entire meal, and the CNA did not assist or prompt resident #19 during the remainder of the meal. During an interview on 4/18/18 at 9:11 a.m., staff member B said there were several systems in place to identify weight loss. Staff member B was not aware of a weight loss for resident #19. Staff member B did not remember resident #19's down trending weight being discussed or monitored in the daily clinical meetings. Staff member B did not identify what part of the facility's weight loss systems failed, or identify the various systems which were stated to be in place. During an interview on 4/18/18 at 9:55 a.m., staff member B said the facility had dietary and nurse practitioner notes from (MONTH) (YEAR) showing resident #19 had experienced a weight decline, which had shown to be a trend over time. Staff member B said the facility had nothing more current than that on resident #19's weights. Review of resident #19's weight records showed the resident was 129.4 pounds in (MONTH) (YEAR). She was 144 pounds in February, as the weight of the wheelchair was added in. She was 123 pounds in March, and on (MONTH) 11th she was 117.8 pounds. The resident was standing when the weights were taken in January, March, and (MONTH) of (YEAR). A review of resident #19's Quarterly MDS, with an ARD of 1/26/18, showed a base weight of 133 pounds. From 1/26/18 to 4/11/18, the resident had lost approximately 16 pounds per the documentation in the resident's record. This was a severe weight loss in under three months of just over 12%. During an interview on 4/18/18 at 10:14 a.m., staff member G said she was aware of resident #19's weight loss from (MONTH) of (YEAR) to (MONTH) (YEAR), and the weight loss was addressed in staff member G's progress note dated 12/8/17. Staff member G said the facility had not notified her of any recent weight loss for resident #19. Staff member G said she saw resident #19 every other month for a recertification visit. Staff member G said she would review the resident's weights prior to coming to the facility for a certification visit. Staff member G said she would have reviewed resident #19's weights last week, and The weight for 4/11/18 would not have been in the system yet, so I guess she would have lost even more weight than I thought. Staff member G said she would have reviewed resident #19's weight that was taken in (MONTH) of (YEAR). Resident #19's weight for (MONTH) of (YEAR) was 123 pounds. During an observation on 4/18/18 at 12:45 p.m., resident #19 had been served a tossed salad, baked fish, rice, and green beans. There was no yogurt on her tray, showing the NEMS intervention was not being provided at the meals, per the dietitian's recommendation for the weight loss, prior to (MONTH) (YEAR). During an interview on 4/18/18 at 5:00 p.m., staff member H said the kitchen provided Mighty Shakes and yogurt on the meal trays if it was ordered by the physician. During an interview on 4/18/18 at 5:07 p.m., staff member I said the nurses gave the Boost and Ensure supplements to the residents. Review of resident #19's medical record showed a nutrition/dietary note, dated 4/18/18 which showed, Wt on 4/11 (117.8#) did show a sign (sic) wt loss (3mo) from 1/8/18 (129.4 at 8.9% loss). and She is eating 50-75% at most meals. Review of resident #19's Meal Monitor records showed: -January (YEAR), 10 meals eaten at 0-25% and 14 meals eaten at 25-50% -February (YEAR), 3 meals eaten at 0-25% and 15 meals eaten at 26-50% -March (YEAR), 3 meals eaten at 0-25% and 15 meals eaten at 26-50% -April (YEAR), 3 meals eaten at 0-25% and 8 meals eaten at 26-50%. There was no meal documentation for 4/1/18. During an interview on 4/19/18 at 8:01 a.m., staff member J said resident #19 refused to eat yogurt so she quit putting it on resident #19's trays. Staff member J said it would just get thrown away otherwise. Staff member J said the CNAs can ask for it if resident #19 tells them she wants it. Staff member J did not tell the dietary manager that resident #19 refused to eat her yogurt. During an observation on 4/19/18 at 8:22 a.m., resident #19 was in the main dining room for breakfast. Resident #19 had been served scrambled eggs, oatmeal, fruit, toast, and a carton of Boost. There was no yogurt on the resident's tray. Resident #19 spent four minutes trying to cut her toast with her fork. No staff offered to assist resident #19 with the cutting of the toast. During an observation on 4/19/18 at 8:26 a.m., resident #19 had picked up her knife and was trying to cut her toast still. Staff continued to not offer the resident assistance. During an observation and interview on 4/19/18 at 8:31 a.m., staff member R finally offered to put jelly on resident #19's toast. Resident #19 asked staff member R to cut her toast up for her. Staff member R said the CNAs don't prompt resident #19 at meals because She is a slow eater anyway. Staff member R said the CNAs don't really assist resident #19 with eating because the resident is fairly independent, and the CNAs want to keep the resident as independent as possible for as long as they can. Staff member R said it can take resident #19 up to two hours to complete a meal. Staff member R said when that happens, staff will take the resident and her food to the restorative dining room where staff were available to watch over resident #19 while she finished eating. Resident #19 did not have yogurt on her tray, and was not provided yogurt during the meal. Review of the facility's policy, Weights, showed: -b. Weekly Weights The following are guidelines for residents who may need to be weighed weekly (not all inclusive): -Food intake as declined and persisted -Slow trending of weight loss/gain -Significant weight loss/gain -New or altered diuretic schedule (unless physician orders [REDACTED]. -New enteral feeding until weight is stable -Change in enteral feeding orders until weight is stable -Multiple Stage II and any Stage II or IV pressure ulcers -Receiving Total [MEDICATION NAME] Nutrition (TPN) and for one month after discontinuation -Significant change of condition -Attending physician requests weights monitored weekly (or more frequently) A review of resident #19's Significant Change MDS, with an ARD of 11/30/17 and the Quarterly MDS, with an ARD of 1/26/18, showed the resident had a functional decline in transferring and personal hygiene. The observations in the dining room, completed during the survey period, showed the resident's functional eating abilities reflected she needed physical assistance of staff on at least two occasions, to cut up the resident's food. The staffs goal (per interview provided above) to maintain the resident's independence and not assist during meals was a barrier for the resident when she needed more assistance both physically and with cuing, and it was not provided. Therefore, documentation of the resident's needs and abilities was not adequately reflected in the resident's record.

Based on interview and record review, the facility failed to notify the physician of a severe weight loss, for 1 (#19) of 28 sampled residents. Findings include: Review of resident #19's weight records showed: - (MONTH) (YEAR) was 129 pounds (standing) - (MONTH) (YEAR) was 144 pounds (weighed in wheelchair) - (MONTH) (YEAR) was 123 pounds (standing) - (MONTH) (YEAR) was 117.8 pounds (standing) A review of resident #19's Quarterly MDS, with an ARD of 1/26/18, showed the resident's base weight was documented as 133 pounds. The weight decline from 1/26/18 to the (MONTH) weight of 117.8 was a 16 pound decline in less than three months, which is a severe loss. During an interview on 4/18/18 at 10:14 a.m., staff member G said the facility had not notified her of any recent weight loss for resident #19. The physician was aware of the resident's prior weight loss in (YEAR). During an interview on 4/18/18 at 2:50 p.m., NF1 said the facility had not informed her of the severe weight loss for resident #19. Per documentation review, NF1 had been informed of the prior weight loss concern in (YEAR), but not the more recent loss in (YEAR). Review of the facility's policy, Weights, showed, If a significant variance is actual after re-weigh, the nurse documents in the medical record, revises the care plan, refers to Nutritional Hydration Skin Committee and notifies the physician and resident/resident's authorized representative.

Based on observation, interview, and record review, the facility failed to address, monitor, and re-assess the interventions on the individualized resident care plan, for continued weight loss; and failed to identify and define new interventions and goals for an unplanned, severe weight loss, in three months, for 1 (#19) of 28 sampled residents. Findings include: Review of resident #19's care plan showed: -Problem, The resident has a nutritional problem or potential nutritional problem (at risk for wt loss) r/t intake of 50%. Date initiated: 12/11/2017 -Goal, The resident will maintain adequate nutritional status as evidenced by maintaining weight, no s/sx of malnutrition, and consuming at least (75)% of meals daily through review date. Date initiated: 12/11/2017, Revision on: 12/11/2017. -Interventions, Diet per MD order. Labs as ordered. Meal Monitor. If intake <50% offer substitute or supplement. Observe for s/s of dehydration: (i.e. dry mouth). Offer liquids (including thick liquids) between meals. Provide and serve diet as ordered. Refer to OT/ST as appropriate. Refer to RD as appropriate. Weigh per facility protocol. Date initiated: 12/11/2017. Review of resident #19's nutrition note, dated 12/4/17, showed the assessment was not completed due to the dietitian not having the resident's current weight. Review of resident #19's FNP progress note, dated 12/8/17, showed the resident's Functional and Cognitive Status: Functionally, needs assistance with mobility and meds. She is able to feed herself. Cognitively, has dementia but is alert and conversational today. No concerns for agitation or depression today. Documentation reviewed: Reviewed prior records, Aspen chart, Case discussed with: Aspen nursing. Listed under the Impression and Plan, 10. Weight loss. Eats 50-75% of meals. Will order a nutrition consult. The FNP's progress note did not show the resident's weight loss to be unavoidable due to her functional or cognitive status. The document showed the resident needed to be at the facility for medication and meal assistance, although the level of meal assistance was not specified. Review of resident #19's nutrition/dietary note, dated 12/11/17, showed the dietician had identified a weight loss of 10.2 pounds or 7.93% in six months, from (MONTH) (YEAR) to (MONTH) (YEAR). The dietician said the weight loss was not significant but trending down. The dietitian had documented the resident's past weights on the report, which showed: 9/4/17 - 133 lbs 12/6/17 - 127.8 lbs The dietician documented the resident was eating 50 to 75% of her meals. The dietician recommended nutritionally enhanced meals and added yogurt to resident #19's meal trays for the weight decline. The dietitian did not follow up to ensure the provision of the yogurt, or the resident's care plan relating to the yogurt as an intervention for the prevention of weight loss. A review of resident #19's Quarterly MDS, with an ARD of 1/26/18, showed the resident's base weight was 133 pounds. This was down 5.2 pounds from the prior month, of the 127.8 pounds. A review of resident #19's nutritional note, dated 4/11/18, showed the resident was down to 117 pounds. From 1/26/18 to 4/11/18, the resident had declined in weight by 16 pounds. The continued weight decline was not addressed on the care plan adequately for the prevention of further decline in weight. During an observation on 4/17/18 at 8:45 a.m., resident #19 was eating breakfast. There was no yogurt on resident #19's tray. During an observation and interview on 4/18/18 at 8:44 a.m., resident #19 was eating her breakfast. There was no yogurt on the resident's breakfast tray. During an observation on 4/18/18 at 12:45 p.m., resident #19 had been served a tossed salad, baked fish, rice, and green beans. There was no yogurt on her tray. During an interview on 4/18/18 at 8:54 a.m., staff member F said she reviewed all resident weights monthly. Staff member F said she had not been monitoring resident #19's weights, although the review of the nutritional note, dated 12/11/17, showed the staff member recommended NEMS for the resident. During an interview on 4/18/18 at 9:11 a.m., staff member B said he was not aware of a weight loss for resident #19. Staff member B did not remember resident #19's down trending weight being discussed or monitored in the daily clinical meetings. Review of resident #19's Meal Monitoring records for (YEAR) showed the resident consumes from 0 to 50% of the meal 24 times in January, 18 times in February, and 18 times in March. The facility failed to address the frequent times the resident had consumed low percentages of the meal, in an attempt to identify further concerns or potential interventions. The care plan did not reflect what staff could attempt, if unsuccessful on interventions attempted previously, to try to increase the resident's intake. Review of resident #19's medical record showed a nutrition/dietary note dated 4/18/18 which showed, Wt on 4/11 (117.8#) did show a sign (sic) wt loss (3mo) from 1/8/18 (129.4 at 8.9% loss). and She is eating 50-75% at most meals. The nutrition note did not address the frequent times the resident had low intake of under 50% at meals. During an interview on 4/19/18 at 8:01 a.m., staff member J said resident #19 refused to eat yogurt so she quit putting it on resident #19's trays. Staff member J said it would just get thrown away otherwise. Staff member J said the CNAs can ask for it if resident #19 tells them she wants it. Staff member J did not tell the dietary manager that resident #19 refused to eat her yogurt. The current status of the yogurt was not reflected on the care plan. During an observation on 4/19/18 at 8:22 a.m., resident #19 was in the main dining room for breakfast. Resident #19 had been served scrambled eggs, oatmeal, fruit, toast, and a carton of Boost. There was no yogurt on the resident's tray. Resident #19 spent four minutes trying to cut her toast with her fork. No staff offered to assist resident #19. The care plan failed to show what staff were to do if the resident struggled with her meal preparation on her own, or the level of assistance she may need, or if that level of assistance varied. During an observation on 4/19/18 at 8:26 a.m., resident #19 had picked up her knife and was trying to cut her toast, but was having difficulty. No staff offered assistance to the resident, although staff were in the dining room. During an observation on 4/19/18 at 8:31 a.m., staff member R offered to put jelly on resident #19's toast. Resident #19 asked staff member R to cut her toast up. Staff member R did cut the resident's toast into smaller pieces. Staff member R said the CNAs don't prompt resident #19 at meals because she is a slow eater anyway. Staff member R said the CNAs don't really assist resident #19 with eating because the resident is fairly independent, and the CNAs want to keep her as independent as possible for as long as they can. Staff member R said it can take resident #19 up to two hours to complete a meal. Staff member R said when that happened, staff would take the resident and her food to the restorative dining room so staff were available to watch over resident #19 while she finished eating. Resident #19 did not have yogurt on her tray. The care plan failed to adequately meet the resident's current needs for meal service and intake.