Every finding on record at Bend Transitional Care

Based on observation, interview and record review it was determined the facility failed to implement appropriate Enhanced Barrier Precautions (EBP) and Contact Precautions for 2 of 4 (#s 9 and 401) reviewed for infection control. This placed residents at risk for the spread of infection. Findings include: The CDC's 4/2/24 Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDROs) included to don gown and gloves when high-contact activities were performed. The facility's undated Enhanced Barrier Precautions policy indicated the following: -Staff must clean hands with sanitizer when entering room and leaving room. -Staff must don gown and gloves before entering resident rooms during high contact resident care activities, including transferring (assisting residents to transfer/providing transfer assistance to residents). 1. Resident 401 was admitted to the facility on [DATE] with diagnoses including osteomyelitis (bone infection). A review of Resident 401's 6/20/25 Care Plan indicated EBP interventions. The facility's undated Enhanced Barrier Precautions policy indicated the following: -Staff must clean hands with sanitizer when entering room and leaving room. -Staff must donn gown and glove before entering resident rooms during high contact resident care activities, including transferring (assisting residents to transfer/providing transfer assistance to residents). On 6/24/25 at 3:24 PM, Staff 5 (CNA) and Staff 6 (CNA) were observed to enter Resident 401's room with gloves and mask but without gowns. They transferred the resident out of bed to the shower chair. On 6/24/25 from 3:27 PM to 3:35 PM, Staff 5 and Staff 6 stated they did not wear gowns to help Resident 401 transfer out of bed because they did not touch the resident's arm that had a PICC line (form of intravenous access to deliver medications directly into the bloodstream). Staff 5 and Staff 6 stated a staff nurse indicated donning gowns was not necessary. On 6/25/25 at 1:43pm, Staff 7 (CNA) stated she did not wear PPE when residents were assisted to the bathroom who were on enhanced barrier precautions related to having a PICC line as she was not near the resident's PICC line. On 6/27/25 at 9:10 AM, Staff 2 (Director Nursing Services) stated she expected staff to follow the CDC guidelines on enhanced-barrier and transmission-based precaution signs outside of resident rooms when high-contact activities were provided that included transferring. 2. Resident 9 was admitted to the facility on [DATE] with diagnoses including MRSA (bacterial infection that is resistant to several antibiotics). A review of Resident 9's 4/18/25 Care Plan indicated to implement Contact Precautions. On 6/24/25 at 8:42 AM, A Contact Precaution sign outside Resident's 9 door indicated residents, visitors, and staff must perform hand hygiene before entering and when leaving the resident's room. On 6/24/25 at 10:34 AM and 10:43 AM Resident 9 was observed to leave her/his room and not perform hand hygiene. Resident 9 stated she/he never used the hand sanitizer outside of her/his room. Resident 9 stated she/he was not aware about performing hand hygiene prior to leaving her/his room and stated the doctors thought she/he had MRSA but she/he never believed them. On 6/25/25 at 8:48 AM, Resident 9 was observed to leave her/his room and not perform hand hygiene. Resident 9 went to a table near the nurses station to complete her/his meal order. She/he used the staff's pen and returned it back to them after completing the form. No hand hygiene was completed by staff or the resident. On 6/26/25 at 12:46 PM, Staff 8 (Infection Preventionist) stated staff were expected to remind Resident 9 to perform hand hygiene prior to leaving her/his room. Staff 2 stated staff were expected to follow the Contact Precaution sign outside of Resident 9's room and to remind the resident to perform hand hygiene.

Based on interview and record review it was determined the facility failed to ensure the daily staff posting was accurate for 19 out of 50 days reviewed for staffing. This placed residents, public and staff at risk for lack of accurate staffing information. Findings include: On 3/3/23 at 3:30 PM the Direct Care Staff Daily reports were provided from 10/7/23 through 11/10/23 and from 2/2/24 through 3/1/24. The forms revealed 19 instances when portions of the form were left blank or were incomplete. The incomplete information included census, number of staff working and number of hours worked. On 3/6/24 at 10:16 AM Staff 4 (CMA-Staffing Coordinator) and at 11:32 AM Staff 3 (RN-Assistant DNS) acknowledged the Direct Care Staff Daily reports forms were incomplete. On 3/7/24 at 9:56 AM Staff 1 (Administrator) acknowledged the Direct Care Staff Daily reports were incomplete for 19 out of 50 days.

Based on interview and record review it was determined the facility failed to accurately document immunization choices for 1 of 5 sampled residents (#11) reviewed for immunizations. This placed residents at risk for resident vaccination choices not being followed. Findings include: The facility's 10/2019 Influenza Vaccine Policy revealed: -Employees hired and residents admitted between October 1st and March 31st shall be offered the vaccine within five (5) working days of the employee's job assignment or the resident's admission to the facility. -A resident's refusal of the vaccine shall be documented on the Informed Consent for Influenza Vaccine and placed in the resident's medical records. The facility's 10/2019 Pneumococcal Vaccine Policy revealed: -Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. -Assessments of pneumococcal vaccination status will be conducted within five (5) working days of the resident's admission if not conducted prior to admission. -Resident/representatives have the right to refuse vaccination. If refused, appropriate entries will be documented in each resident's medical records indicating the date of the refusal of the pneumococcal vaccination. Resident 11 was admitted to the facility in 11/2023 with diagnoses including COVID-19. A 12/1/23 Admission MDS revealed Resident 11 had a BIMS score of 15, which indicated the resident was cognitively intact. Resident 11's Admission MDS dated [DATE] indicated Resident 11 was not eligible for both influenza and pneumococcal vaccinations. Resident 11's Quarterly MDS dated [DATE] indicated Resident 11 was not eligible for both influenza and pneumococcal vaccinations. Resident 11's immunization records listed on 3/6/24 reported Resident 11 as not eligible for influenza and pneumococcal vaccinations. On 3/6/24 at 12:52 PM Staff 3 (Assistant DNS-Infection Preventionist) stated she recalled Resident 11 refused all immunizations and these immunization choices were not documented correctly. Staff 3 stated Resident 11's immunization records should have been updated to reflect Resident 11 refused influenza and pneumococcal vaccinations rather than not being eligible to receive vaccines. On 3/6/24 at 1:27 PM Staff 2 (DNS) confirmed Resident 11's immunization choices were not correctly documented.

Based on observation, interview, and record review it was determined the facility failed to ensure sufficient staffing to meet resident care needs for 4 of 5 halls (A, C, D, and E) reviewed for staffing. This placed residents at risk for delayed and unmet care needs. Findings include: On 2/6/23 and 2/9/23 the facility provided lists of residents who: -Required assistance with eating: 2. -Required two-person assistance or a mechanical lift with transfers: 11. -Required one or two-person assistance with dressing and toileting: 43. -Were fully dependent on staff for toileting and dressing: 2. - Required one or two-person assistance with bathing: 45. -Were fully dependent on staff for bathing: 2. -Had behavioral healthcare needs: 5. Resident Council Notes were reviewed for 1/2023 and indicated residents requested more staff and more shower times and days. Residents indicated there were not enough staff to meet resident needs and residents did not always receive their scheduled showers or receive them timely. A review of the facility Direct Care Staff Daily Reports from 1/6/23 through 2/6/23 revealed the facility had insufficient CNA staff for one or more shifts on the following dates: -1/6/23: Day and Evening Shift. -1/7/23: Day Shift. -1/8/23: Day and Evening Shift. -1/14/23: Day Shift. -1/22/23: Evening Shift. -2/5/23: Day Shift. Interviews with residents revealed the following concerns: On 2/5/23 at 2:50 PM Resident 17 stated she/he had an accident from having to wait so long for toileting assistance. On 2/6/23 at 9:24 AM Resident 196 stated she/he felt the facility was understaffed and had to wait a long time to get toileting assistance. On 2/6/23 at 9:56 AM Resident 24 stated staffing could be good and then bad. Resident 24 stated at times she/he waited 15-20 minutes for her/his call light to be answered to use the restroom. On 2/6/23 at 10:29 AM Resident 143 stated she/he waited 20 minutes for her/his call light to be answered to use the restroom and there were not enough staff at night. On 2/6/23 at 10:56 AM Resident 192 stated she/he thought the facility needed more staff and waited up to 30 minutes for toileting assistance. Resident 192 stated she/he had incontinence episodes from waiting a long time for assistance. On 2/6/23 at 12:10 PM Resident 32 stated she/he wanted more showers and was told she/he could only receive them twice a week due to staffing shortages. Resident 32 further stated she/he sometimes waited a long time for her/his call light to be answered and staff were good but stretched thin. Interviews with staff revealed the following concerns: On 2/6/23 at 9:20 AM Staff 18 (CNA) stated the facility did not have enough staff, showers were difficult to complete for residents, and the facility was down two CNAs on 2/5/23. Staff 18 stated weekends were short staffed. On 2/7/23 at 8:13 AM Staff 6 (CNA) stated the facility was short staffed on weekends and Mondays. Staff 6 stated when the facility was short staffed, weights and showers were more difficult to complete for residents. On 2/8/23 at 6:03 PM Staff 19 (CNA) stated it was difficult to answer call lights on evening shift due to serving dinner and the facility was always short staffed on evening shifts. Staff 19 stated residents waited a long time for their call lights to be answered during evening shift. On 2/8/23 at 6:07 PM Staff 21 (CNA) stated between 4:00 PM and 7:00 PM it could be chaos working on evening shift. Staff 21 stated staff were busy getting residents ready for dinner and there was only one CNA per each hall (five halls total). On 2/8/23 at 6:14 PM Staff 20 (CNA) stated evening shifts were often short staffed and it was difficult to answer resident call lights due to multiple new admissions, serving dinner, and having to complete resident showers. Staff 20 stated there were times showers were unable to be completed and residents were unable to be toileted timely and had accidents due to staffing shortages. On 2/10/23 at 8:56 AM Staff 1 (Administrator) acknowledged the staffing concerns and stated the facility was working on staffing as it was their biggest issue. 2. Resident 32 admitted to the facility on [DATE] with diagnoses including a stroke. Resident 32's 12/15/22 Admission MDS indicated the resident was cognitively intact. Resident 32's ADL Shower Task Sheet indicated Resident 32 received showers Mondays and Fridays. On 1/30/23 (Monday) the shower sheet completed by Staff 20 (CNA) indicated Resident 32 did not receive her/his shower due to the resident's refusal. On 2/6/23 at 12:10 PM Resident 32 stated she/he wanted more showers and was told she/he could only receive them twice a week due to staffing shortages. Resident 32 further stated staff were good but stretched thin. On 2/8/23 at 6:14 PM Staff 20 stated there were days residents did not receive showers due to staffing shortages. Staff 20 stated he was unable to provide Resident 32 a shower last week due to not enough staff and had marked resident refused because there was no other option to mark on the shower task sheet. On 2/9/23 at 10:32 AM Staff 2 (DNS) stated the expectation was if staff could not provide a resident a shower to report it to the next shift and offer the resident a shower the next day. Staff 2 acknowledged there was no indication the resident was re-offered a shower the next day (1/31/23). Staff 2 stated staff were not to document refused if the resident did not refuse their shower. Staff 2 further acknowledged staffing concerns related to providing residents with showers. 3. Resident 15 admitted to the facility in 1/2023 with diagnoses including Parkinson's disease. Resident 15's 1/12/23 Admission MDS indicated the resident required extensive, one-person assistance with dressing. On 2/8/23 at 6:00 PM Resident 15's call light was observed to be initiated for 16 minutes per the call log at the nurses' station. Resident 15 was observed in bed and stated she/he had been waiting awhile for assistance with toileting and getting into her/his pajamas prior to dinner. When asked if call lights often took a long time to be answered by staff, Resident 15 stated it occurred enough. On 2/8/23 at 6:01 PM Staff 19 (CNA) was observed to deliver Resident 15's dinner meal tray and asked Staff 20 (CNA) to assist her with pulling the resident up in bed. Resident 15's call light was turned off. On 2/8/23 at 6:03 PM Staff 19 (CNA) stated staff were unable to assist Resident 15 with toileting/dressing due to passing meal trays down another hall but would come back. Staff 19 confirmed Resident 15 had been waiting 17 minutes and did not receive assistance. Staff 19 stated residents waited a long time for assistance from staff but was unable to state any outcomes to residents due to long call light times. On 2/8/23 at 6:10 PM Resident 15 was observed eating her/his meal in the same clothes as prior and stated she/he wanted to get into her/his pajamas. Resident 15 stated she/he did not need to use the restroom. Resident 15 stated staff did not tell her/him why she/he could not be changed prior to dinner and just turned off her/his call light. When asked if staff often turned off the call light prior to assisting the resident, the resident stated it occured enough. On 2/8/23 at 6:14 PM Staff 20 (CNA) stated staff were unable to assist Resident 15 as staff were busy passing the dinner meal and there were three new admission residents, which made it difficult to answer call lights. On 2/10/23 at 8:56 AM Staff 1 (Administrator) acknowledged the staffing concerns and stated the facility was working on staffing as it was their biggest issue. 4. Resident 24 admitted to the facility on [DATE] with diagnoses including a leg amputation. On 2/6/23 at 9:56 AM Resident 24 stated staffing could be good and then bad. Resident 24 stated at times she/he waited 15-20 minutes for her/his call light to be answered to use the restroom. Call Light Logs were reviewed for Resident 24 from 1/21/23 through 2/7/23 and indicated four instances when the resident waited 15 minutes or longer for her/his call light to be answered by staff: -1/21/23, 16 minutes. -2/1/23, 15 minutes. -2/2/23, 16 minutes. -2/4/23, 29 minutes. On 2/10/23 at 8:56 AM Staff 1 (Administrator) acknowledged the identified long call light wait times. 5. Resident 192 admitted to the facility on [DATE] with diagnoses including a UTI and a hip fracture. Resident 192's 1/28/23 Admission MDS indicated the resident was cognitively intact. On 2/6/23 at 10:56 AM Resident 192 stated she/he thought the facility needed more staff and waited up to 30 minutes for toileting assistance. Resident 192 stated she/he had incontinence episodes from waiting a long time for toileting assistance. Call Light Logs Were Reviewed for Resident 192 from 1/24/23 through 2/7/23 and indicated four instances when the resident waited over 15 minutes for her/his call light to be answered by staff: -1/29/23, 16 minutes, 18 minutes, and 30 minutes. -2/5/23, 24 minutes. On 2/10/23 at 8:56 AM Staff 1 (Administrator) acknowledged the identified long call light wait times. 6. Resident 143 admitted to the facility on [DATE] with diagnoses including sepsis. Resident 143's 2/2/23 Admission MDS indicated Resident 143 was cognitively intact. On 2/6/23 at 10:29 AM Resident 143 stated she/he waited 20 minutes for her/his call light to be answered to use the restroom and there were not enough staff at night. Call Light Logs Were Reviewed for Resident 143 from 1/31/23 through 2/7/23 and indicated two instances when the resident waited over 15 minutes for her/his call light to be answered: -2/3/23, 16 minutes. -2/4/23, 26 minutes. On 2/10/23 at 8:56 AM Staff 1 (Administrator) acknowledged the identified long call light wait times.

Based on interview and record review it was determined the facility failed to ensure MDS assessments were comprehensive for 3 of 9 sampled residents (#s 8, 13 and 15) reviewed for skin, medications, and staffing. This placed residents at risk for inaccurate assessments. Findings include: 1. Resident 13 admitted to the facility in 1/2023 with diagnoses including diabetes. Review of the resident's progress notes indicated the resident was alert and oriented. Resident 13's 1/16/23 Admission MDS, Section C (cognitive assessment) indicated the BIMS was to be conducted. The subsequent assessment questions were marked not assessed. On 2/9/23 at 8:45 AM Staff 2 (DNS) acknowledged Section C was not completed as part of Resident 13's Admission MDS. 2. Resident 15 admitted to the facility in 1/2023 with diagnoses including Parkinson's disease. Review of the resident's progress notes indicated the resident was alert and oriented. The 1/12/23 Admission MDS, Section C (cognitive assessment) indicated the BIMS was to be conducted. The subsequent assessment questions were marked not assessed. On 2/9/23 at 8:45 AM Staff 2 (DNS) acknowledged Section C was not completed as part of Resident 15's Admission MDS. 34324 3. Resident 8 was admitted to the facility on [DATE] with diagnoses including paraplegia. Review of the resident's progress notes indicated the resident was alert and oriented. Resident 18's 1/14/23 Admission MDS, Section C (cognitive assessment) indicated a Brief Interview for Mental Status (BIMS) was to be conducted. The subsequent assessment questions indicated not assessed. On 2/9/23 at 8:45 AM Staff 2 (DNS) acknowledged Section C was not completed as part of Resident 18's Admission MDS.

Based on interview and record review it was determined the facility failed to ensure physician orders were followed for 1 of 5 sampled residents (#24) reviewed for medications. This placed residents at risk for adverse side effects. Findings include: Resident 24 admitted to the facility on [DATE] with diagnoses including diabetes. A 1/23/23 Physician Order indicated Resident 24 was to be administered Insulin Aspart Injection Solution (diabetic injection medication) and staff were to hold (not give) the medication for CBGs less than 120. The 2/2023 MAR indicated Resident 24 experienced CBGs outside parameters and was administered insulin on the following dates: -2/1/23: CBG 107. -2/6/23: CBG 104. Resident 24's clinical record did not indicate the resident experienced adverse outcomes due to receiving insulin on the identified dates. On 2/9/23 at 10:43 AM Staff 2 (DNS) stated physician orders were expected to be followed and acknowledged Resident 24 received Insulin Aspart when the resident's CBGs were outside of physician ordered parameters on the identified dates.

Based on interview and record review it was determined the facility failed to ensure residents were provided information related to the formulation of an Advance Directive for 1 of 3 sampled residents (#24) reviewed for Advance Directives. This placed residents at risk for not having their treatment decisions honored. Findings include: Resident 24 admitted to the facility on [DATE] with diagnoses including a below the knee amputation. Resident 24 was listed as her/his own responsible party. Resident 24's clinical record revealed no documentation to indicate the resident had an Advance Directive or was provided information concerning the right to formulate an Advance Directive prior to 2/6/23. On 2/7/23 at 10:36 AM Staff 12 (Social Services) confirmed Resident 24 was not informed or provided written information concerning her/his right to formulate an Advance Directive until the information was requested by the Surveyor on 2/6/23.

Based on interview and record review it was determined the facility failed to code the MDS accurately for 1 of 1 sampled resident (#40) reviewed for hospitalization . This placed residents at risk for inaccurate assessments. Findings include: 1. Resident 40 was admitted to the facility on [DATE] with diagnoses including pneumonia and diabetes. The 1/14/23 Discharge Return Not Anticipated MDS indicated Resident 40 discharged to an acute hospital. The 1/14/23 progress note indicated Resident 40 elected to leave the facility AMA (against medical advice). The resident left the facility in stable condition via private vehicle. On 2/9/23 at 12:27 PM Staff 2 (DNS) acknowledged the MDS was coded to reflect the resident discharged to an acute hospital, she stated she/he left AMA. Staff 2 acknowledged the MDS was not accurately coded to reflect the resident discharging home.

Based on observation, interview and record review it was determined the facility failed to ensure a resident's pressure ulcer was assessed and monitored to prevent worsening for 1 of 2 sampled residents (#13) reviewed for pressure ulcers. This placed residents at risk for worsening pressure ulcers. Findings include: Resident 13 admitted to the facility on [DATE] with diagnoses including diabetes and COPD (chronic obstructive pulmonary disease) and utilized a BiPAP (bilevel positive airway pressure) machine. Resident 13's 1/16/23 Admission MDS indicated the resident had no pressure ulcers upon admission. A 1/24/23 Physician's Progress Note indicated Resident 13 developed a pressure ulcer on the bridge of her/his nose from her/his BiPAP machine. A 1/24/23 Physician Order indicated staff were to place Duoderm (pressure ulcer dressing) on Resident 13's nasal bridge once daily to help with skin breakdown. The 1/2023 TAR indicated on 1/24/23 the Physician Order was implemented to place Duoderm on the resident's nasal bridge every night shift to help with skin breakdown and was completed as ordered. A 2/1/23 Physician's Progress Note indicated Resident 13's pressure ulcer appeared to be healing and the resident told the physician she/he had a friend who was planning to bring in a new mask for the resident's BiPAP machine. Prior to 2/7/23, there was no evidence in Resident 13's medical record to indicate the resident's pressure ulcer was assessed, measured, staged, and/or monitored after being identified by the physician on 1/24/23. On 2/5/23 at 3:14 PM Resident 13 was observed with a bandage on her/his nose. Resident 13 stated the wound was due to her/his BiPAP machine because she/he did not have any more masks in the correct size. On 2/7/23 at 8:16 AM Staff 6 (CNA) stated she worked with Resident 13 and believed the resident's nose wound was from the resident's BiPAP machine. On 2/7/23 at 8:50 AM Staff 5 (RN) stated it was her first time working with Resident 13 and she was unsure why the resident had a bandage on her/his nose. On 2/7/23 at 8:58 AM Staff 16 (CNA) told Staff 3 (RN) Resident 13's nose wound was from her/his BiPAP machine. On 2/7/23 the Surveyor requested all skin evaluations for Resident 13's pressure ulcer. A 2/7/23 Skin & Wound Evaluation indicated Resident 13 sustained a facility acquired, Stage II medical device pressure ulcer to her/his nose from the resident's BiPAP machine. The wound measured 0.2 cm x 0.7 cm x 0.5 cm with no reported pain. The evaluation indicated the wound was healing. On 2/7/23 at 2:06 PM Staff 2 (DNS) stated Staff 7 (RNCM) was aware of Resident 13's pressure ulcer on the resident's nose but did not complete an investigation prior to 2/7/23 and did not have documentation for monitoring healing. Staff 2 further stated the wound was a medical device pressure ulcer from the resident's BiPAP machine mask not being the correct fit.

Based on interview and record review it was determined the facility failed to ensure residents were assessed after dialysis treatments for 1 of 1 sampled resident (#17) reviewed for dialysis. This placed residents at risk for dialysis complications. Findings include: The Facility's 2020 Living Care of the Dialysis Resident policy indicated nursing staff were to complete the post dialysis assessment upon the resident's return to the facility. Resident 17 admitted to the facility on [DATE] with diagnoses including renal dialysis. Resident 17's 1/23/23 Care Plan indicated the resident went to dialysis three days a week on Monday, Wednesday, and Friday. Review of Resident 17's 2/2023 Dialysis Communication forms indicated on 2/1/23, 2/3/23 and 2/6/23 the post-dialysis assessments were not completed. On 2/7/23 at 8:54 AM Staff 7 (RNCM) acknowledged Resident 17's post dialysis assessments were not completed for the identified dates.

Based on interview and record review it was determined the facility failed to provide prescribed medications for 1 of 5 sampled residents (#24) reviewed for medications. This placed residents at risk for medication-related adverse consequences. Findings include: Resident 24 admitted to the facility on [DATE] with diagnoses including diabetes and hyperlipidemia (high cholesterol). Resident 24 had physician orders for the following: -1/18/23: simvastatin oral tablet (cholesterol medication) to be administered once daily. -1/24/23: Phos-NaK oral packet (medication to treat low phosphorus levels) to be administered twice daily. A review of Resident 24's 1/2023 and 2/2023 MARs revealed the following medications were not administered because they were not available: -Phos-NaK Oral Packet from 1/25/23 through 1/28/23. -simvastatin from 2/5/23 through 2/6/23. Resident 24's Progress Notes reviewed from 1/25/23 through 2/6/23 indicated the following: -1/25/23 at 5:13 PM: Note indicated med not in cart regarding Phos-NaK. There was no follow-up notes. -1/26/23 at 8:07 AM and 3:55 PM: Notes indicated med not in cart and OUT OF MED WILL CONTACT PHARMACY regarding the resident's Phos-NaK. -1/27/23 at 8:48 AM and 4:39 PM: Notes indicated have not received will call pharmacy and pharmacy contacted regarding the resident's missed Phos-NaK. -2/5/23: The resident's dose of simvastatin on 2/5/23 was unavailable and was ordered from the pharmacy on 2/5/23 and the provider was notified. There was no follow-up notes regarding the resident missing simvastatin on 2/6/23. On 2/9/23 at 10:43 AM Staff 2 (DNS) acknowledged the medications were not administered due to not being available and the expectation was for staff to re-order medication prior to running out. Staff 2 stated if the issue was related to the pharmacy, staff were expected to let the physician know of the missed medication.

Based on interview and record review it was determined the facility failed to provide adaptive equipment for 1 of 3 sampled residents (#2) reviewed for skin breakdown. This placed residents at risk for skin breakdown. Findings include: Resident 2 was admitted to the facility in 5/2020 with [DIAGNOSES REDACTED]. An Admission MDS dated [DATE] indicated Resident 2 was at risk for developing pressure ulcers and had one unstageable DTI (a deep tissue injury (Intact skin with localized area of persistent non-blanchable deep red, maroon or purple discoloration due to damage of underlying soft tissue)) to the tailbone upon admission. A care plan initiated on 5/13/20 revealed Resident 2 had potential and actual impairment to skin integrity related to multiple pelvic fractures, medications, vasculitis [MEDICAL CONDITION], incontinence, foley catheter, deconditioning and decline in mobility. Resident 2 was at high risk for pressure ulcer. Staff were to evaluate skin integrity, perform objective pressure ulcer risk tool such as Braden/Norton scale. A revision on 5/19/20 directed staff to float heels always. A revision on 5/21/20 directed staff to float Resident 2's heels while in bed, monitor suspected DTIs to both bilateral heels, offer to reposition the resident in bed as needed and to reposition the resident so her/his heels were not on the resident's mattress. A 5/19/20 Pressure Injury report revealed the following: -Staff 14 (RN) assessed legs bilaterally and noted [MEDICAL CONDITION], skin was cool to the touch and assessed pedal pulses. Staff 14 lifted the patient's heels and identified Resident 2 had deep tissue injuries to both her/his bilateral heels, and Resident 2 denied pain at the site. -The patient was informed there was one bruise on each heel and was educated to keep her/his heels off the bed and a heel float would be provided to support her/his legs/feet. -Staff interviews were conducted and revealed staff did not identify any bilateral deep tissue injuries on 5/13, 5/15, 5/16, 5/17 and 5/18/20. Staff indicated Resident 2 did not always like to be repositioned in bed. -The conclusion of the investigation determined Resident 2 appeared to have DTIs to her/his bilateral heels. Resident 2's heels noted to be resting on the edge of the mattress due to her/his height and the mattress length. Nurse assessed and noted purple, non-blanching areas to both bilateral heels that were not present on admission. Resident 2 denied pain. -Interventions were Resident 2 was at risk for skin impairment related to decreased mobility, height of six foot four, history of pressure injury and vasculitis. Heel floats would be utilized when the resident was in bed. Staff were to ensure Resident 2 was repositioned in bed with heels not on the edge of the mattress. Resident was added to weekly wound rounds. The provider and family was notified. -The Interdisciplinary team felt the DTIs were brewing many days prior to admission (Resident 2 admitted to the facility on [DATE]), The DTIs probably started at her/his assisted living facility after she/he fell and continued through her/his extended hospitalization (two weeks) and became visible at the facility on 5/18/20. -Abuse and neglect were ruled out. On 6/17/20 Resident 2 discharged back to her/his assisted living facility. On 3/9/21 at 9:29 AM Staff 19 (RN) stated she remembered Resident 2 and stated the DTIs were discovered roughly two weeks after her/his admission. Staff 19 stated the resident was tall and she thought the end of her/his bed was open and Resident's 2's feet were toward the edge of the bed due to her/his height. Staff 19 stated the resident had limited mobility, did not like to be repositioned and did not complain of pain to her/his bilateral feet. On 3/10/21 at 11:11 AM Staff 14 (RN) stated she recalled Resident 2 and discovered her/his bilateral DTIs when doing a wound treatment to the resident's coccyx. Resident 2 did not complain of pain or discomfort to the area and she recalled her/him being very hesitant about getting in and out of bed. Staff 14 stated she did not work with Resident 2 much and could not recall if the resident's bed had a foot board at the end or not. Staff 14 stated she reported her findings to Staff 7 (Infection Preventionist/Assistant Director of Nursing) and Staff 15 (DNS) immediately and the resident was assessed, and interventions put into place. On 3/10/21 at 1:45 PM Staff 15 stated Resident 2 was assessed upon admission and weekly skin checks were completed to identify any new skin conditions. Staff 15 stated Resident 2 had multiple co-morbidities and the DTI's were unavoidable. Staff 15 stated she could not recall if there was a foot board at the end of her/his bed or if it was open. When asked how you would address residents who were tall and needed a longer bed Staff 15 replied due to Resident 2's height they would have had to order special equipment to accommodate for her/his size. Staff 15 stated she did not recall the facility ordering any additional equipment for Resident 2's bed.

Based on interview and record review it was determined the facility failed to follow physician orders [REDACTED].# 1) reviewed for diabetic management. This placed residents at risk for adverse side effects. Findings include: Resident 1 admitted to the facility in 12/2019 with a [DIAGNOSES REDACTED]. A 4/8/20 physician order [REDACTED]. Staff were to hold insulin if blood sugar was less than 120 or if Resident 1 was not going to eat a meal. A review of the MARs from 10/2020 through 12/2020 revealed the following: -10/2020: There were seven instances at 7:00 AM when Resident 1's blood sugar was less than 120 and the resident was administered insulin. On two instances one at 7:00 AM and one at 6:00 PM there was no documentation inputted. -11/2020: There were nine instances at 7:00 AM when Resident 1's blood sugar was less than 120 and the resident was administered insulin. -12/2020: There were nine instances at 7:00 AM when Resident 1's blood sugar was less than 120 and the resident was administered insulin. On 2/19/21 a public complaint was received which alleged care and service were not provided regarding Resident 1's diabetic management. On 3/8/21 at 11:47 AM Staff 10 (LPN) stated she was aware Resident 1 was a diabetic and her/his blood sugar was taken often. Staff 10 stated she would hold administering insulin based on the physician order [REDACTED]. Staff 10 was unaware Resident 1 received insulin when she/he was supposed to have the insulin medication held. On 3/9/21 at 9:17 AM Staff 13 (RN) stated she was aware of Resident 1 and the physician order [REDACTED]. Staff 13 was unaware Resident 1 received insulin when it should have been held. On 3/10/21 at 1:04 PM and 3/12/21 at 8:11 AM Staff 15 (DNS) stated she would expect her staff to follow and implement physician insulin orders, and acknowledged staff administered insulin when the insulin should have been held.

Based on interview and record review it was determined the facility failed to timely report allegations of neglect to the State Survey Agency for 1 of 3 sampled residents (#3) reviewed for incontinence care, treatment of [REDACTED]. This placed residents at risk for unmet needs. Findings include: Resident 3 was admitted to the facility in 2020 with [DIAGNOSES REDACTED]. A 2/2/20 Admission MDS revealed Resident 3's BIMs score was nine indicating moderately cognitive impairment. On 3/3/2020 at 1:47 PM a facility reported incident was received by the State Survey Agency which indicated Resident 3 had discharged with multiple complaints related to her/his care. On 3/10/20 the facility sent copies of Resident 3's call light records and her/his care plan to the State Survey Agency. On 3/16/20 the facility had not submitted the State Survey Agency requested investigations to the allegations, and a few of the allegations were too vague to triage. The allegations that were triaged were as followed: -The facility failed to ensure Resident 3's rash was treated timely. -The facility failed to provide necessary care and services related to incontinent care. -The facility failed to ensure the resident was treated with dignity and respect. On 3/1/21 at 2:00 PM Staff 16 (Administrator) stated they initiated and submitted the facility reported incident (FRI) 3/3/20 however, they turned the FRI into a grievance report related to the three allegations and Staff 17 (Regional Director of Operations) completed the grievance/investigation. On 3/10/21 at 2:02 PM Staff 17 stated Staff 16 initiated the FRI however, he completed the grievance form which was his investigation. Staff 17 was not aware the completion of his grievance was not submitted to the State Survey Agency within the 5 day time period.

Based on interview and record review it was determined the facility failed to thoroughly investigate incontinence care, dignity and respect and appropriate treatment of [REDACTED].#3) reviewed for incontinence care, dignity and respect and appropriate treatment of [REDACTED]. Findings include: Resident 3 was admitted to the facility in 2020 with [DIAGNOSES REDACTED]. A 2/2/20 Admission MDS revealed Resident 3's BIMs score was nine indicating moderately cognitive impairment. On 3/3/2020 at 1:47 PM a facility reported incident (FRI) was received by the State Survey Agency and indicated Resident 3 had discharged with multiple complaints related to her/his care to the State Survey Agency. On 3/10/20 the facility sent copies of Resident 3's call light records and her/his care plan. On 3/16/20 the facility had not submitted State Survey Agency requested investigations to the allegations, and a few of the allegations were too vague to triage. The allegations that were triaged are as followed: -The facility failed to ensure Resident 3's rash was treated timely. -The facility failed to provide necessary care and services related to incontinent care. -The facility failed to ensure the resident was treated with dignity and respect. A Grievance Summary Form initiated 3/2/20 revealed the following: -3/2/20 Witness 11 (Family Member) had concerns regarding Resident 3's care at the facility and it was horrible. -3/3/20 Staff 17 (Regional Director of Operations) spoke with Witness 11 and she stated call lights were not answered timely, Resident 3 was left soiled briefs for long periods of time, a rash not dealt with in a timely manner and two staff members being rude when assisting Resident 3 with her/his tube feeding. -3/4/20 responses to the above concerns were as followed: -Call lights and incontinences care not being completed timely Staff 19 (LPN/RCM) indicated Resident 3 had a couple of falls and was wet both of those instances however, she could not recall any other instance. Call logs were reviewed, and three times call lights were greater than 15 minutes from 1/28/20 through 2/23/20. Overall call lights did not look too bad. There are three that Staff 17 would investigate further. -Rash not being dealt with timely Staff 19 stated the rash was identified however, the order from the physician took two days to receive and implement. -Staff being rude when assisting Resident 3 with her/his tube feeding something around the bags. Staff 16 (Administrator) was unsure of this allegation and family members had asked her about Resident 3's tube feeding she recalled stepping out of the room to close the door and the family was right behind her and Staff 16 opened the door up. Staff 16 stated she told the family members when leaving Resident 3's room she needed to ask Staff 19 a question about her/his tube feeding and did not recall it being a funny conversation. -3/4/20 Staff 17 reviewed progress notes and risk management for Resident 3 and no concerns were noted, and abuse and neglect were ruled out. Staff 17 called and spoke with Witness 11 regarding his findings and Witness 11 appreciated the callback but voiced her frustration with the findings and the facility. The Grievance form did not include any other interviews with staff members, no follow up regarding the long call light wait times, delay in physician orders [REDACTED]. On 3/1/21 at 2:00 PM Staff 16 (Administrator) stated they initiated and submitted the FRI to the State Survey Agency on 3/3/20 however they turned the FRI into a grievance report related to the three allegations and Staff 17 (Regional Director of Operations) completed the grievance/investigation. On 3/10/21 at 2:02 PM Staff 17 stated he had Staff 16 initiate the FRI however, he completed the grievance form which was his investigation. Staff 17 stated he should have included more interviews with staff regarding the above allegations and could not recall if he spoke with any other staff members regarding the concerns.

Based on observation, interview and record review it was determined the facility failed to provide care and services to ensure residents were free from falls for 1 out of 3 sampled residents (#3) reviewed for accidents. This placed residents at risk for injury. Findings include: Resident 3 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The resident was discharged home on[DATE]. Resident 3's Admission MDS dated [DATE] indicated the resident had a BIMS (Brief Interview for Mental Status) of 13. The resident's Fall CAA revealed the resident had a previous fall resulting in a TBI, a history of falls (prior to admission to the facility), needed assistance with ADLs and remained at risk for falls. Resident 3's care plan initiated on 12/24/18 indicated the resident was at high risk for falls and required assistance of one person with transferring and toileting. Care plan interventions included to not leave the resident unsupervised in the bathroom. The facility reported a 1/27/19 and completed an incident report the same day. The report revealed Resident 3 was assisted to bathroom to toilet by Staff 13 (CNA). Once seated, Staff 13 handed Resident 3 the call light and instructed the resident to press the call light for assistance when ready because Staff 13 wanted to answer another call light one room over. When Staff 13 returned to Resident 3, the resident was found on the floor. The report indicated the resident's care plan instructed to not leave the resident unattended in the bathroom. A fall assessment was immediately completed and revealed no injuries were identified from the unwitnessed fall. On 7/31/19 at 10:51 AM Staff 12 (LPN) confirmed the resident fell because he was left alone on the toilet and the care plan was not followed. 7/31/19 11:25 AM Staff 2 (DNS) confirmed Resident 3's fall occurred because the care plan intervention to not leave the resident on the toilet unattended did not occur. On 7/31/19 at 12:40 PM Staff 13 (CNA) stated on 1/27/19 she left Resident 3 on the toilet to go assist another resident and confirmed she did not follow the care plan which resulted in Resident 3's fall.

Based on observation, interview and record review it was determined the facility failed to prevent non-pressure skin injuries for 1 of 2 sampled residents (#1) reviewed for unknown injuries. This placed residents at risk for further injuries. Findings include: Resident 1 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. Resident 1's Annual MDS dated [DATE] indicated the resident was at risk for skin injuries, had increased skin fragility, had a cognitive deficit resulting in a communication breakdown and was easily startled. Resident 1's care plan updated 6/16/19 indicated the resident was at risk for non-pressure related skin injuries related to cogitative impairment, immobility, fragile skin and advanced age. Care plan interventions included daily nail inspection, provide nail care, to encourage and guide the resident's hands away from scratching, to ensure Geri- Sleeves (arm sleeves to protect skin from injury) were on. An incident report dated 5/14/19 indicated Resident 1 incurred a skin tear to her/his left forearm. The incident report revealed the skin tear occurred because the resident was not wearing Geri-Sleeves and scratched her/his arm with her/his finger. On 6/16/19 at 2:05 PM Staff 5 (CNA) stated Resident 1 had fragile skin, resisted care, would grab her/his arms with her/his hands, pulled her/his arms towards her/his chest and grab her/his arms tightly. Staff 5 stated the resident was to wear Geri-Sleeves sleeves at all times. On 6/19/19 at 1:00 PM Witness 1 (Complainant) and Witness 2 (Family) stated they believed staff did not always follow the care plan to ensure Geri-Sleeves were on the resident's arms. They acknowledged the resident's skin was fragile and the resident tensed up during care. On 6/19/19 at 3:00 PM during care, Resident 1's skin was observed to be fragile with skin deformities. Resident 1 was observed to be guarded, resistive with care and had her/his arms pulled in tightly towards her/his chest. On 6/20/19 at 10:45 PM Staff 4 (RNCM) stated Resident 1's skin was paper thin and at increased risk of injury due to the resident's advanced age and resistance to care. She confirmed the 5/14/19 skin tear occurred due to the resident not wearing Geri-Sleeves since there were none available as they were in the laundry. On 7/31/19 at 11:42 AM Staff 2 (DNS) confirmed the care plan was not followed during the 5/14/19 incident due to Geri-Sleeves not being on the resident because they were in the laundry. She stated by the time the CNA came back from laundry with the sleeves, the resident had scratched her/his arm, resulting in the skin tear.

Based on interview and record review it was determined the facility failed to timely report allegations of abuse to the State Survey Agency for 2 of 2 sampled residents (#s 1 and 2) reviewed for abuse. This placed resident at risk for abuse. Findings include: 1. Resident 1 was admitted to the facility in 11/2018 with [DIAGNOSES REDACTED]. a. Resident 1's 2/17/19 progress notes revealed the resident appeared confused and placed her call light in her vagina and indicated she was assaulted by the crippled guy. The 2/27/19 progress note revealed the resident stated she needed to go to the hospital because she was raped. The facility was unable to find documentation the incidents on 2/17/19 and 2/27/19 were reported to the State Survey Agency. On 4/4/19 at 2:47 PM Staff 1 (DNS) indicated the incidents on 2/17/19 and 2/27/19 were not reported to the State Survey Agency. b. On 4/4/19 at 11:48 AM Witness 1 (Hospice Nurse) indicated on 4/2/19 Resident 1 reported a man entered her/his room and abused her/him. Witness 1 indicated she reported the incident to Staff 2 (RCM) on 4/2/19. On 4/4/19 at 12:48 PM Staff 2 (RCM) indicated Witness 1 reported the incident to her but she did not report the incident to facility staff. The incident was reported to the State Survey Agency on 4/3/19 at 1:37 PM, more than two hours after the facility knew about the incident on 4/2/19. On 4/4/19 at 2:47 PM Staff 1 (DNS) acknowledged they reported the incident late. Refer to F 610 2. Resident 2 was admitted to the facility in 10/2017 with [DIAGNOSES REDACTED]. On 4/4/19 at 11:20 AM Staff 2 (DNS) indicated Resident 2 was investigated for allegations of rape on 2/19/19. The 2/20/19 (Resident 2) Investigation document revealed Resident 2's daughter alerted the facility Resident 2 alleged she was raped. The facility conducted an investigation on 2/20/19 and revealed Resident 2 stated there were one to three guys in her room and the date and time were unknown. Resident 2 was unable to provide details of the incident. The facility notified the police and Resident 2 provided the police with a different story. There was no documentation to support the facility reported the incident to the State Survey Agency. On 4/4/19 at 2:47 PM Staff 2 indicated they did not report the incident to the State Survey Agency. Refer to F 610.

Based on interview and record review it was determined the facility failed to ensure investigations for sexual abuse were thorough for 2 of 2 sampled residents (#s 1 and 2) reviewed for sexual abuse. This placed residents at risk for ongoing sexual abuse. Findings include: The facility's 3/15/17 Abuse Prevention Policy and Procedure revealed the following: -It was the policy of the facility that all suspected, alleged, or actual cases of resident abuse shall be thoroughly and completely investigated and reported according to State and Federal regulations. The investigation would include at a minimum the following steps: -Identification of the parties involved. -Signs and symptoms, or the complaint received that required investigation. -Identification of witnesses. -Interview all parties involved including the resident. This may include signed and dated statements from individuals that described the incident. -An assessment of the involved for injury and the need for medical and emotional support. -The investigation would be completed within five days. 1. Resident 1 was admitted to the facility in 11/2018 with [DIAGNOSES REDACTED]. The 1/23/19 Care Area Assessment for Cognition reveled the resident was confused and forgetful at times, and had dementia with behavioral disturbances. a. Resident 1's progress notes revealed on 2/17/19 the resident appeared confused and placed her call light in her vagina and indicated she was assaulted by the crippled guy. The facility provided a document dated 2/18/19 titled (Resident 1) Interview of Being Molested. The document noted the resident stated a midget crippled molested her and was unable to state what happened to her. The resident was safe and was told the police were on the way. A CNA indicated nothing unusual happened that evening. When the police investigated, the resident had a different story. The facility noted the resident had a history of [REDACTED]. The document did not rule out abuse or have the administrator's signature or a name of who completed the document. On 4/4/19 at 2:47 PM Staff 2 (DNS) acknowledged the investigation was not thorough. b. The 2/27/19 progress note revealed Resident 1 reported she needed to go to the hospital because she was raped. The facility provided a document dated 2/27/19 which was completed by the Administrator In Training. The resident denied the allegation she/he was raped. The document only included an interview with the resident. The facility failed to identify and interview staff or others who may have been involved. On 4/4/19 at 2:47 PM Staff 1 (DNS) indicated the incident report for 2/27/19 was not thorough. 2. Resident 2 was admitted to the facility in 10/2017 with [DIAGNOSES REDACTED]. The 1/11/19 Quarterly MDS revealed the resident had a BIMS (Brief Interview for Mental Status) score of 5 which indicated the resident was severely cognitively impaired. On 4/4/19 at 11:20 AM Staff 2 (DNS) indicated Resident 2 was investigated for allegations of rape on 2/19/19. The 2/20/19 (Resident 2) Investigation document indicated she woke up and saw 1-3 guys in her room. The date and time were unknown. The resident indicated she was raped but was unable to tell staff how it happened. Staff were interviewed and indicated the resident's neighbor (Resident 1) was yelling all night that she was being molested. The facility completed a physical assessment of the resident (with the family consent) and there was no redness or bruising. The witness statements did not include last names, there was no name on the document of who wrote the investigation and there was no administrator sign off. On 4/4/19 at 2:47 PM Staff 1 (DNS) acknowledged the investigation was incomplete.

Based on observation, interview and record review it was determined the facility failed to provide adequate supervision to prevent accidents for 1 of 3 residents (#3) reviewed for accidents. This placed residents at risk for falls. Findings include: Resident 3 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. Resident 3's 7/6/18 Quarterly MDS section C indicated the resident had a BIMS score of 0 (indicating severe cognitive impairment). Section G indicated the resident required two-person physical assistance with bed mobility. The 12/2017 Care Plan indicated Resident 3 required two person assistance with all peri-care and brief changes. A 9/28/18 Fall Incident Report indicated Staff 7 (CNA) changed Resident 3 in bed and rolled her/him to the side and proceeded to grab wipes and brief. The resident had her/his arms against the couch holding on. When grabbing supplies the resident rolled out of bed onto the fall mat. The bed was approximately one foot off the ground. After the fall Staff 7 informed Staff 8 (RN) that she needed help with Resident 3. Staff 8 assessed the resident and the resident was assisted back into bed with a Hoyer lift with three staff. A 9/28/18 progress note by Staff 8 (RN) indicated Resident 3 had fallen out of bed while a CNA was changing her/him. Upon entering the room the resident was on her/his left side on top of the fall mat. Resident was mumbling unknown words and giggling per her/his baseline. Resident had scattered bruising to the face, with a 3 cm x 2 cm bruise to the forehead, a 1 cm x 1 cm bruise to the bridge of the nose, a 1 cm abrasion to the right shoulder noted and a 3 cm x 4 cm bruise surrounds the abrasion. Unknown if the 18 cm x 4 cm raised bruising to right shin was related to the fall or to the residents stasis [MEDICAL CONDITION]. Full set of vitals were taken. Resident unable to communicate how fall occurred. On 11/28/18 at 2:58 PM and 11/29/18 at 9:34 AM Resident 3 was observed in bed resting with the bed in a low position and fall mats on both sides of the bed. There were no mobility bars or side rails observed on the bed. A couch was observed to be approximately one and a half feet away from the left side of the bed on the other side of the fall mat. On 11/29/18 at 11:05 AM Staff 3 (RNCM) stated the care plan that was in place on 9/28/18 did not identify the amount of assistance the resident needed with bed mobility. She stated the care plan was updated to reflect two-person assist for brief changes and bed mobility after the resident's fall. On 11/30/18 at 1:23 PM Staff 7 stated Resident 3 was a two-person transfer but on 9/28/18 the Kardex and care plan did not indicate how many staff were needed to assist the resident with bed mobility. She stated she often changed Resident 3's brief by herself. She further stated she instructed the resident roll onto her/his side and hold onto the couch that was approximately one to one and a half feet away from the bed during the brief change and when she turned to grab supplies the resident rolled off the bed and onto the fall mat. On 11/30/18 at 1:48 pm Staff 8 stated Resident 3 had always been a two person assist for bed mobility and brief changes due to her/him not being alert and oriented. She further stated Staff 7 attempted to change Resident 3's brief by herself on 9/28/18. She stated she checked the Kardex for Resident 3 and it did not specify assistance for bed mobility or brief changes. On 12/3/18 at 12:52 PM Staff 4 (DNS) stated she would expect staff to notify her of Resident 2 grabbing the couch during brief changes so she/he could be assessed for assistive devices or additional staff assistance. She further stated she expected the care plan to match the MDS to indicate Resident 2 needed two person physical assistance with bed mobility.

Based on observation, interview and record review it was determined the facility failed to maintain acceptable parameters of nutritional status for 2 of 3 sampled residents (#s 17 and 36) reviewed for nutrition. Residents 17 and 36 experienced unplanned severe weight loss. Findings include: 1. Resident 17 was readmitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. Resident 17's weight summary revealed the resident was 126 pounds on 4/12/18 and was 108 pounds on 8/15/18. This was an 18 pound or 14.3% body weight loss in 125 days. This indicated a severe weight loss. A 4/18/18 Registered Dietitian Assessment indicated Resident 17 required supervision with meals for dysphagia (difficulty swallowing). The resident's acceptable weight range was 115 to 135 pounds. The resident's food intake was inadequate related to dysphagia as evidenced by the resident's intake record compared to estimated daily requirements. A nutritional supplement was added to the resident's diet. Resident 17's meal monitoring log from 7/31/18 through 8/29/18 indicated the resident consumed 0-25% of her/his meals 20 times, 26-50% 15 times, 51-75% 33 times and 76-100% 20 times. Resident 17's current care plan as of 8/30/18 indicated the resident required one staff assistance to eat. The resident used a scoop plate and a nosey cup (a cup with a cutout on one side which provides space for the nose allowing the cup to be tilted for drinking without having to tilt the head). The resident used a tray table instead of a dining room table because it was too high for her/him. The resident was to be supervised in the dining room for all meals. Resident 17's MDS-Eating Assistance log from 7/31/18 through 8/29/18 indicated the resident was only provided Supervision - Oversight, encouragement or cueing assistance with meals for 65 out of 88 meals documented. For 12 meals the resident was documented as Independent - No help or staff oversight at any time. A NAR (Nutrition at Risk) assessment dated [DATE] indicated the resident's poor food intake was identified and the resident received 120 ml of a nutritional supplement two times daily. The resident's weight was 125 pounds on 4/17/18. A NAR assessment dated [DATE] indicated the resident's weight was noted as 118 pounds on 5/2/18. This was identified as an eight pound weight loss (this was a severe 6.3% body weight loss in 20 days). The resident's nutritional supplement was increased to three times daily. A NAR assessment dated [DATE] indicated the resident's current weight of 116 pounds was not identified (this was an additional two pound weight loss since the previous week). No new interventions were planned despite the continued weight loss. A NAR assessment dated [DATE] indicated the resident's weight of 116 pounds on 5/10/18 was identified as a two pound weight loss. The resident's weight on 5/17/18 of 116 pounds was not identified. The resident was removed from NAR monitoring because the assessment indicated the resident's weight and intake were stable. Resident 17's weight summary revealed on 6/12/18 the resident weighed 112 pounds (this was an additional four pound weight loss). On 6/13/18 the resident weighed 108 pounds, this was an additional four pound weight loss for a total of 14.3% body weight loss since 4/12/18. A NAR assessment dated [DATE] identified the 6/13/18 weight of 108 pounds and the resident's 25-49% intake of meals only met 50-60% of the resident's needs. The assessment failed to identify the 6/14/18 weight of 111 pounds. New interventions included speech therapy evaluation to change the resident's diet to a regular texture because she/he did not like the mechanically altered diet. A review of Resident 17's clinical record revealed no comprehensive assessment of the resident's nutritional status with a clinical rationale for the severe weight loss or indication the resident's physician was notified of the severe weight loss or assessed the resident's nutritional status related to the weight loss. On 8/29/18 at 7:45 AM Resident 17 was assisted to the dining room for breakfast and was seated at a regular dining room table, not a tray table. Staff 9 (CNA) and Staff 10 (CNA) were observed assisting resident's in the dining room. A glass of orange juice in a regular glass was placed on the table at the resident's place setting but beyond the reach of the resident to drink independently. The resident waited until 8:12 AM (27 minutes after arriving in the dining room) before her/his breakfast was delivered including a scoop plate with scrambled eggs and a crumbled muffin. A small dish with diced watermelon was placed next to the resident's juice. Staff did not assist the resident with eating. With difficulty the resident was able to take a few bites of scrambled eggs before she/he gave up. The resident was not provided with cueing or encouragement to eat more. Staff were observed assisting another resident at the same table and encouraging that resident to eat. Resident 17 made no attempts to reach for her/his juice or watermelon. At 8:34 AM Staff 10 (CNA) told the resident You didn't eat very much and asked the resident if she/he wanted the watermelon and placed it in front of the resident. The resident independently took about six bites of the watermelon and stopped. No other assistance or encouragement was provided. At 8:39 AM (54 minutes after the resident was brought to the dining room) Staff 10 placed the resident's orange juice in front of her/him and the resident independently drank about half of the juice. At 8:51 AM the resident was assisted from the dining room. On 8/29/18 at 8:51 AM Staff 9 (CNA) acknowledged Resident 17 was not provided a nosey cup or tray table. She was not aware the resident needed one staff assistance with eating and acknowledged the resident did not receive assistance with breakfast. On 8/29/18 at 9:01 AM and 8/30/18 at 3:32 PM Staff 5 (RNCM) verified Resident 17's care plan indicated the resident required one staff assistance with eating, a scoop plate, nosey cup and tray table. Staff 5 verified Resident 17's severe weight loss, the resident continued to lose weight, was removed from NAR monitoring, the resident's physician was not notified of the severe weight loss by the facility and the physician did not assess the resident's nutritional status related to the severe weight loss. 2. Resident 36 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A hospital history and physical dated 7/21/18 indicated Resident 36 weighed 220 pounds. Review of the residents 7/25/18 care plan indicated a potential nutritional problem related to hypertension (high blood pressure) and hyperlidemia (high level of fat lipids in the blood) with a goal of no significant weight loss. Interventions included a regular diet, drugs and supplements per orders, to offer snacks and house protein shakes and for the Registered Dietitian to evaluate and make diet changes as needed. The 7/31/18 MDS Nutritional CAA revealed Resident 36 indicated a healthy weight reduction was recommended for improving long-term health outcomes. The resident was on hydration pass related to inadequate intake with meals and offered snacks or protein shakes related to variable intake. The resident was at risk for nutritional deficit. Review of the 8/1/18 admission Dietitian Assessment indicated the resident weighed 213 pounds on 7/25/18. There were no recent lab values indicated. The assessment indicated the resident's intake was not adequate to meet needs while promoting healthy weight reduction. The nutritional analysis further indicated the resident was at increased risk for malnutrition and lean body mass loss related to inadequate intake to meet estimated needs. Recommendations included 180 ml hydration pass with meals and snacks or house protein shakes BID. Review of the resident's weight record from 7/25/18 through 8/22/18 revealed the following: *7/25/18- 213 pounds *8/1/18- 208 pounds *8/3/18- 206 pounds *8/4/18- 201 pounds *8/5/18- 200 pounds *8/6/18- 197 pounds *8/7/18- 196 pounds *8/8/18- 203 pounds *8/9/18- 198 pounds *8/10/18- 197 pounds *8/11/18- 197 pounds *8/12/18- 198 pounds *8/15/18- 193 pounds *8/19/18- 194 pounds *9/22/18- 192 pounds This was a 20 pound weight loss or 10.6% in 28 days, which indicated a severe weight loss. An 8/6/18 nutritional progress note indicated a weight value of 200 pounds and weight appeared to be resident's baseline and monitoring would continue. An 8/8/18 nutritional progress note indicated a weight value of 196 pounds. Weight loss was expected related to obesity. An 8/14/18 nutritional progress note indicated a weight value of 198 pounds. Weight was within baseline and resident was at risk for fluid imbalance due to [MEDICAL CONDITION]. An 8/17/18 nutritional progress note indicated a weight value of 193 pounds. A reweigh was to be obtained. An 8/20/18 nutritional progress note indicated a weight value of 194 and indicated the resident was obese and weight loss was expected related to increased mobility and therapy services. An 8/23/18 nutritional progress note indicated a weight value of 192 and was at resident's baseline. On 8/29/18 at 10:00 AM Staff 9 (Registered Dietitian) stated she came to the facility three times a week and would do a weekly review and run reports of weights of residents. She stated residents who were appropriate for NAR (nutritional at risk) were residents who had a weight loss of 5% or more in a month. She stated snacks and protein shakes were implemented for Resident 36. She stated Resident 36 was not on NAR but recommended she/he be added. Staff 9 stated Resident 36 had weight loss. She acknowledged the weight loss was not a healthy weight loss and the resident's weights were continuing to decrease. She stated nursing staff were supposed to contact the physician if there was a significant weight loss. On 8/29/18 at 11:07 AM Staff 4 (RNCM) stated Resident 36's weight loss was considered healthy. She stated the resident was not moving for a time and the weight loss was expected. When asked how a healthy weight loss was determined she stated it was determined by the dietitian. She further stated the physician should also confirm the resident's weight loss was healthy. Staff 4 confirmed the resident's trending weight loss was severe. Staff 4 confirmed there was no documentation to indicate the physician was notified of Resident 36's weight loss and the weight loss was considered healthy.

Based on observation, interview and record review it was determined the facility failed to prevent the development of pressure ulcers, identify new pressure ulcers and accurately assess pressure ulcers for 1 of 1 sampled resident (#37) reviewed for pressure ulcers. This resulted in the development of one Unstageable and three Stage 2 pressure ulcers for Resident 37. Findings include: CMS Appendix PP defined the following pressure ulcer stages: Stage 2 Pressure Ulcer: Partial-thickness skin loss with exposed dermis: Partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. Unstageable Pressure Ulcer: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) should only be removed after careful clinical consideration and consultation with the resident's physician, or nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws. If the slough or eschar is removed, a Stage 3 or Stage 4 pressure ulcer will be revealed. If the anatomical depth of the tissue damage involved can be determined, then the reclassified stage should be assigned. The pressure ulcer does not have to be completely debrided or free of all slough or eschar for reclassification of stage to occur. Resident 37 was admitted to the facility in 8/2018 with [DIAGNOSES REDACTED]. Resident 37's Admission care plan related to pressure ulcer potential dated 8/9/18 indicated the resident required staff assistance to reposition and turn in bed, was a two-person physical assist with the mechanical lift for transfers and was a one-person staff assist for mobility. The resident had the potential for pressure ulcer development related to immobility. A Registered Dietitian assessment dated [DATE] indicated Resident 37 was able to dine independently and had a healthy body mass index. A Urinary Incontinence CAA dated 8/14/18 revealed Resident 37 was continent and was at risk for incontinence related to limited mobility. Staff were to assist with toileting needs routinely and PRN. A Pressure Ulcer CAA dated 8/14/18 revealed the resident did not currently have any pressure wounds but was at risk secondary to: limited mobility from recent hospitalization [MEDICAL CONDITION] and shingles, [MEDICAL CONDITION], [MEDICATION NAME] and narcotic use. The resident was at high risk for breakdown related to risk factors. The resident was at risk for pain and infection if skin impairment occurred. A Progress Note dated 8/19/18 initially identified an open wound. The resident's sacrum (area above tailbone) and coccyx (tailbone) were red and there were four open sores with one about the size of a quarter. An 8/20/18 Skin/Wound Note indicated a skin check was performed and the resident had four open areas present on the buttocks/coccyx. An 8/27/18 Daily Skilled Charting Note revealed the wound to the coccyx showed signs of worsening and measured 5 cm x 4 cm. On 8/28/18 at 7:49 AM Witness 1 (family) relayed the resident had acquired a pressure ulcer on the buttocks after admission to the facility. Witness 1 stayed with the resident at least 12 hours a day in the facility. Witness 1 said staff were not repositioning the resident every 2 hours but were coming in maybe every 3-4 hours. The resident was usually continent and if staff got the resident up she/he would use the toilet, however since the resident was a mechanical lift and it was sometimes hard for staff to find a second person to assist the resident would just use her/his brief per her choice. On 8/28/18 a revision to Resident 37's care plan indicated the resident had a new skin impairment to the right buttock. The care plan did not identify the Stage of the wound or that it was a pressure ulcer. Interventions in the care plan were dated 8/9/18 and no new care and treatment interventions were added to the care plan related to the new facility acquired pressure ulcer identified on 8/19/18. A Nursing Wound Assessment Report dated 8/28/18 indicated the resident's wound was first identified on 8/21/18, was located on the right upper buttock and was a Stage 2 facility acquired pressure ulcer. The wound was described as [MEDICATION NAME] (pale, pink or red) = 40%, slough-white fibrous = 30%, necrotic soft adherent= 30%. New wound orders were implemented for the decline in the wound. The information on the assessment was not accurate related to the date identified (identified 8/19/18 not 8/21/18), the location of the wound (left side not right side), and the Stage of the wound (Unstageable due to the presence of slough in the wound not a Stage 2 wound). An 8/31/18 Nursing Order Note revealed a new wound order was received with wound dressings changed to twice a day due to frequent incontinence to improve healing of the wound. There was no information or reason expressed as to why the resident's incontinence was more frequent or how the facility was going to address the incontinence to keep the resident clean and dry. On 9/5/18 at 2:36 PM Staff 11 (CNA) indicated she was aware the resident had a pressure ulcer on her/his bottom. Staff 11 was aware the resident should be repositioned every two hours as a standard of care. However, Staff 11 indicated they did not have a good way to document when they were repositioning the resident so they documented it under bed positioning and there was no good way to verify the repositioning was being done consistently. On 9/5/18 at 2:52 PM Staff 4 (RNCM) acknowledged the resident had an Unstageable facility acquired pressure ulcer. Staff 4 added the four open areas originally noted had combined into one main wound. Per Staff 4 she had documented there was a new wound in the care plan but the care plan did not reflect the actual plan she had to address the wound. Staff 4 explained the previous interventions in place were an air mattress and use of barrier cream. Staff 4 stated the cause of the pressure ulcer was likely the resident's decline and increased incontinence. Staff 4 also indicated the resident did not refuse care giving and the pressure ulcer was not improving. On 9/6/18 at 7:42 AM a wound observation was conducted with Staff 12 (LPN) for Resident 37. There was a main wound located on the left upper buttock not the right buttock as documented on the Nursing Wound Assessments. Additionally, multiple open areas were observed on the left and right buttocks that were not identified on the Nursing Wound Assessments. The main wound contained approximately 30-40% eschar which indicated the wound was Unstageable not a Stage 2 as indicated on the Nursing Wound Assessment. Staff 12 indicated, the main wound was getting worse, but the surrounding skin was better. There were scattered Stage 2 open areas on the buttocks which had been there for a couple of weeks and which had not been previously identified or staged and had no treatment orders. Resident 37's four wounds were identified from the Wound Rounds wound tracking in her/his clinical record as follows and included Wound Site, Date Identified, Type, Classification, Status, Clinical Stage, PUSH (Pressure Ulcer Scale for Healing), Tissue Types, Exudate, Length x Width x Depth, Last Assessment Date; - L Buttock 8/19/2018 Pressure Ulceration Active Unstageable 16 [MEDICATION NAME] (Pale Pink or Red)-50% Slough Non-adherent-10% Necrotic Hard, Firm, Adherent-40% Serosanguineous 7.30 9.50 0.10 9/6/2018 9:28 AM - L Distal Buttock 9/6/2018 Pressure Ulceration Active Stage 2 4 [MEDICATION NAME] (Pale Pink or Red)-100% None 1.20 0.80 0.10 9/6/2018 9:23 AM - L Lateral Buttock 9/6/2018 Pressure Ulceration Active Healed Stage 2 4 [MEDICATION NAME] (Pale Pink or Red)-100% None - R Buttock 9/6/2018 Pressure Ulceration Active Stage 2 10 Intact Skin-50% [MEDICATION NAME] (Pale Pink or Red)-50% None 6.50 3.00 0.10 9/6/2018 9:20 AM On 9/6/18 at 9:40 AM Staff 4 (RNCM) and Staff 2 (DNS) acknowledged the initial wound was first identified on 8/19/18 not 8/21/18, it was on the left side not the right side and the wound was on the buttocks not the coccyx. Additionally, there were three Stage 2 pressure ulcers on Resident 37's buttocks which had not been previously identified and no treatment had been ordered for them. With the presence of eschar, the initial wound was Unstageable not a Stage 2 and the wound did not contain 30% slough as previously identified, it contained pale [MEDICATION NAME] (skin). Staff 4 acknowledged the assessment of the wound in the 8/28/18 Nursing Wound Assessment was not accurate and the care plan had not been updated to reflect new treatments and interventions for a worsening pressure ulcer. Staff provided no evidence the wounds were unavoidable.