Every finding on record at Bridgeview Post Acute

Based on observation, interview, and record review, the facility failed to provide services that met professional standards of quality for one of five sampled residents (Resident 1) when therapy staff and licensed nursing staff did not adhere to accepted pain management practices. When: Therapy staff did not promptly report Resident 1's pain to nursing staff and continued therapy that exacerbated the resident's pain. Licensed nursing staff failed to conduct timely, accurate assessments and did not implement physician ordered interventions to address Resident 1's reported pain.This failure resulted in Resident 1 experiencing uncontrolled pain related to a newly fractured arm and feeling ignored and distressed.Findings: A review of the facility's policy and procedures titled, Pain Assessment and Management, dated 4/2025, indicated the facility requires a multidisciplinary approach to pain management, including: identifying and assessing pain; recognizing conditions that may cause pain; determining the cause, intensity, duration, type, and characteristics of pain; implementing pain management interventions consistent with accepted standards of practice; and monitoring the effectiveness of those interventions.A review of Resident 1's admission record, indicated that Resident 1 was admitted to the facility on [DATE] with diagnoses including lung cancer with metastasis (spread of cancer to other parts of the body), chronic obstructive pulmonary disease (a long-term lung condition that makes it hard to breathe), and kidney failure (when kidneys cannot filter waste and extra fluid from the blood).A review of Resident 1's physician orders indicated the following pain management treatments: Voltaren gel ((anti-inflammatory medication) applied daily to the arm (starting date: 8/1/2026); Tylenol 650 mg every four hours as needed for pain rated 1-10/10 (starting date: 8/3/2026); and a 4% lidocaine patch applied daily to the left arm, with up to two patches allowed on the left shoulder every 12 hours (starting date: 8/8/2026).A review of Resident 1's pain management care plan, dated 7/11/26, indicated the resident was identified as being at risk for pain. The care plan directed staff to administer Tylenol as ordered, anticipate and respond immediately to any pain complaints, and evaluate the effectiveness of pain management interventions.During a telephone interview on 8/20/2026 at 3:43 pm with Resident 1's Family Member (FM), FM reported that Resident 1 called her on 8/13/2026 at 11:00 pm stating he wanted to go to the emergency room due to severe left arm pain experienced during therapy earlier that day and that he had not received any pain medication. FM stated Resident 1 subsequently called 911, was sent to the hospital, and diagnosed with a fractured left arm. During a concurrent observation and interview on 8/21/2026 at 10:25 am with Resident 1, in Resident 1'room, Resident 1 reported chronic left arm pain for six years and a recent fracture, and was observed with compression dressing on the left forearm and palm and red purple discoloration between the thumb and pointer finger. Resident 1 stated the nurses did not believe he was in pain, which made him feel angry, and reported difficulty obtaining pain medication due to too many restrictions and hoops. Resident 1 explained that on 8/13/26, at the beginning of therapy before lunch, he informed the Physical Therapy Assistant (PTA)and Occupational Therapist (OT) that his left hand and fingers hurt when gripping his platform walker; after walking approximately 50 feet, he felt a crunch and pop, followed by intense burning pain, rapid swelling, and his arm becoming Monster sized. Resident 1 stated he reported the swelling and pain to nursing staff and asked a nurse to call 911 but was told to wait until the physician could evaluate him the next day. Believing something was seriously wrong, Resident 1 contacted FM and then called 911 himself. During an interview on 8/21/26 at 3 pm with the Director of Rehabilitation (DOR), the DOR stated therapy staff are expected to report changes in condition promptly and discontinue activities when a resident reports pain. In a separate interview at 3:40 pm with OT, the OT confirmed continuing therapy despite Resident 1's report of left hand pain and acknowledged Resident 1's arm swelled during the session. During a concurrent observation and interview on 8/26/26 at 10:11 am with Resident 1 in Resident 1's room, Resident 1 activated the call light and reported 9/10 left arm pain. Certified Nursing Assistant (CNA) A responded to the call light and notified LVN A. At 10:30 am, Resident 1 stated he still had not received his pain medication. At 10:52 am, approximately 40 minutes after Resident 1's initial complaint of pain 9/10, LVN A entered Resident 1's room but did not assess the location, intensity, or characteristics of the pain before administering pain medication at 11 am. During an interview on 8/26/26 at 1:44 pm with Registered Nurse (RN) A, RN A stated Licensed Vocational Nurse (LVN) A informed her during shift change on 8/13/26 at 2:30 pm that Resident 1 was experiencing 8/10 pain in the left hand with swelling. RN A reported she checked Resident 1 at 4:00 pm and confirmed she did not administer pain medication in response to the reported 8/10 pain at the time of shift change.During an interview on 8/26/26 at 12:05 pm, the Nurse Practitioner (NP) stated a nurse notified her on 8/13/26 that Resident 1 had pain and localized swelling in the left arm. NP reported she ordered the arm to be elevated and monitored and planned to evaluate Resident 1 the following day, 8/14/26. NP indicated the nurse did not report that Resident 1 felt a pop in the arm or that there was bruising between the thumb and pointer finger. NP stated that, based on the information provided, she did not identify the situation as urgent.During a concurrent interview and record review on 8/26/26 at 2:22 pm, with the Director of Nursing (DON), the DON stated licensed nurses are expected to determine the location and intensity of a resident's pain and visually assess the affected area. The DON further explained that once pain is identified, nurses should review the resident's pain management orders and contact the physician if pain medication is not ordered or if the resident's pain is not adequately controlled. The DON stated nurses are also expected to reassess residents within one hour after administering pain medication to evaluate its effectiveness. The DON confirmed that Resident 1's reported pain on 8/13/2026 was not addressed and that required one hour pain reassessments were not completed on multiple occasions.

Based on observation, interview, and record review, the facility failed to provide effective pain management for one of five sampled residents (Resident 1) when staff did not manage Resident 1's reports of severe pain.This failure resulted in unmanaged pain associated with a newly diagnosed fractured left arm and caused Resident 1 to feel ignored and distressed.Findings:A review of the facility's policy and procedures titled, Pain Assessment and Management, dated 4/2025, indicated the facility requires a multidisciplinary approach to pain management, including: identifying and assessing pain; recognizing conditions that may cause pain; determining the cause, intensity, duration, type, and characteristics of pain; implementing pain management interventions consistent with accepted standards of practice; and monitoring the effectiveness of those interventions.A review of Resident 1's admission record, indicated that Resident 1 was admitted to the facility on [DATE] with diagnoses including lung cancer with metastasis (spread of cancer to other parts of the body), chronic obstructive pulmonary disease (a long-term lung condition that makes it hard to breathe), and kidney failure (when kidneys cannot filter waste and extra fluid from the blood).A review of Resident 1's Minimum Data Set (MDS - resident assessment tool) Section C-Cognitive (thinking and remembering) assessment, dated, 7/23/26, indicated Resident 1 had intact cognition, impaired function in one arm, required substantial to maximum assistance for personal hygiene, and was dependent on staff for mobility and transfers. A review of Resident 1's physician orders indicated the following pain management treatments: Voltaren gel ((anti-inflammatory medication) applied daily to the arm (starting date: 8/1/2026); Tylenol 650 mg every four hours as needed for pain rated 1-10/10 (starting date: 8/3/2026); and a 4% lidocaine patch applied daily to the left arm, with up to two patches allowed on the left shoulder every 12 hours (starting date: 8/8/2026).A review of Resident 1's pain management care plan, dated 7/11/26, indicated the resident was identified as being at risk for pain. The care plan directed staff to administer Tylenol as ordered, anticipate and respond immediately to any pain complaints, and evaluate the effectiveness of pain management interventions. A review of Resident 1's Nursing Progress Notes dated 8/13/2026 at 2:41 pm, indicated that Resident 1 reported 8 out of10 pain (severe pain) with localized swelling on the left forearm, and the provider was contacted for further instructions. Note at 2:54 pm indicated the Nurse Practitioner (NP) ordered elevation of the arm with plans to evaluate the resident the following day, but no medication was ordered for the reported severe pain. At 11:00 pm, documentation indicated that Resident 1 utilized the call light to request hospital transport for a checkup on the left arm swelling.Resident 1 declined to wait and contacted 911 independently. A review of Resident 1's Emergency Department (ED) Physician Note, dated 8/13/26, at 11:46 pm, indicated that Resident 1 arrived at the local ED on 8/13/26 at 11:45 pm, and was diagnosed with left distal radius fracture (a broken wrist) and the left hand was placed in a volar splint (a rigid device applied to the palm side of the hand, wrist, and forearm to limit movement, ease pain, and protect soft tissues or bones while allowing room for swelling). During a telephone interview on 8/20/2026 at 3:43 pm with Resident 1's Family Member (FM), FM reported that Resident 1 called her on 8/13/2026 at 11:00 pm stating he wanted to go to the emergency room due to severe left arm pain experienced during therapy earlier that day and that he had not received any pain medication. FM stated Resident 1 subsequently called 911, was sent to the hospital, and diagnosed with a fractured left arm. During a concurrent observation and interview on 8/21/2026 at 10:25 am with Resident 1, in Resident 1'room, Resident 1 reported chronic left arm pain for six years and a recent fracture, and was observed with compression dressing on the left forearm and palm and red purple discoloration between the thumb and pointer finger. Resident 1 stated the nurses did not believe he was in pain, which made him feel angry, and reported difficulty obtaining pain medication due to too many restrictions and hoops. Resident 1 explained that on 8/13/26, at the beginning of therapy before lunch, he informed the Physical Therapy Assistant (PTA)and Occupational Therapist (OT) that his left hand and fingers hurt when gripping his platform walker; after walking approximately 50 feet, he felt a crunch and pop, followed by intense burning pain, rapid swelling, and his arm becoming Monster sized. Resident 1 stated he reported the swelling and pain to nursing staff and asked a nurse to call 911 but was told to wait until the physician could evaluate him the next day. Believing something was seriously wrong, Resident 1 contacted FM and then called 911 himself. During an interview on 8/21/2026 at 3:40 pm with OT, OT confirmed Resident 1 complained of pain in the left hand between the thumb and pointer finger prior to the start of therapy. The OT reported Resident 1's left upper arm and hand swelled during the therapy session and confirmed the pain was reported to nursing staff after therapy.During an interview on 8/26/26 at 1:44 pm with Registered Nurse (RN) A, RN A stated Licensed Vocational Nurse (LVN) A informed her during shift change on 8/13/26 at 2:30 pm that Resident 1 was experiencing 8/10 pain in the left hand with swelling. RN A reported she checked Resident 1 at 4:00 pm and confirmed she did not administer pain medication in response to the reported 8/10 pain at the time of shift change. During a concurrent interview and record review on 8/26/2026 at 2:22 pm with the Director of Nursing (DON), Resident 1's clinical record was reviewed. DON indicated she expected the oncoming shift nurse to immediately follow up with any resident reporting severe pain during shift change. The DON confirmed LVN A and RN A did not address Resident 1's reported 8/10 pain on 8/13/2026 during shift change or thereafter.

Based on observation, interview, and record review, the facility failed to ensure nursing services were provided in accordance with professional standards of quality when Licensed Nurse C (LN C) did not document care provided to one of eight sampled residents (Resident 3).This failure resulted in an incomplete medical record for Resident 3 and created the potential for the resident to not be adequately assessed or receive necessary care.Findings:A review of the facility policy titled Charting and Documentation, dated 7/2017, indicates that the following information is to be documented in the resident medical record. treatments or services performed. The policy further states that all services provided to the resident, progress toward care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition shall be documented in the resident's medical record.A review of Resident 3's admission record indicated that Resident 3 was originally admitted to facility on 7/29/2019, with diagnoses that included Urinary Tract Infection, Chronic Obstructive Pulmonary Disease (COPD, a long-term lung disease that makes it hard to breathe because the airways and air sacs in the lungs get damaged and swollen), Muscle Weakness, Quadriplegia (weakness and/or paralysis of all 4 limbs), and Colostomy status (a surgically created opening in the bowels to allow bowel contents to empty). Further review of the record indicated that Resident 3 has a Suprapubic catheter (a urinary catheter placed through the abdominal wall, directly into the bladder), an inverted penis, and has had past, chronic skin problems in his peri area, including redness, swelling, and discharge. Resident 3 was not his own health-care decision maker.During an interview with Certified Nursing Assistant B (CNA B) on 8/4/26 at 11:50am, Certified Nursing Assistant B (CNA B) stated that providing Resident 3 with perineal care (peri care - the washing of a person's genital and anal areas) should be done daily. CNA B further stated that documentation in the medical record must be completed each time care is provided and said, It should be done every time.During a concurrent interview and record review on 8/5/26 at 10:30 a.m. with Licensed Nurse C (LN C), Resident 3's treatment record was reviewed. LN C confirmed they were the facility's Treatment Nurse and stated they had been providing peri care to Resident 3 each day they were scheduled. LN C reported awareness of Resident 3's chronic peri area skin issues and stated they aimed to keep the resident's skin clean to prevent worsening. LN C stated, I am doing peri care daily, up to five to six days a week. It's not a provider order; I've always done it. LN C confirmed they did not document the care provided in the resident's health record and was unable to provide electronic or paper records showing peri care had been completed.During an interview on 8/5/26 at 10:57 am with the Director of Staff Development (DSD), the DSD stated that aides and staff are expected to document every instance of providing peri care, bathing, or noting any skin changes.

Based on the interview and record review, the facility failed to ensure it treated residents in a dignified manner for one of eight residents (Resident 1) sampled for resident rights when: Certified Nursing Assistant (CNA) A entered Resident 1's room without explaining the purpose for being there and pulled Resident 1's pajama bottoms down without asking permission to see if he needed his brief (adult diaper) changed and was unaware that Resident 1 did not wear briefs.This upset and embarrassed Resident 1, who complained to staff about the care he received from CNA A, and Resident 1's family member (FM) expressed she was dissatisfied with the care her husband had received.FindingsA review of the facility's Dignity policy and procedures, dated 10/2025, indicated on Line 9, Staff inform and orient resident to their environment. Procedures are explained before they are performed. Line 12 indicated, Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity.A review of Resident 1's admission Report, dated 1/15/2026, indicated Resident 1 was admitted on [DATE] with diagnoses that included dependence on renal dialysis (a life sustaining treatment used to filter the blood for persons with kidney failure), atherosclerotic heart disease (plaque buildup in the heart arteries), and cirrhosis of the liver (permanent scarring of the liver caused by long term damage).A review of Resident 1's Minimum Data Set (MDS, comprehensive assessment), dated 2/4/2026, indicated, Resident had a Brief Interview for Mental Status (BIMS, thinking and memory assessment) score of 15 out of 15, meaning Resident 1 has no thinking and memory impairments. MDS Section GG Functional Abilities (assessment of a person's mental, physical, and social capacity to perform routine daily activities), dated 2/9/2026, indicated, Resident 1 was continent (having normal voluntary control of bowel and bladder) and was able to independently go to the bathroom and provide personal hygiene.A review of the facility's 5 day Follow Up Report dated 1/20/2026, indicated the Administrator followed up with Resident 1 on 1/15/2026, and Resident 1's account of the event was on 1/13/2026 at 3:00 am, a CNA entered his room and put his finger inside the waistband of his boxer shorts and began to pull them. He said that the CNA suddenly said, Oops, wrong patient and left his room. The resident stated that no introductions had been made, and he didn't know why the CNA needed to do anything at 3:00 am in the morning. Resident 1's FM was also present, and she expressed dissatisfaction with the care her husband received. The report indicated the Director of Staff Development (DSD, CNA supervisor and educator) B spoke with CNA A, and CNA A acknowledged going into Resident 1's room at 3:00 am, but did not turn on the light. The report indicated CNA A states that he woke the resident and told the resident (Resident 1) that he would like to check his brief. He states that the resident (Resident 1) grunted in response. He states that he inserted his fore-finger inside of the resident's waistband and pulled them out and down, approximately one inch. He stated that he immediately recognized that the resident (Resident 1) was wearing boxer shorts instead of a brief. At that point, he removed his finger, apologized, and left the room.A review of the facility's nursing assignment schedule for 1/13/2026 indicated CNA A was assigned to Resident 1 for the night shift (10:00 pm to 6:30 am).During a telephone interview on 7/17/2026 at 9:45 am with CNA A, CNA A confirmed they were a registry (temporary staffing agency) CNA. CNA A indicated on 1/14/2026 they were assigned to Resident 1, and they had not worked with Resident 1 before. CNA A indicated they had not identified Resident 1 before rolling him over to change him. CNA A indicated they touched Resident 1's hip and saw boxer shorts and immediately apologized to Resident 1, acknowledging Resident 1 was not the resident who needed peri care. CNA A indicated for the rest of their shift they provided Resident 1 with space and understood Resident 1 was upset about what happened. CNA A indicated they should have checked Resident 1's wrist band before touching him. CNA A indicated they did not review Resident 1's medical records before entering Resident 1's room.During an interview and record review on 7/17/2026 at 1:52 pm, with DSD B, DSD B indicated it is the facility's expectation were that CNAs knock on the resident's room door, introduce themselves to the resident, and ask permission before performing care tasks. DSD B indicated at night; CNAs check residents who are known to be incontinent to determine if the residents' briefs are wet and if peri care is needed. DSD B confirmed CNA A should have knocked on the door, awoken Resident 1, introduced themselves, and asked permission before touching him. DSD B indicated CNAs do walking rounds (outgoing and incoming CNAs visit residents at shift change to visually check residents' status, review immediate needs, and hand off care) at the beginning of each shift. DSD B indicated during walking rounds CNAs should have identified which residents were incontinent and need routine peri care. DSD B indicated CNA A should have known Resident 1 was continent.

Based on observation, interviews, and record review, the facility failed to protect one of three sampled residents (Resident 1) from neglect when nursing staff failed to recognize and appropriately respond to slurred speech, facial drooping, and right sided arm weakness, which represented of a significant change in condition. The facility failed to ensure timely assessment, provider notification (the physician), and medical intervention.This failure resulted in delayed recognition and treatment of Resident 1's brain bleed, contributing to a permanent and preventable decline in functional abilities, including decreased use and strength of the right arm and loss of independence in performing personal tasks.During a review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, dated 12/2025, the P&P indicated that when a resident experiences a change in condition, nursing staff are to promptly conduct a comprehensive assessment, document relevant changes in the resident's medical record, and notify the physician and resident representative. The policy defined a significant change in condition as a major decline that would not normally be resolved without staff intervention or standard disease-related clinical interventions and that impacts more than one area of the resident's health.During a review of the facility's policy and procedure (P&P) titled, Acute Condition Changes, undated, the P&P indicated that physicians and staff are to identify residents at risk for acute changes in condition, including those related to medications with potential adverse side effects. Nursing staff are required to assess, document, and report pertinent clinical information, including vital signs, neurological status, level of consciousness, and cognitive status. The policy further states that direct care staff, including nursing assistants, must be trained to recognize and communicate significant changes in a resident's condition.A review of Resident 1's admission record indicated that Resident 1 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), heart failure, emphysema (a long-term lung disease that makes it hard to breathe), and high blood pressure.During a review of Resident 1's Minimum Data Set (MDS - an assessment and care screening tool), dated 1/30/26, the MDS indicated that Resident 1 had a brief interview for mental status (BIMS) score of 15 out of 15, indicating no cognitive impairment.During a review of Resident 2's admission record indicated that Resident 2 was admitted to the facility on [DATE] with diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis (muscle weakness or partial paralysis affecting one side of the body) following cerebral Infraction (stroke, when a blood vessel in the brain becomes blocked cutting off the oxygen supply), hyperlipidemia (high cholesterol and triglycerides in the blood), and a depressive disorder.During a review of Resident 2's most recent MDS, dated [DATE], the MDS indicated that Resident 2 had a BIMS score of 15 out of 15, indicating no cognitive impairment.A review of Resident 1's physician order, dated 1/12/26, indicated Eliquis (a medication to prevent blood clots) 2.5 milligrams (mg, a unit of measure), one tablet by mouth twice daily, was prescribed for deep vein thrombosis (a blood clot). A review of Resident 1's Medication Administration Record (MAR), for April 2026, indicated that Resident 1 received the scheduled dose of Eliquis on 4/11/26, 4/12/26, and the 8 am dose on 4/13/26. The record indicated Resident 1 was monitored for symptoms associated with anticoagulant (blood thinner) use, including severe headache and sudden changes in mental status. Documentation reflected that no such symptoms were identified during the month of April 2026.A review of Resident 1's medical record titled, Change in Condition Assessment/ SBAR, dated 4/13/26 at 1:34 pm, indicated that Resident 1 had muscle weakness, however, the assessment did not identify the affected area of the body, describe the severity of the weakness, or indicate the onset or duration of the symptom. The section titled, Reason for Assessment, indicated that the receptionist notified nursing staff that a family member had removed Resident 1 from the facility and transported the resident to the hospital.During an interview on 4/16/26 at 1:10 pm, with a family member (FM), the FM stated that upon arriving at the facility on 4/13/26, they observed Resident 1 was having difficulty following conversations, was unable to use his right side normally, and had slurred speech. When FM approached nursing staff, they were informed that Resident 1 had not gone out for a cigarette for several days and had been sleeping more than usual. FM stated that two nursing staff members assessed Resident 1 and recommended hospital evaluation. FM then transported Resident 1 to the hospital because they were concerned Resident 1 needed immediate medical attention. FM stated that upon arrival at the hospital, Resident 1 was diagnosed with a brain bleed, transferred by helicopter to another facility, required a machine to breathe, and was admitted to the intensive care unit (ICU).During an interview on 4/16/26 at 1:45 pm, with Resident 2, Resident 2 stated that on 4/11/26, while speaking with Resident 1, they observed Resident 1's right arm twitch, after which Resident 1 was unable to use the arm. Resident 2 stated that although Resident 1 was able to speak, his speech sounded different and he appeared very tired. Resident 2 stated that they reported the change to the Activities Director (AD). Resident 2 further stated that over the following days, Resident 1 continued to be unable to use his right side, had slurred speech, spent most of the time in bed, and stopped going out for routine cigarette breaks. Residents 2 stated that the nursing staff did not appear to recognize the changes.During an interview on 4/16/26 at 1:55 pm, with the AD, the AD stated that on 4/11/26, Resident 2 informed them that Resident 1 was not acting like himself. The AD stated that Resident 1 had missed both cigarette breaks, which was unusual, and observed facial drooping, slurred speech, and an inability to use one arm. The AD stated that they escorted Resident 1 to the nurse's station, informed Registered Nurse (RN) B of these observations, and expressed concern that the resident may be having a stroke. The AD stated that Licensed Vocational Nurse (LVN) E and RN G then accompanied Resident 1 to his room. Approximately 30 minutes later, the AD returned and observed that Resident 1 remained in his room, complaining of headache and neck pain, which the AD reported to nursing staff; however, the AD did not recall the names of the staff notified. The AD stated that Resident 1 was typically independent and that the change in condition was concerning.During an interview on 4/16/26 at 2:05 pm, with RN B, RN B stated that on 4/11/26 the AD requested that Resident 1 be assessed. RN B stated that, because it was near the end of the shift, another nurse assessed Resident 1. RN B stated they did not personally assess Resident 1 and, as no concerns were communicated to them, no physician or provider was notified.During an interview on 4/16/26 at 2:28 pm, with Certified Nurse Assistant (CNA) A, CNA A stated that on the evening of 4/11/26, the AD expressed concern that Resident 1 may have been experiencing a stroke. CNA A checked on Resident 1 and observed that Resident 1 was unusually quiet and not acting like themselves. CNA A stated that these observations and concerns, including the possibility of a stroke, were reported to RN B.During an interview on 4/16/26 at 2:40 pm, with RN C, RN C stated that on 4/13/26, CNA F expressed concern because Resident 1 had not gone out for a cigarette break. RN C checked on Resident 1 and reported no unusual observations. RN C stated they were not informed that Resident 1 may have been experiencing stroke-like symptoms and that an assessment was not completed.During an interview on 4/16/26 at 3:15 pm, with LVN D, LVN D stated that on 4/13/26, CNA F reported concerns that Resident 1 was exhibiting stroke-like symptoms. Upon assessment, Resident 1 was unable to raise their right arm. LVN D stated that Resident 1 required a hospital evaluation; however, before emergency medical services (EMS) could be contacted, a family member transported Resident 1 from the facility. LVN D confirmed that neither EMS nor the provider had been notified prior to the resident leaving the facility, and that the provider was notified only after the resident had departed.During an interview on 4/16/26 at 3:35 pm, with the facility Temporary Director of Nursing (TDON), the TDON stated that when nursing staff are alerted to a resident's change in condition, they are expected to perform a comprehensive assessment, including evaluating signs and symptoms of a stroke, and promptly notify the provider of their findings. The TDON confirmed there was no documentation reflecting notification of the provider or Resident 1's family member until 4/13/26, and that the provider was notified only after Resident 1 had been transported from the facility by a family member to a local hospital.During an interview on 4/16/26 at 3:50 pm, with the Administrator (ADMIN), the ADMIN confirmed there was no documentation of an assessment for a possible stroke or notification of the provider on 4/11/26, when staff first reported a change in Resident 1's condition, or on 4/12/26. The ADMIN stated that when the staff report a resident's change in condition to nursing staff, the expectation is that an assessment is completed, documented, and the provider is notified of the findings.During an interview on 4/22/26 at 9 am, with LVN E, LVN E stated that on 4/11/26, the AD reported concerns that Resident 1 was not acting normal and had facial drooping. LVN E stated that they and a RN G assessed Resident 1 in the resident's room and did not identify any abnormalities. LVN E confirmed that this assessment was not documented in Resident 1's medical record and acknowledged that documentation should have been completed.During a concurrent observation and interview in Resident 1's room, on 5/26/26 at 11 am, with Resident 1, Resident 1 stated they had recently experienced a stroke but could not recall how much time had passed before being taken to the hospital or how they arrived there. When asked how long it took to receive help, Resident 1 stated, They would have waited so long that they would have let me die. Resident 1 further stated that since the stroke, they have been unable to use their right arm and hand, which had been their dominant hand, and are no longer able to independently dress themselves, button clothing, or write. Resident 1 stated that he was unable to hold his urinal (a disposable device to collect urine when residents are bedbound) and spilled urine because he could not use his right hand. During the interview, Resident 1 was observed sitting at the edge of his bed and unable to lift his right arm.During an interview on 5/26/26 at 1:50 pm, with RN G, RN G stated that on 4/11/26 they assessed Resident 1 in his room with LVN E and did not observe any abnormalities. RN G stated that the assessment was not documented because Resident 1 was not assigned to them. RN G further stated that, even after Resident 1 returned from the hospital, the resident appeared to be themself and that they had not observed any obvious signs of stroke. When asked whether they were aware that Resident 1 had lost the use of their right arm, RN G stated that they were aware and confirmed that loss of use of an arm would be a sign of a stroke.During an interview on 5/26/26 at 2:20 pm, with CNA F, CNA F stated that Resident 1 had not been acting like themself for approximately three days before being taken to the hospital. CNA F stated that on 4/12/26, Resident 1 remained in bed throughout the day and did not go out for cigarette breaks. CNA F further stated that on 4/13/26, they requested that a nurse check on Resident 1 earlier in the day due to concerns regarding the resident's condition and were told that the resident appeared fine. Later that day, a family member visited Resident 1 and expressed concern that the resident may have had a stroke, prompting another nursing assessment. CNA F stated that during the assessment, Resident 1 was unable to raise their right arm. CNA F further stated that after the nurse left the room, the family member assisted Resident 1 into a wheelchair, transferred the resident's oxygen to the wheelchair, and transported the resident to the local hospital. CNA F stated they did not observe emergency medical services arriving at the facility to transport Resident 1.During an interview on 5/26/26 at 2:35 pm, with the Director of Nursing (DON), the DON stated that the assessment documented for Resident 1 on 4/13/26 could have been more thorough, including clarification of whether the muscle weakness was new, the location of the weakness, and a more comprehensive neurological assessment appropriate for reported stroke-like symptoms. The DON confirmed there was no documented assessment of resident condition on 4/11/26 or 4/12/26. The DON stated that when a change in condition is reported or suspected, nursing staff are expected to complete and timely document an assessment that either confirms or rules out the change in condition. The DON further stated that additional intervention should have occurred for Resident 1, including notification of the provider, family and referral to the local hospital for further evaluation.During an interview on 5/27/26 at 10:00 am, with the facility Nurse Practitioner (NP), the NP stated that when nursing staff are alerted to stroke-like symptoms, the expectation is that the resident is immediately assessed, including vital signs and a neurological assessment for deficits such as facial droop, slurred speech, arm weakness, and decreased grip strength, and prompt provider notification. The NP stated that normal vital signs do not rule out stroke, making a comprehensive assessment important, and that deficits such as loss of use of an extremity are expected to persist, not resolve and recur. The NP further stated that residents on anticoagulants (blood thinners) such as Eliquis (a medication used to thin the blood) are at increased risk for bleeding, and reported stroke-like symptoms should prompt immediate assessment and provider notification. The NP confirmed they were not notified of Resident 1's symptoms until after the resident had already been transferred to the hospital by a family member, and stated that, had they been notified, they would have directed an immediate emergency evaluation, as delays can result in permanent neurological damage.During a review of Resident 1's medical record titled, ED [Emergency Department] Physician Notes, dated 4/14/26 at 3:14 pm, indicated that Resident 1 arrived at the hospital with a reported two-to-three-day history of decreased right arm movement, weakness, increased fatigue, and being less vocal than usual. Physical examination findings included right-sided weakness compared to the left. The note further indicated that a computed tomography (CT- a medical imaging test) scan identified a thalamic (a structure located deep in the brain) bleed in a distribution consistent with the resident symptoms. Resident 1 required reversal (treatment used to stop or reduce the effects) of the medication Eliquis and was airlifted to another hospital for higher level of care. The final diagnosis was intracranial hemorrhage (bleeding within the brain).

Based on interview and record review, the facility failed to notify the physician and resident representative for one of three sampled residents (Resident 1), when Resident 1 experienced a significant change in condition.This failure resulted in delayed timely treatment, during which Resident 1 experienced a preventable decline in functional status, losing strength in the right arm and becoming unable to independently perform personal care tasks.Findings:During a review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, dated 12/2025, the P&P indicated that when a resident experiences a change in condition, nursing staff are to promptly conduct a comprehensive assessment, document relevant changes in the resident's medical record, and notify the physician and resident representative. The policy defined a significant change in condition as a major decline that would not normally be resolved without staff intervention or standard disease-related clinical interventions and that impacts more than one area of the resident's health.During a review of Resident 1's admission record indicated that Resident 1 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), heart failure, emphysema (a long-term lung disease that makes it hard to breathe), and high blood pressure.During a review of Resident 1's Minimum Data Set (MDS, an assessment and care screening tool), dated 1/30/26, the MDS indicated that Resident 1 had a brief interview for mental status (BIMS) score of 15 out of 15, indicating no cognitive impairments.During a review of Resident 2's admission record indicated that Resident 2 was admitted to the facility on [DATE] with diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis (muscle weakness or partial paralysis affecting one side of the body) following cerebral infarction (stroke, when a blood vessel in the brain becomes blocked cutting off the oxygen supply), hyperlipidemia (high cholesterol and triglycerides in the blood), and a depressive disorder.During a review of Resident 2's most recent MDS, dated [DATE], the MDS indicated that Resident 2 had a BIMS score of 15 out of 15, indicating no cognitive impairment.During an interview on 4/16/26 at 1:45 pm, with Resident 2, Resident 2 stated that on 4/11/26, while speaking with Resident 1, they observed Resident 1's right arm twitch, after which Resident 1 was unable to use the arm. Resident 2 stated that although Resident 1 was able to speak, his speech sounded different and he appeared very tired. Resident 2 stated that they reported Resident 1's change to the Activities Director (AD). Resident 2 further stated that over the next few days, Resident 1 continued to be unable to use his right side, had slurred speech, spent most of the time in bed, and stopped going out for routine cigarette breaks. Residents 2 stated that the nursing staff did not appear to recognize the changes. During an interview on 4/16/26 at 1:55 pm, with the AD, the AD stated that on 4/11/26, Resident 2 informed them that Resident 1 was not acting like himself. The AD stated that Resident 1 had missed both cigarette breaks, which was unusual, and observed facial drooping, slurred speech, and an inability to use one arm. The AD stated that they escorted Resident 1 to the nurse's station, informed Registered Nurse (RN) B of these observations, and expressed concern that the resident may be having a stroke. The AD stated that two nurses then accompanied Resident 1 to his room. Approximately 30 minutes later, the AD returned and observed that Resident 1 remained in his room, complaining of headache and neck pain, which the AD reported to nursing staff. The AD stated that Resident 1 was typically independent and that the change in condition was concerning. During an interview on 4/16/26 at 2:05 pm, with RN B, RN B confirmed that on 4/11/26, AD requested that Resident 1 be assessed. RN B stated that, because it was near the end of the shift, Licensed Nurse (LVN) D assessed Resident 1. RN B stated they did not personally assess Resident 1 and, as no concerns were communicated to them, no physician or provider was notified. During an interview on 4/16/26 at 3:15 pm, LVN D stated that on 4/13/26, AD reported concerns that Resident 1 was exhibiting stroke-like symptoms. Upon LVN D's assessment, Resident 1 was unable to raise their right arm. LVN D stated that Resident 1 required a hospital evaluation; however, before emergency medical services (EMS) could be contacted, a family member transported Resident 1 from the facility. LVN D confirmed that neither EMS nor the provider (Doctor) had been notified prior to Resident 1 leaving the facility, and that the provider was notified after Resident 1 had departed. During an interview on 4/16/26 at 3:35 pm, with the facility Temporary Director of Nursing (TDON), the TDON stated that when nursing staff are alerted to a resident's change in condition, they are expected to perform a comprehensive assessment, including evaluating signs and symptoms of a stroke, and promptly notify the provider of their findings. The TDON confirmed there was no documentation reflecting notification of the provider or Resident 1's family member until 4/13/26, and that the provider was notified only after Resident 1 had been transported from the facility by a family member to a local hospital. During an interview on 4/16/26 at 3:50 pm, with the Administrator (ADMIN), the ADMIN confirmed there was no nursing documentation that a nurse assessed Resident 1 for a possible stroke or notified his doctor on 4/11/26 or 4/12/26, when RN B and LVN D had knowledge that Resident 1's condition had changed. The ADMIN stated that when the staff report a resident's change in condition to nursing staff, the expectation is that an assessment is completed, documented, and the provider is notified of the findings. During an interview on 5/27/26 at 10 am, with the facility Nurse Practitioner (NP), the NP stated that when nursing staff are alerted to a resident exhibiting stroke like symptoms, the expectation is that the resident is immediately assessed and that the provider promptly notified. The NP stated that had they been notified of possible stroke symptoms, they would have immediately directed the resident to the hospital for emergency medical evaluation, as timely intervention is critical and delays can result in permanent neurological damage. The NP confirmed they were not notified of the resident's stroke like symptoms until after Resident 1 had already been transported from the facility by a family member to a local hospital. During a review of Resident 1's medical record titled, Progress Note - Alert Note, dated 4/13/26, indicated that the receptionist notified nursing staff that a family member had removed Resident 1 from the facility and reported Resident 1 was exhibiting signs and symptoms of a stroke, including arm weakness and changes in speech. The family member reported they were transporting the resident to the local hospital. The progress note indicated the nurse practitioner was notified and that Resident 1 left the facility at approximately 1:15 pm.

Based on interview and record review, the facility failed to ensure that the physician's orders for psychiatric evaluation and treatment were implemented and incorporated into the care plan for two of the three residents (Residents 1 and 2). This failure resulted in Resident 1 and 2 not receiving mental health evaluation and had the potential for both residents not to reach their highest practicable level of mental and psychosocial well-being.Findings: A record review of the facilities policy and procedures titled, Behavioral Assessment, Intervention and Monitoring dated 2/2025, indicated: - Behavioral symptoms are identified using facility approved behavioral screening tools and a comprehensive assessment. - Behavior is the response of an individual to a wide variety of factors. These factors may include medical, physical, functional, psychosocial, emotional, psychiatric, or environmental causes. - Behavior can be a way for an individual in distress to communicate unmet needs, indicate discomfort, or express thoughts that cannot be articulated. - The nursing staff identify, document, and inform the physician about changes in an individual's mental status, behavior, and cognition including onset, duration, intensity, and frequency of behavioral symptoms. - The Interdisciplinary Team (IDT- a coordinated group of healthcare professionals who collaborate to manage a resident's comprehensive care) thoroughly evaluates new or changing behavioral symptoms to identify underlying causes and address any modifiable factors that may have contributed to the resident's change in condition, including, emotional, psychiatric, or psychological stressors such as depression and loneliness; functional, social, or environmental factors such as alteration in routine, sleep disturbances, decline in ability to perform self-care or tasks that they could previously complete without help. 1. A record review of Resident 1's admission record, indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), cognitive communication deficit, and history of alcohol abuse. A record review of Resident 1's Minimum Data Set (MDS, resident assessment tool), dated 7/27/25, indicated, Resident 1's had no cognitive impairment and had depression. Resident 1's MDS Mood assessment indicated Resident 1 was feeling tired, had a poor appetite, and felt their life was a failure. MDS indicated Resident 1 expressed they had little interest or pleasure in doing things. A record review of Resident 1's hospital Discharge Summary dated 7/14/25 indicated Resident 1 was discharged with a medication order for Paroxetine (anti-depressant) for depression. A record review of Resident 1's physician order from 7/14/25 to 12/14/25, indicated, Resident 1 was not prescribed Paroxetine or other anti-depressant medications. A record review of Resident 1's physician order, dated 7/14/25, indicated Resident 1 had an order for Psychiatric evaluation and treatment per psychiatrist for management of psychotropic meds and Psychological services as needed. A record review of Resident 1's Care Plans dated 7/19/25, indicated a care plan was initiated due to Resident sometimes feels lonely or isolated from those around them. A record review of Resident 1's Nurse Practitioner (NP) progress notes, dated 7/22/25, indicated that NP ordered a psychiatric referral to assess for depression. A record review of Resident 1's Physical Therapy (PT) progress notes, indicated, from 7/19/25 to 8/9/25, Resident 1 refused PT 6 out of 15 times. PT progress notes indicated Resident 1 had low motivation and required maximum encouragement to participate in therapy. A record review of Resident 1's Occupational Therapy (OT) progress notes, dated, from 7/30/25 to 8/1/25, and 8/6/25 to 8/8/25, Resident 1 refused to get out of bed. OT progress note, dated 8/7/25, indicated that the nursing was made ware of Resident 1's Lack of participation. A record review of Resident 1's care plans indicated a care plan was initiated on 9/4/25 for episodes of refusing showers. A record review of Resident 1's Social Services (SS) progress note, dated 11/6/25, indicated, Resident 1 immediately shut down and did not respond verbally when Family member (FM) notified him of the intent to file for divorce. During an interview on 1/29/26 at 11:51 am with CNA A, CNA A stated that Resident 1 was upset that FM was divorcing them and sometimes asked, Why did FM leave me here?. CNA A stated Resident 1 minimally participated in personal hygiene care. During a concurrent interview and record review with the Social Serves Director (SSD) on 1/29/26 at 12:26 pm, Resident 1's admission assessment was reviewed. When asked if Resident 1 had received any type of counseling or psychological evaluation, SSD stated, No. SSD confirmed that Resident 1 was identified to have depression during admission assessment. When asked about Resident 1's emotional state after Resident 1 was informed about FM wanting a divorce, SSD stated Resident 1 shut down and wouldn't talk to anyone. SSD confirmed that the facility did not initiate a new care plan or change in condition. During an interview with Director of Nursing (DON) on 1/29/26 at 1:23 pm DON stated Resident 1's orders for Paroxetine were discontinued by the NP upon admission [DATE]). DON confirmed Resident 1 was not prescribed medications for treating depression from 7/15/25 to 12/14/25. DON confirmed Resident 1 had orders for a psychiatric evaluation dated 7/22/25. DON confirmed Resident 1 should have been evaluated by psychiatry following their admission MDS assessment which identified depression. During an interview with DON on 2/5/26 at 2:02pm DON stated, Resident 1's psychiatric referral Got away from them and confirmed Resident 1 had no psychiatric services while at the facility. During a concurrent interview and record review with NP on 2/5/26 at 3:15 pm NP stated, they avoid prescribing Paroxetine for Residents due to the medicine's anticholinergic (dry mouth, constipation, urinary retention, blurry vision, and confusion) effects. NP stated at the time of admission Resident 1 did not want to continue Paroxetine however Resident 1's MDS Mood assessment indicated depression, and a new psychiatric referral was ordered on 7/22/25. NP verbalized that they were unaware that Resident 1 had not been evaluated by psychiatry and acknowledged Resident 1's psychiatric referral was not followed up on by the nursing staff or the clinicians. 2. A record review of Resident 2's admission Summary Report, indicated that Resident 2 was admitted to the facility on [DATE] to with diagnoses of major depressive disorder, cognitive decline, and cancer. A record review of Resident 2's MDS Cognitive and Mood assessments, dated 11/15/25, indicated Resident 2 had mild cognitive impairment and depression. Mood assessment indicated Resident 2 had expressed that they felt bad about themselves, down and depressed, having little pleasure in doing things, and difficulty staying asleep. A record review of Resident 2's physician order, indicated that Resident 2 had a psychiatric referral, evaluation, and treatment orders, dated 11/7/25 and 12/15/25. No psychiatric evaluations were found in Resident 2's medical record. A record review of Resident 2's NP progress notes dated 11/7/25 indicated, Resident 2 had orders for monitoring for signs and symptoms of depression as evidenced by episodes of crying. A record review of Resident 2's NP progress notes dated 12/15/25 indicated, Resident 2 had been monitored for sign and symptoms of depression as evidenced by poor oral intake. During a concurrent interview and record review with Registered Nurse (RN) B on 2/6/26 at 10:40 am, Resident 2's medical record was reviewed. RN B was unable to locate any documentation regarding Resident 2 having a psychiatric evaluation or treatment. RN B stated whoever received the order for psychiatric referral is responsible for placing the order in the electronic health record (EHR) and to communicate to the appropriate staff to coordinate care. During an interview with Activities Assistant (AA) on 2/6/26 at 11:35 am, AA stated, on Monday (2/2/26) Resident 2 was upset and crying. AA stated Resident 2 told them that they were upset because they were dying. During an interview with SSD on 2/6/26 at 11:40 am, SSD stated, [Resident 2] does get emotional and had episodes of crying.

Based on observation, interview and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety when: Several kitchenware stacked wet, and few kitchenware had oily substances and stored in the clean and ready-to-use areasTwo cooking pans were not well maintainedOne kitchen staff verbalized the process of the manual dishwashing with 3-compartment sink incorrectlyThe arrangement of the food stored in the walk-in refrigerator was not in a food safety mannerOne kitchen staff did not have hair restraint to cover the facial hairResidents' food in residents' food refrigerator found did not store and label properly These failures had the potential to cause food contamination which could cause illness to the medically vulnerable residents who consumed food from the kitchen and resident refrigerator in the facility. There were 117 out of 117 residents who consumed food from the kitchen.Findings:1. During an observation and concurrent interview with Dietary Aide (DA N), DA N on 1/6/26, at 9:45 a.m., was putting away dishes on racks and stated the racks were for dry and clean dishes and kitchenware should be completely dried before they are stored away. DA N stated she was responsible for checking the dishes and kitchenware to ensure they were clean and dry before stored on the racks. DA N confirmed the following items were stacked wet:-8 of 4-quart (fluid volume measurement) plastic containers-1 of 6-quart plastic container-1 of 12-1quart plastic container-1 of 3-gallon (fluid volume measurement) plastic container-5 plastic pitchers-5 plastic pitcher lids-3 plastic sippy cupsAn observation and concurrent interview with Certified Dietary Manager (CDM) was conducted on 1/6/26, at 10:10 a.m., observed there were issues found on the rack as followed:5 of full sheet metal pans (stacked wet; 3 of 5 had white substances on inside)8 of 1/6 sheet metal pans (stacked wet)11 of 1/3 sheet metal pans (stacked wet)2 of 1/2 sheet metal pans (stacked wet)CDM confirmed and stated the three pans were not clean and the substances looked like pan coating spray. CDM also stated all dishes, pot, and pans should be air-dried before stored away. CDM stated the wetness on the dishes would create problems.During an interview with Registered Dietitian (RD), on 1/8/26 at 3:01 p.m., RD stated the dishes and kitchenware should be air-dried before being stored away. She further stated they should be clean and checked before being stored away. RD stated the reason for air-dried was to prevent bacteria growth by the moisture.A review of facility policy and procedure (P&P) titled, Dishwashing, dated 2023, indicated, .Dishes are to be air dried in racks before stacking and storing.A review of facility P&P titled, Sanitation, dated 2023, indicated, .All utensil, counters, shelves, and equipment shall be kept clean.2. During an observation and concurrent interview with CDM on 1/6/26 at 10:11 a.m., two cooking pans (10 and 16) with coating found significant deep scratches on the coating cooking surfaces. In addition, both pans had brown substances on the cooking surfaces. CDM confirmed and stated she was aware of the scratches and they were old and should be discarded.A review of facility P&P titled, Sanitation, dated 2023, indicated, .All utensil. and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks, and chipped areas.According to 2022 FDA (Food and Drug Administration) Food Code, on section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, the document indicated (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. 3. During an interview with KS on 1/6/26 at 9:35 a.m., KS stated if the dishwashing machine was not working, they would use the 3-compartment sink to perform manual dishwashing. KS verbalized the process to wash, rinse, sanitize and air-dry. KS did not know the water temperature of the wash and rinse procedures. KS stated that after the dishes were washed and rinsed, they would submerge into the sanitizer for 5-10 minutes. KS stated the concentration of the sanitizer (quat ammonia) should be 300 ppm and he read the poster and restated it should be 150-400 ppm.During an interview on 1/6/26 at 9:41 a.m., CDM acknowledged KS did not know the wash and rinse water temperature for the 3-compartment sink dishwashing procedure. CDM stated the temperature should be at least 110 F for washing and rinse water. CDM acknowledged KS stated 5-10 mins for the immersion time for the dishes in the sanitizer, CDM stated it should be one minute. CDM stated KS had been trained but never practiced the procedure of 3- compartment sink dishwashing yet. CDM stated however, KS should have knowledge of the 3-compartment sink dishwashing procedure in case of emergency.During a follow up interview with RD and CDM on 1/8/26 at 3:01 p.m., RD stated KS had not practiced the 3-compartment sink process yet. CDM stated she did not know if KS got the training regarding the 3-compartment sink dishwashing when he was newly hired. CDM and RD agreed and stated KS should know the process just in case the dishwashing machine was not working. CDM stated she would do an in-service for KS with return demonstration to ensure KS knows the process.During an interview with CDM on 1/8/26 at 3:35 pm, CDM stated she did not have any in-service record for the 3-compartment sink because the in-service had not been done.A review KS's employee file and KS's date of hire was on 5/20/25. KS's file included a document titled, Dietary Aide Competency Assessment, completed on 5/23/25 for KS, completed by CDM. It did not show 3-compartment sink dishwashing to be available for KS to be evaluated.A review of facility P&P titled, 3-Compartment Procedure for Manual Dishwashing, dated 2023, indicated the process involved washing, rinsing, sanitizing, and air-dried, and .sanitizer solution.must read 150-400 ppm.immerse all washed items (in the sanitizer solution) for at least 1 minute (60 seconds) .A review of job description titled, Certified Dietary Manager, revised July 2024, indicated, Duties and Responsibilities.conduct departmental performance evaluations in accordance with the facility's policies and procedures.Review and check competence of personnel and make necessary adjustments/corrections as required or that become necessary.Assist in developing, implementing and maintaining an effective orientation program that orients the new employee to the department, facility policies and procedures and to his/her job position and duties.4. During an observation of walk-in refrigerator on 1/06/26 at 10:24 a.m., there were issues with food storage arrangements found as followed:a full sheet pan of ready-to-eat raspberry jello stored on the bottom level of shelf next to thawing raw ground porkthree boxes of fully cooked sliced bacon stored on the same bottom level of shelf next to the thawing raw chickenA concurrent review of poster located on the refrigerator titled Refrigerate For Safety, indicated the arrangement of the refrigerated food for the top to bottom shelves based on the food's internal temperature. The arrangement as followed:First level: Ready-to-eat (Fruits and vegetables, cheese, deli meat)Second level: Cooked fruits and vegetables (135 degrees Fahrenheit (F)Third level: Whole beef, pork, and seafood (145 degrees F)Fourth level: Ground beef or pork, Fish nuggets or sticks, and cubed or Salisbury steak (155 degrees F)Fifth level: Poultry, stuffed beef, pork, and seafood, stuffed pasta (165 degrees F)During an interview with CDM on 1/6/26 at 10:39 a.m., CDM confirmed and stated the ready-to-eat and cooked food should not be stored at same level of raw meats.A review of facility provided undated document titled, Store Foods in the following order to prevent cross-contamination, it indicated food should store in the arrangement from the top to the bottom: Ready-to-eat food, whole raw fish, whole raw meat, raw ground meat, and raw poultry.5. During observation of dishwashing 1/6/26 at 9:29 a.m., it was noted KS had mustache and beard at the chin without wearing facial hair/beard net.During an interview on 1/6/26 at 10:44 a.m., CDM confirmed KS mustache and beard without any hair restraint. CDM stated they had the beard net available at the door and KS should have covered his facial hair.A review of facility P&P titled, Dress Code, dated 2023, indicated, .If applicable, beards and mustaches (any facial hair) must wear beard restraint .6. During an interview on 1/6/26 at 11:23 a.m., with CDM, when asked about the Resident food refrigerator and food brought in from outside the facility, CDM stated dietary was responsible for monitoring the temperature of the residents' food refrigerator every morning and dietary staff recorded the refrigerator/freezer temperature on the temperature log. CDM stated dietary restocked the snacks (for example, sandwiches, hummus, yogurt, etc.) in the resident's food refrigerator. The dietary staff would check the cleanliness of the refrigerator during restock and would clean as needed. The dietary staff was responsible for cleaning the refrigerator every week. CDM stated dietary was not responsible for monitoring the residents' food from outside, and the nursing staff had that responsibility.During an observation of the residents' food refrigerator (located in the utility room) and concurrent interview with Infection Control Nurse (IP) on 1/6/26 at 3:32 p.m., IP stated the food from outside and from family (cooked from home) could be kept in the residents' food refrigerator for 72 hours. When the food was brought in, the nursing staff should label with residents' names, date received and the use-by date. IP stated nurses were responsible for monitoring the food. Observed there was a poster on the refrigerator, stated, Food Belonging to A Resident Must Include their: Name, Room Number, Opened Date, use by date.Items improperly labeled or personal staff items will be discarded. IP stated she was not sure how long the food items could be kept in the residents' food refrigerator if they were opened. She further stated if the food items were open, then the staff should put an opened date on it.Findings in Refrigerator section and concurrent confirmation with IP:one opened one-gallon iced tea (no opened date, manufacturer's expired date of 1/27/26) (IP stated it should have an opened date and would follow the manufacturer's expired date)a bottle (96 oz.) of almond milk with expired date of 1/6/26 (IP stated the almond milk dated 1/6/26, today was last day and should be discarded)a jello cup with expired date of 1/5/26 (IP stated it was expired and should be discarded)a yogurt cup with expired date of 12/29/25 (IP stated it was expired and should be discarded)a tray of 14 prepacked hummus dips with used by date of 12/22/25 (IP stated the use by date was 12/22/25 on the tray and the hummus cups were expired and should be discarded)Freezer section, found:an unopened pack of [NAME] chocolate cups (no resident's name or room number) (with manufacturer expired date of 8/2025) (IP stated the chocolate package without name and it was expired; it should be discarded)an opened box with three sherbet tubes, used by date 12/4/25 (IP stated it was expired and should be discarded)one opened tub of blue bunny ice cream (no resident's name or room number, and no opened date) (IP stated there was no name on the ice cream and no opened date, and it should be discarded)A review of facility P&P titled, Foods Brought by Family/Visitors, revised 10/2017, indicated, .Perishable food must be stored in a refrigerator and labeled with the resident's name, item and use by dates.The nursing staff will discard perishable foods on or before the use by date. The P&P did not indicate opened date as compared to the poster on the residents' food refrigerator stated, Food Belonging to A Resident Must Include their: Name, Room Number, Opened Date, use by date.Items improperly labeled or personal staff items will be discarded.

Based on observation, interview and record review, the facility failed to provide care in a manner and in an environment that promoted maintenance of quality of life for 9 out of 33 sampled residents (Resident 30, Resident 33, Resident 50, Resident 73, Resident 102, Resident 117, Resident 122, Resident 124, Resident 132) when:Staff spoke a non-English language in resident rooms during resident care when English was the residents' primary language.Resident 73 was not able to use eating utensils to eat his meal and had to use his hands. These practices had the potential for residents to not have their right for dignity, respect, and negatively impact on residents' physical, mental, and psychosocial wellbeing.Findings: During a review of facility policy titled, English Only Rule (undated) indicated, it was the facility's policy that staff only spoke English . in resident rooms . and in any area of the facility that a resident could hear staff speaking. The English Only Rule, indicated, a violation of this policy was a violation of resident rights and that when staff signed the document, they understood, speaking in a language the resident did not understand could cause fear, confusion, and disturb residents. During a review of the facility's policy titled, Resident Rights dated 12/1/21, indicated, Employees shall treat all residents with kindness, respect, and dignity. 1.During a review of the facility's record titled, Resident Council (an organized group of residents that met regularly to discuss and address concerns regarding their rights) meeting notes, dated 9/8/25 and 11/13/25, indicated, residents of the facility voiced concerns when facility staff did not speak English in their rooms, the hallways, and at the nurse's station. During a review of the facility's record titled, Resident Compliment or Concern document, dated 9/10/25, indicated the Director of Staff Development (DSD) provided education to facility staff regarding the facility policy for speaking English and the issue was resolved on 9/12/25. During a review of the facility's record titled, Resident Compliment or Concern document, dated 11/10/25, indicated the DSD provided education to facility staff regarding the facility policy for speaking English and the issue was resolved on 11/12/25. During a review of Resident 30's medical record indicated that Resident 30 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes (high blood sugar), obesity, and high blood pressure. During an interview on 1/6/26 at 9:08 am, Resident 30 stated that staff will come into his room and they will be talking in a language other than his own primary language and that he does not like it when they do that. Resident 30 states that this happens most often on the night shift. During a review of Resident 33's medical record indicated that Resident 33 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes, stroke, and difficulty sleeping. During an interview on 1/6/26 at 11:10 am, Resident 33 stated that staff will come into his room and they will be speaking [NAME] to each other. He did not like this as it made him feel like the staff were talking about him. During a record review of Resident 50's admission record, indicated that Resident 50 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes, peripheral vascular disease (a circulation disorder where narrowed, blocked, or spasming blood vessels outside the heart and brain reduce blood flow to limbs and organs), and aortocoronary bypass graft (heart surgery that reroutes blood flow around blocked coronary arteries by grafting healthy blood vessels from another part of the body to create new pathways). During an interview on 1/6/26 at 8:45 am, Resident 50 confirmed that staff spoke [NAME] in her room during resident care. Resident 50 stated she did not like it. During a record review of Resident 102's admission record, indicated that Resident 102 was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm of bone (a cancerous tumor that starts in bone cells), cognitive communication deficit (difficulty with talking, listening, or understanding due to problems with thinking skills), and generalized muscle weakness. During an interview on 1/6/26 at 8:24 am, Resident 102 stated that the staff often spoke a Different language in her room and she did not like it. During a record review of Resident 117's admission record, indicated that Resident 117 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease (the final stage of chronic kidney disease, where the kidneys lose almost all function), dialysis (a life-sustaining medical treatment that filters waste products and excess fluid from your blood when your kidneys can no longer do so), and hypokalemia (having abnormally low levels of potassium in your blood). During an interview on 1/6/26 at 8:41 am, Resident 117 stated [NAME] is being spoken on the floor and in our rooms. Resident 117 stated Administrator (Admin) was fully aware of this issue. Resident 117 stated she was frustrated because it made her feel like the staff spoke about her or one of her roommates. Resident 117 stated it made her feel isolated. Resident 117 stated she was the president of the resident council and this had been an issue discussed a lot of times during the monthly meetings. During a review of Resident 122's admission record, indicated that Resident 122 was admitted to the facility on [DATE] with diagnoses that included encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition), dementia (a progressive state of decline in mental abilities), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During an interview on 1/6/26 at 8:31 am, Resident 122 stated that the staff spoke another language in her room and she wished they would speak English, so she could understand if they were talking about her. During a review of Resident 124's admission record, indicated that Resident 124 was admitted to the facility on [DATE] with diagnoses that included fracture of right lower leg, pancytopenia (a lower-than-normal count of all three types of blood cells in the blood, resulting in increased infection risk, and bleeding issues), and cirrhosis of the liver (the liver becomes permanently scarred and damaged due to long-term injury). During an interview on 1/6/26 at 9:04 am, Resident 124 stated that staff spoke [NAME] in their room, and she had asked them to speak English many times. Resident 124 stated she would like to know if staff spoke about her because that would make her feel isolated. During a review of Resident 132's admission record, indicated that Resident 132 was admitted to the facility on [DATE] with diagnoses that included fractured femur (break, crack, or crush injury to the thigh bone), osteoporosis (a bone disease that makes bones thin, weak, and brittle), and anxiety disorder (mental health condition characterized by intense, persistent, and excessive worry or fear about everyday situations, going beyond normal occasional stress). During an interview on 1/6/26 at 9:00 am, Resident 132 stated staff spoke [NAME] in her room and it made her feel uncomfortable. Resident 132 stated she felt staff did not understand English when she expressed her wants and needs. Resident 132 stated she felt the quality of care from staff was diminished because of the language barrier. Resident 132 stated she has communicated her concerns with the Director of Nursing (DON) but did not receive feedback. During an interview on 1/6/26 at 8:52 am, Certified Nursing Assistant (CNA) A confirmed she has heard staff speak [NAME] in resident rooms. CNA A confirmed the facility's primary language is English, and she signed a form upon hire that required her to speak English in resident rooms. During an interview on 1/8/26 at 11:34 am with DSD, the DSD stated that the facility's expectation was for staff to treat the building as the residents' personal home. The DSD confirmed staff spoke [NAME] in resident rooms, and the residents have complained in resident council meetings. DSD stated his current interventions of staff in-services to adhere to the facility English only policy have not been effective. DSD confirmed staff were required to sign an English only document upon hire. DSD confirmed staff did not follow the English only policy and should have. During an interview on 1/8/26 at 12:01 pm with Director of Nursing (DON), the DON confirmed that residents felt disturbed and concerned that staff continued to speak in [NAME] in their rooms and in the hallways. DON confirmed staff was not following facility policy for English-only and stated that she wished staff cared more, but felt that the existing culture was creating resistance to change. During an interview on 1/8/26 at 2:46 pm with Admin, Admin acknowledged that staff spoke [NAME] in resident rooms and the residents had informed Admin that it made them feel uneasy and wondered if staff talked about them. The Admin confirmed that staff did not follow English-only policy and as they should have. 2.During a review of Resident 73's admission record indicated that Resident 73 was admitted to the facility on [DATE] with diagnoses which included stroke affecting his right side and abnormal mobility (difficulty with movement). During a review of Resident 73's quarterly Minimum Data Set (MDS - resident assessment tool), section GG (evaluates the resident's need for assistance with self-care and mobility activities), dated 11/2/25 , indicated that when eating, Resident 73 required 'Supervision or touching assistance' – a helper provides verbal cues and/or touching/steading and/or contact guard assistance as resident completes activities. Assistance may be provided throughout the activity or intermittently. During a concurrent observation and interview on 1/6/26 at 12:40 pm, Resident 73 was sitting at a table in the dining room eating his lunch. Resident 73 was eating with his left hand and had his silverware sitting on the right side of the plate. When asked if he wanted to eat his food with his hands and he said, No! and asked where the silverware was. Resident 73 had to be directed to where the silverware was on the table. No staff assisted Resident 73 with finding his silverware and some of his meal items still had lids on them. During an interview on 1/9/26 at 8:05 a.m. with the DON, the DON indicated that residents should not have to eat with their hands if they do not want to.

Based on observation, interview, and record review, the facility failed to ensure the medication administration error rate did not exceed 5% for 2 of 34 sampled residents (Resident 66 and Resident 89).1. For Resident 89, a licensed nurse administered canagliflozin (medication used to treat diabetes) not in accordance with Manufacturer's Specifications.2. For Resident 66, a license nurse administered two medications, spironolactone (used to help remove extra body fluid and swelling) and megace (a type of hormonal medication that increases appetite), not in accordance with Physician Orders, resulting in two sperate medication errors. As a result of this failure, 3 errors were identified of 25 opportunities during the observation of medication administration; the facility medication error rate was 12%. Findings: A review of facility policy titled Preparation and General Guidelines: Medication Administration, dated 8/2024, showed that Medications are administered as prescribed in accordance with good nursing principles and practices.1. During an observation of medication administration on 1/6/26 at 8:49 am, in Resident 89's room, Registered Nurse C (RN C) was observed to prepare and administer Resident 89's canagliflozin tablet medication by mouth. During an observation of Resident 89 on 1/6/26 at 8:49 am, in Resident 89's room, Resident 89 stated to RN C, Yes I've already eaten my breakfast, around 8 am. During an interview with RN C on 1/6/26 at 8:49 am, RN C confirmed that Resident 89 had already eaten breakfast, around 8 am that day. During a reconciliation of the observed medication administration with Resident 89's current physician orders indicated an order for Canagliflozin Oral Tablet 100 Milligrams (MG) Give 1 tablet by mouth one time a day for dm (Diabetes Mellitus). A review of Manufacturer's Specifications for Canagliflozin, indicated, The recommended starting dosage of Canagliflozin is 100 mg orally once daily to improve glycemic control, taken before the first meal of the day.During an interview with Director of Nursing (DON) on 1/9/26 at 9:58 am, the DON stated, I was not aware that Canagliflozin should be taken on an empty stomach. 2. During an observation of medication administration on 1/6/26 at 9:23 am, Licensed Vocational Nurse B (LVN B) was observed to administer Resident 66's medications. During this observation, LVN B was observed to not be wearing gloves during preparation, crushing, nor administration of potentially hazardous medications spironolactone and megace (Potentially hazardous medications are those that can alter your body's internal organs or hormones, and can be dangerous to handle without protective gear, especially when prepared or crushed, but are safe for the prescribed patient to take). During a reconciliation of the observed medication administration with Resident 66's current Physician Orders included the following orders:a) Oral tablet 25 milligram (mg) spironolactone (used to help remove extra body fluid and swelling), give 1 tablet by mouth two times a day for edema, use gloves when administering medication.b) megestrol acetate (a type of hormonal medication that increases appetite), suspension 400 mg/10 milliliter (ml). Give 10 ml by mouth one time a day, for appetite stimulant wear gloves when administering medication.During an interview with DON at 9:58 am, the DON stated Yes that nurse should have worn gloves for the spironolactone and megestrol, since they're hazardous.

Based on observation, interview and record review, the facility failed to ensure the menu was followed for the therapeutic diet (a modification of a regular diet, tailored to fit the nutritional needs of a particular person - may be part of a treatment or medical condition and usually prescribed by a physician) during the lunch meals on 1/6/26 and 1/7/26 when:A. During a dining observation on 01/6/26:Resident 35 was on soft and bite size (sb) texture diets (all foods must be soft and able to mash with a fork and chopped into pieces no larger than1.5 centimeters (cm) x 1.5 (cm) designed for residents who experience biting limitations but are able to chew food items for swallowing) received regular green salad instead of hot canned green beansResident 70 was on low fat and low cholesterol (lflc) diet (a diet designed to lower elevated levels of serum cholesterol and other lipids to reduce the risk of heart disease) received a cranberry crunch square instead of fresh fruit for dessertEight residents with sb and mince and moist (mm) texture diets (a diet soft, moist with excess fluid drained and minced to a size no larger than 4-millimeter x 15 millimeter designed for residents who experience biting, chewing, or swallowing limitations) did not receive hot canned green beans.B. During a meal service observation on 1/7/26Seven residents with 2g (gram) Na (sodium) diet (restricted sodium 2-2.5 g/day in diet to manage heart disease, renal disease, and hypertension) diet received 1 whole serving of cake, crisp fish with tartar sauce, tator tots with ketchup, instead of 1/2 serving of cake, baked fish with lemon wedge and salt free french fries without ketchup.24 residents with regular portions of CCHO (Consistent Carbohydrate) diet (a therapeutic diet to manage diabetic disease and/or to stabilize blood sugar level) diet should not receive dinner roll and margarine but they did.Resident 70 and Resident 114 with sb size texture diet received a whole regular dinner roll instead of soft and chopped rolls soaked in milk.Five residents with renal diet (diet used with renal insufficiency or with renal failure that are not on dialysis, a diet that regulates the dietary intake of sodium, potassium and protein to lighten the work if the diseased kidney) received oven crisp fish instead of baked fish.Four residents with lflc diet got tartar sauce for fish and margarine for roll instead of lemon wedge and no margarine.Eleven residents should have received dinner roll with their lunch meal did not receive them.Resident 17 and Resident 66 should have received a serving of cake with their meal who did not receive them.Resident 31 and Resident 117 with Renal 60g protein received three ounces (oz.) of fish instead of two oz.These deficient practices had the potential to result in compromising the medical and nutritional status of 57 residents for a census of 117 who consumed meals from the facility kitchen.Findings:A. During dining observation on 1/6/26, at 12:30 p.m. in the dining room, it was noted as followed:Resident 35 on sb diet received green salad and did not receive hot canned green beans. A concurrent review of the facility spreadsheet (a menu excel sheet that indicated what items and portions to be served for each prescribed diet) titled, Winter menus, Week 2 Tuesday, indicated sb diet should receive hot canned green beans, not green salad. Resident 70, on the lflc diet, received a cranberry crunch square. A concurrent review of the facility spreadsheet titled, Winter menus, Week 2 Tuesday, indicated lflc diet should receive 1/2 cup fresh fruit, not cranberry crunch square.Eight residents with sb and mm diet did not receive them. A concurrent review of the facility spreadsheet titled, Winter menus, Week 2 Tuesday, indicated sb and mm diet should receive hot canned green beans.B. During the lunch meal distribution on 1/07/26, beginning at 12:11 p.m., it was noted as followed:Seven residents with 2g Na diet received one whole serving of cake, crisp fish with tartar sauce, tator tots with ketchup. A concurrent review of facility spreadsheet titled, Winter menus, Week 2 Wednesday, indicated 2g Na diet should have received 1/2 serving of cake, baked fish with lemon wedge, and [NAME] free french fries with no ketchup.24 residents with regular portions of CCHO diet received dinner roll and margarine. A concurrent review of facility spreadsheet titled, Winter menus, Week 2 Wednesday, indicated CCHO diet should not receive dinner roll and margarine.Resident 70 and Resident 114 with sb size texture diet received a whole regular dinner roll instead of soft and chopped rolls soaked in milk. A concurrent review of facility spreadsheet titled, Winter menus, Week 2 Wednesday, indicated sb diet should have received a wheat roll that was chopped, soaked and drained.Five residents with renal diet received oven crisp fish instead of baked fish. A concurrent review of facility spreadsheet titled, Winter menus, Week 2 Wednesday, indicated renal diet should receive baked fish and tartar sauce.Four residents with lflc diet got tartar sauce for fish and margarine for roll. A concurrent review of facility spreadsheet titled, Winter menus, Week 2 Wednesday, indicated lflc diet should have crip fish with lemon wedge no margarine for the roll.Eleven residents should have received dinner roll with their lunch meal did not receive them. A concurrent review of facility spreadsheet titled, Winter menus, Week 2 Wednesday, indicated regular diets should have a wheat roll with margarine.Resident 17 and Resident 66 should have received a serving of cake with their meal who did not receive them. A concurrent review of facility spreadsheet titled, Winter menus, Week 2 Wednesday, indicated regular diets should have one serving apple hill cake.During an interview conducted with [NAME] 1 on 1/7/26, at 12:28 p.m., cook 1 confirmed and stated all crisp fish prepared were three oz. each. During meal distribution, noted Resident 31 and Resident 117 with Renal 60g protein received three oz. of fish instead of two oz. A concurrent review of facility spreadsheet titled, Winter menus, Week 2 Wednesday, indicated renal 60g protein should have two oz baked fish with tartar sauce.During an interview with Registered Dietitian (RD) and Certified Dietary Manager (CDM), on 1/7/26 at 2:20pm, RD and CDM acknowledged and confirmed the findings above. For the lunch meal during the dining observation on 1/6/26, RD reviewed the spreadsheet, she stated on 1/6/26 lunch meals, residents with sb and mm diet should get hot canned green beans. RD stated residents with sb texture diet should not get green salad but should get hot canned green beans. She acknowledged a resident with lflc diet who got cranberry crunch square, and concurrent review of spreadsheet, RD stated the resident should have received fresh fruit for dessert. Rd and CDM acknowledged the findings of the meal distribution on 1/7/26, there were residents with 2g Na received 1 whole serving of cake, crisp fish with tartar sauce, tator tots with ketchup, concurrent review of the spreadsheet, RD confirmed they should have got 1/2 serving of cake, baked fish with lemon wedge and salt free French fries without ketchup. There were residents with regular portion of CCHO diet who received a dinner roll and margarine, concurrent review of the spreadsheet, RD confirmed they should not receive dinner roll and margarine. There were residents with sb texture diet that received regular dinner rolls, concurrent review of the spread, RD confirmed and stated they should have received chopped roll soaked in milk. There were residents with Renal diet that received oven crisp fish, concurrent review of spreadsheet, RD confirmed they should have received baked fish. There were residents with lflc diet that received tartar sauce for fish and margarine for the roll, concurrent review of the spreadsheet, RD confirmed and stated they should have received lemon wedge for fish and no margarine. There were residents who should have received a dinner roll with their lunch meal that did not receive a roll. RD stated, they should have the roll as the spreadsheet indicated. There were residents who should have received a serving of cake, but they did not. RD stated, they should have received cake as indicated on the spreadsheet. There were residents on Renal 60g protein diet that received 3 ounces of fish instead of 2 ounces of fish, concurrent review of the spreadsheet, RD confirmed and stated renal 60 g protein diet should have received two ounces of fish.During a follow up interview on 1/8/26 at 3:01 p.m., RD stated the dietary staff needed to follow the spreadsheet/menu, recipe and the meal tickets (a ticket including resident's diet, date, allergies, specific food and beverage items, dislikes, and likes) to follow the residents' preferences. RD stated she and CDM needed to provide in-service and would implement a tool to monitor the staff for following spreadsheet/menu.A review of the facility's policy and procedure titled, Menu Planning, dated 2023, indicated, 4. The menus are planned to meet nutritional needs of residents in accordance with established national guidelines., Procedure 1. The facility's diet manual and diets are ordered by the physician should mirror the nutritional care provided by the facility. 2. Menus are written for regular and therapeutic diets in compliance with the diet manual.A review of the facility document titled, Job Description: Cook, revised July 2024, it indicated, .essential duties.inspect special diet trays to ensure the correct diet is served to the resident.review menus prior to preparation of food.prepare food in accordance with standardized recipe.planned menus and special diet orders.serve food in accordance with established portion control procedures

Based on observation, interview and record review, the facility was failed to ensure the two dietary staff had proper skill to prepare the appropriate texture for Soft and Bite Size (SBS) texture (chopped or cut into pieces size no larger than 1.5 centimeter(cm) by 1.5cm) and Mince and Moist (MM) texture (soft and moist (with all excess fluid drained), size no larger than 4 millimeters (mm) by 15 mm), food items.This deficient practice had the potential to increase risk for the residents with swallowing and/or chewing difficulties to choke and/or aspirate (a condition in which food, liquids, saliva, or vomit is breathed into the airway). There were 31 residents on sb size texture diets and seven residents on mm texture diets, out of the census of 117.Findings:An observation of preparation of food items with SBS texture and MM texture and concurrent interview with [NAME] (CK) M was conducted on 01/7/26 at 10:30 a.m. CK M understood stated she had three food items: carrot, tater tots and crisp fish to make SBS, MM and puree textures. CK M stated she had to prepare 35 servings of SBS, 12 servings of MM, and four servings of puree for each food item.Observation of the SBS carrot preparation:CK M scooped the carrot into the food processor without measurement and blended the carrot. The final product looked like lumpy puree with chunks of carrot. CK M did not measure or test the texture of the processed carrot. Observed CK M did not review the recipe while making the SBS carrot.Observation of the MM carrot preparation:CK M prepared a pitcher of 16 ounces (oz) vegetable broth and added 16 pumps of liquid thickener to make thickened broth. CK M scooped an unmeasured amount of carrots into the food processor and added 1/4 cup of the thickened broth, then blended. The final product looked like puree and gluey. CK M did not measure or test the texture of the processed carrot. Observed CK M did not review the recipe while making MM carrots.Concurrent review of the bottle of liquid thickener, the instruction indicated eight oz. (1 cup) of fluid should add eight pumps of liquid thickener to make extremely thick or pudding thick consistency.Observation of pureed carrots preparation: CK M scooped an unmeasured amount of the carrots in the food processor, then she added unmeasured thickened vegetable broth, and blended. The blending time was longer than MM carrot. The texture was smoother without lumps. CK M did not test the texture of the pureed carrots and did not review the recipe while making the puree.Observation of the SBS tater tots preparation:Observed CK M scooped the tater tots into the food processor unmeasured and then blended. The final product looked like dry minced potato. CK M did not measure the size and test the final product. Observed CK M did not review the recipe while making the SBS tater tots.Observation of the MM tater tots preparation:CK M prepared 3/4 cup of milk and added 16 pumps liquid thickener in a measuring pitcher to make thickened milk. CK M scooped the tater tots into the food processor without measurement and added 3/4 cup of thickened milk and blended. The final product looked like puree with some lumps and sticky. CK M did not measure the size and test the final product. Observed CK M did not review the recipe while making the mm tater tots.Observation of the pureed tater tots preparation:CK M scooped the tater tots into the food processor without measurement. CK M added an unmeasured amount of milk into the food processor, then blended. The final product looked like mashed potato. Observed CK 1 did not review the recipe while making the pureed tator tots.Observation of the SBS crisp fish preparation:CK M counted 35 portions of crisp fish and added into the food processor and blended. CK M confirmed and stated each piece of the fish was three oz. The final product looked like dry minced fish. CK M did not measure the size and test the final product. Observed CK M did not review the recipe while SBS fish.Observation of the MM crisp fish preparation:CK M prepared one (eight oz.) cup of milk and added 16 pumps of liquid thickener to make thickened milk. CK M then put in 12 pieces of fish and add 1/2 cup of thickened milk in the food processor and blended the fish. The final product looked like coarse puree fish with lumps and was sticky when CK M scooped up the fish. Observed CK M did not measure the size or test the final product. CK M did not review the recipe while making the MM crisp fish.Observation of the pureed crips fish preparation:CK M put four pieces of fish and added 1/2 cup of thickened milk in the food processor and blended. The blending time was longer than the MM fish. The final product looked smooth and pudding like fish. Observed CK M did not test the puree fish and did not review the recipe while making the pureed fish.During an interview with Registered Dietitian (RD) on 1/7/26 at 11:26 a.m., RD stated the facility started the transition from the old diet to IDDSI diet (The International Dysphagia Diet Standardization Initiative (IDDSI) is an international organization and it developed a standard that can be used to describe the characteristics of foods and drinks - from the point of view of a person with swallowing difficulties) on 12/1/25. Dietary staff had training of IDDSI with liquid thickener company representative. RD stated the representative came in once to do the training for all the dietary staff and Certified Dietary Manager (CDM). RD stated she attended as well. RD stated she had a brief in-service about IDDSI with the nurses and Certified Nurse Assistants (CNA)s. RD further stated the MM texture should not be sticky or gluey because those textures would be hard for the resident to swallow when they have problems with swallowing.RD stated CK M should measure and test after final products of each texture was done, A concurrent review of the recipes of carrot, tater tots and crisp fish, RD stated all the SBS texture should be chopped into the measurement of 1.5 cm by 1.5 cm in size and should perform testing to confirm the texture was correct. RD further stated all the MM texture food should be minced into the measurement of 4 millimeters (mm) by 15 mm by the food processor and moistened with gravy or sauce if needed. RD stated MM texture also needed to perform testing to confirm the texture was correct. For the puree texture, RD stated CK M should perform testing to confirm the texture is correct, RD confirmed and stated CK M did not prepare the SBS and MM texture correctly without measurement and confirmation testing and there was no confirmation testing for the puree texture.An observation and concurrent interview with Dietary Aide (DA) O on 1/7/26 at 11:39 a.m. was conducted. DA O stated she was prepping SBS dinner rolls, and observed DA O cut the rolls in half and added a small amount of milk in small bowl and let the rolls soak, then she drained the milk. DA O did not perform measurement and testing of the SBS rolls and did not review the instruction or recipe during the preparation.An observation and concurrent interview with DA O on 1/7/26 at 11:56 a.m. was conducted. DA O stated she was preparing MM dinner rolls and observed DA O put the rolls in the food processor and added an unmeasured amount of milk and then blended. DA O used a strainer to drain the milk. The final product was unable to measure and looked like oatmeal. DA O did not measure and test of the MM rolls and did not review the instruction or recipe during the preparation.An interview and concurrent recipes/diet manual (a written guide for healthcare facilities that provides guidelines for diets modified for consistency, specific nutrients, allergies, or medical conditions) review with RD was conducted on 1/7/26 at 12:02 p.m. RD stated the SBS dinner rolls should be chopped in the size of 1.5 cm by 1.5 cm and then soaked with milk and should not be cut in half. RD further stated the MM rolls should be chopped or processed to have a measurement of 4 mm by 15 mm in size and soaked in milk and then drained. RD agreed DA O did not make the SBS and MM rolls correctly and stated DA O needed to follow the instructions.A review of the IDDSI training report indicated CK M and DA O completed the training on 10/22/25 and 10/29/25 respectively. The training included using measurement and critical tests to confirm the appropriate textures for different food items as followed:For puree, the appearance indicated no lumps and passed the ford drip test (food sits in a mound above the dinner fork and does not drop or flow continuously through dinner fork) and spoon tilt test (food can hold shape on teaspoon and slides off spoon with little food left on the teaspoon).For MM texture, the appearance should be equal or less than 4 mm by 15 mm and passed the fork pressure test (food can be easily mashed with little pressure from a dinner fork) and the spoon tilt test.For SBS texture, the appearance should be equal or less than 1.5 cm by 1.5 cm and passed the fork/spoon pressure test (when pushing down on 1.5 cm by 1.5 cm food sample with a dinner fork or teaspoon, with enough pressure that the thumb nail turns white, the food can be squashed and will not return to original shape).A review of the departmental document titled, Recipe: Seasoned Carrots, dated 2025, indicated, .IDDSI #6/Soft & Bite Size: soft, chop into pieces = 1.5 cm by 1.5 cm in size.utilize the critical tests and IDDSI audit to confirm texture meets level #6 specifications.IDDSI #5/Mince & Moist: Mince before or after cooking. Measure desired # of servings into a food processor. Mince until food is in pieces = 4 mm by 15 mm. Moisten with gravy/sauce at appropriate thicken if needed.utilize the critical tests and IDDSI audit to confirm texture meets level #5 specifications.IDDSI #4/Puree: .Puree following the pureed recipe.Utilize the critical tests and IDDSI audit to confirm texture meets level #4 specifications.A review of the departmental document titled, Recipe: Hashbrowns or Fried Potatoes (same as tater tots), dated 2025, indicated, .IDDSI #6/Soft and Bite Size: Soft, no skin, chop into pieces = 1.5 cm by 1.5 cm in size. Be careful not to puree the potatoes.Utilize the critical tests and IDDSI audit to confirm texture meets level #6 specifications.IDDSI #5/Mince & Moist: Soft, no skin. Mince until the food is in pieces = 4 mm by 15 mm. Be careful not to puree the potatoes.IDDSI #4/Pureed: .Puree following the pureed recipes.utilize the critical tests and IDDSI audit to confirm texture meets level #4 specifications.A review of departmental document titled, Recipe: Oven Crisp Fish, dated 2025, indicated, .IDDSI #6/Soft & Bites Size: Tender, chop into pieces = 1.5 cm by 1.5 cm in size. Moisten with broth if needed.IDDSI #5/Mince & Moist: Tender, measure desired # of servings into the food processor. Mince until food is in pieces = 4 mm by 15 mm. Moisten with sauce at appropriate thickness if needed. Utilize the critical tests and IDDSI audit to confirm texture meets level #5 specifications.IDDSI #4/Pureed: . Puree following the puree recipes.utilize the critical test and IDDSI audit to confirm texture meets level #4 specifications.A review of Diet Manual, dated 2025, indicated grain (included baked goods) with IDDSI #5 Minced and Moist should be .without any added texture, moistened entirely through, that meet size specifications (no larger than 4 mm x 15 mm), with all excess fluid drained, must pass IDDSI #5 testing requirements (i.e. size, fork pressure, and spoon tilt tests) . It also indicated grain (included baked goods) with IDDSI #6 Soft and Bite size should be .without any added texture, moistened entirely through, that meet size specifications (no larger than 1.5 cm x 1.5 cm), with all excess fluid drained.must pass IDDSI #6 testing requirements (i.e. the fork test, for pressure tests) .A review of the facility document titled, Job Description: Cook/Kitchen Staff, revised July 2024, it indicated, .review menus prior to preparation of food.prepare food in accordance with standardized recipe.A review of facility document titled, Job Description: Registered Dietitian, revised July 2024, indicated, .Develop and evaluate regular and therapeutic diets including texture of foods and liquids to meet the specialized needs of residents.

Based on Interview and Record Review, the facility failed to ensure that 1 of 34 sampled residents (Resident 8) were free of Unnecessary Medication, when Resident 8 had inaccurate diagnoses indications for receiving divalproex sodium, a psychotropic medication. This failure resulted in Resident 8 continuing to receive unnecessary psychotropic medications. Findings:A review of facility policy titled Medication Monitoring & Management, dated 8/2014, showed When a resident receives a new medication, the medication order is evaluated for the following . A written diagnosis, an indication, and/or documented objective findings support each medication.A review of Resident 8'S medical records titled admission Summary, indicated that Resident 8 was admitted to the facility on [DATE] with diagnoses included Unspecified Atrial Fibrillation (an irregular heartbeat), Metabolic Encephalopathy (confusion caused by illness), Chronic Obstructive Pulmonary Disease (a lung disease that causes breathing problems), Chronic Diastolic (Congestive) Heart Failure (weakly pumping heart that causes breathing problems), and Unspecified Psychosis (hearing or seeing things that are not real) not due to a substance or known physiological condition.A review of Resident 8's Minimum Data Set (MDS, an assessment tool), dated 8/22/25, indicated Resident 8 had multiple past episodes of psychosis and hallucinations. This record also indicated that Resident 8 had a Brief Interview for Mental Status (BIMS) score of 99 (unable to participate in interviews, and were severely cognitively altered.)During an interview with Registered Nurse K (RN K) on 1/8/26 at 1:46 pm, RN K stated they had taken care of Resident 8 many times in the last year, and knew them well. RN K stated that Resident 8 had previous episodes of psychosis and hallucinations, with behavioral outbursts. RN K stated that Resident 8 had no history of seizures.A review of Resident 8's medical record titled Order Summary, dated 1/8/26, indicated the following prescription: divalproex sodium (used to treat certain types of seizures) oral tablet extended release (ER) 24 hour 500 milligrams (MG), give 1 tablet by mouth one time a day for seizures, wear gloves when administering meds swallow whole do not crush/chew/open. The record indicated that Resident 8 began taking divalproex sodium on 9/30/25, and continued to, as of 1/8/26.During an interview with Director of Nursing (DON) on 1/9/26 at 9:58 am, the DON acknowledged that Resident 8 had an incorrect diagnosis of seizures documented as the indication for receiving divalproex sodium.During a concurrent interview and record review with Nurse Practitioner D (NP D) on 1/8/26 at 3:34 pm, NP D identified and confirmed the current medication orders for Resident 8 included Divalproex Sodium, and also confirmed the active diagnoses for Resident 8. NP D stated I see no seizure diagnosis for this Resident. NP D went on to say [Resident 8] has no history of seizures, that medication should have been for behavior. NP D also stated the order for Divalproex Sodium was entered incorrectly.

Based on observation, interview, and record review, the facility failed to provide the necessary care related to activities of daily living (ADL) to maintain good personal hygiene when one of three sampled residents (Resident 26) fingernails were long, untrimmed, jagged, and had dirt and food under and on top of the nails. This failure had the potential for self-injury and infection due to unkept nails.Findings: During a review of the facility policy titled Fingernails/Toenails, Care of, dated 2/2018 indicated that nail care includes regular cleaning and trimming, trimmed nails prevent injury, and can aid in the prevention of skin problems. During a review of Resident 26's medical record indicated that Resident 26 was admitted to the facility on [DATE] with diagnoses that included muscle weakness, infection of the lower leg, and heart failure (the heart can't pump enough blood and oxygen to meet the body's needs). Resident 26's care plan dated 12/17/25 indicated that Resident 26 has an ADL self-care performance deficit related to weakness, poor endurance, and poor balance. During a review of facility Comprehensive Certified Nursing Assistant (CNA) Shower Review sheets for Resident 26, indicated that on 1/3/26 Resident 26 did not have his fingernails cut/cleaned. During an observation on 1/6/26 at 11:16 am, in Resident 26's room, Resident 26's nails were long, jagged, and dirty under the nails. During a concurrent observation and interview on 1/7/26 at 2:31 pm, in Resident 26's room, Resident 26 stated that he could not remember the last time staff cut his nails, but that staff could cut his nails and wash his hands any time they wanted. Resident 26 stated that he had two nails that were broken and jagged and needed to be cut. Resident 26's fingers were long, hand dirt and food on top and under them. During a concurrent observation and interview on 1/7/26 at 2:33 pm with CNA H, while in Resident 26's room CNA H confirmed that Resident 26's hands were dirty and had two nails that we broke and jagged. CNA H stated that they would have someone come in and clean Resident 26's hands and cut his nails. There was no documentation noting that any nail care had been done for Resident 26 on 1/7/26.

Based on observation, interview, and record review, the facility failed to follow its enteral tube (delivers liquid food, medication, and fluids directly into the digestive system (stomach or intestines) when a person can't eat or swallow safely) medication administration policy when staff did not flush enteral feeding tubing with purified or distilled water as required. Instead, staff used tap water to flush the tubing.This deficient practice had the potential to introduce contaminants and place immunocompromised residents at risk for infection.Findings: During a review of the facility's policy and procedure titled, Enteral Tube Medication Administration, revised August 2014, it was indicated that warm purified, or sterile water is to be used for dissolving medications and flushing tube. During a review of Resident 2's medical record indicated Resident 2 was admitted to the facility on [DATE] with diagnosis including: cerebral infarction (stroke), dysphagia (difficulty swallowing), gastrostomy tube (a tube inserted through the wall of the abdomen directly into the stomach) for nutrition and hydration. A review of Resident 2's physician orders, indicated that it included flushing tube with 75 milliliters (ml) of water every 6 hours. During an observation on 1/8/2026 at 9:15 am in Resident 2's room, Registered Nurse (RN) L was observed using tap (sink) water to dissolve and flush medications through Resident 2's enteral feeding tube. During an interview with RN L on 1/10/26, at 10:00 am, RN L stated that she uses water from the sink for administering medications via an enteral tube as her standard of practice. Rn L stated that she has been following this method for the past 14 years and has not received any instruction on alternative procedures. During a concurrent interview and record review on 1/10/26, at 10:00 am, with the Director of Nursing (DON), the facility's policy and procedure titled, Enteral Tube Medication Administration, revised August 2014, was reviewed. The DON verified that the policy requires the use of warm purified, or sterile water for flushing enteral feeding tubes during medication administration. The DON acknowledged that the facility's current practice was to use tap water or water obtained from the kitchen for flushing enteral feeding tubes and stated the policy would need to be updated to reflect current facility practice.

Based on observation, interview, and record review, the facility failed to ensure the risk and benefits of bed rails ( bed canes - safety device placed on the side of the bed used to help people with mobility issues move) for two of five sampled residents (Resident 10, Resident 14), when Resident 10 and 14 were using bed rails and did not have a bed safety assessment completed. This failure had the potential to put residents at risk for entrapment, accidents, and injuries.Findings: During a review of the facility policy titled Bed Safety and Bed Rails, dated 8/2022 indicated that bed rails come in different types, shapes and sizes and that the use of bed rails or side rails is prohibited unless the criteria for the use of bed rails has been met. The criteria includes attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent. The resident assessment determines the risk for entrapment, accidents and hazards, mobility restrictions, and psychosocial outcomes. During a review of Resident 10's medical record indicated that Resident 10 was admitted to the facility on [DATE] with diagnoses that included fracture of the left femur, type 2 diabetes (the body does not use insulin effectively or does not produce enough insulin causing sugar to build up in the blood), and muscle weakness. During a concurrent interview and record review on 1/8/26 at 1:44 pm, with the Director of Nursing (DON), the DON confirmed that Resident 10 had a physician order for bed canes dated 12/30/25 and Resident 10 did not have a bed safety assessment to ensure the safe use of the bed rails. During a review of Resident 14's medical record indicated that Resident 14 was admitted to the facility on [DATE] with diagnoses that included heart failure (the heart can't pump enough blood and oxygen to meet the body's needs), acute respiratory failure (a serious condition where the lungs can't pump enough oxygen into the blood), and muscle weakness. During a concurrent interview and record review on 1/8/26 at 2:05 pm with the DON, the DON confirmed that Resident 14 had a physician order for bed canes dated 10/25/25 and resident 14 did not have a bed safety assessment completed until 11/22/25 and it should have been completed when the bed canes were first installed.

Based on observation, interview, and record review, the facility failed to ensure that their emergency drug kits (E-kit) had accurate or complete record keeping, when 1 of 4 antibiotic tablets was found to be unaccounted for. This failure had the potential for medications to be potentially lost or diverted without documentation. Findings:A review of facility policy titled Medication ordering and receiving from pharmacy: 1C5: Emergency Pharmacy Service and Emergency Kits, dated 8/2014, indicated, The nurse records the medication use from the emergency kit on the medication order/use form and Calls the pharmacy for replacement of the kit/dose and/or flags the kit with a color-coded lock to indicate need for replacement of kit/dose as soon as possible after the medication has been administered.During an inspection of the facility's medication storage room on 1/6/26 at 10:32 am, the emergency supply kit (a locked, specialized container or electronic cabinet that holds a small supply of critical medications, and allows staff to access and give medications without waiting for delivery) box # PO-27 was observed to be previously opened and accessed. The space for antibiotic sulfamethoxazole/trimethoprim tablet 800/160 MG (a combo of two meds, used to treat infections) was found to have 1 tablet inside, and receipts for two more tablets, which were taken out for resident use. This E-kit indicated that the box should contain 4 tablets, leaving 1 tablet unaccounted for. During an interview with Licensed Vocational Nurse (LVN) J on 1/6/26 at 10:32 am, LVN J stated, There has to be 4 pills, so one is missing.During an interview with Director of Nursing (DON) on 1/8/26 at 9:58 am, DON acknowledged the missing medication that the E-kit box was not accounted for.

Based on interview and record review, the facility failed to ensure that Pharmacy staff were conducting accurate Medication Regimen Reviews for 1 of 34 sampled residents, when Resident 8 was found to have unnecessary medication prescribed for an incorrect diagnosis for 3 months. This failure had the potential to harm residents when medications were not monitored by pharmacy. Findings:A review of facility policy titled, Medication Monitoring & Management, dated 8/2014, indicated, When a resident receives a new medication, the medication order is evaluated for the following . A written diagnosis, an indication, and/or documented objective findings support each medication. This policy also showed The interdisciplinary team reviews the resident's medication regimen for efficacy and actual or potential medication-related problems (on an ongoing basis).A review of Resident 8'S medical records titled admission Summary, indicated that Resident 8 was admitted to the facility on [DATE] with diagnoses included Unspecified Atrial Fibrillation (an irregular heartbeat), Metabolic Encephalopathy (confusion caused by illness), Chronic Obstructive Pulmonary Disease (a lung disease that causes breathing problems), Chronic Diastolic (Congestive) Heart Failure (weakly pumping heart that causes breathing problems), and Unspecified Psychosis (hearing or seeing things that are not real) not due to a substance or known physiological condition. This admission record did not list any diagnoses of seizures.During an interview with Registered Nurse K (RN K) on 1/8/26 at 1:46 pm, RN K stated they had taken care of Resident 8 many times in the last year, and knew them well. RN K stated Resident 8 did not have any history of seizures. RN K stated that Resident 8 had previous episodes of psychosis and hallucinations, with behavioral outbursts. A review of Resident 8's medical record titled Order Summary, dated 1/8/26, indicated the following prescription: divalproex sodium (used to treat certain types of seizures) oral tablet extended release (ER) 24 hour 500 milligrams (MG), give 1 tablet by mouth one time a day for seizures, wear gloves when administering meds swallow whole do not crush/chew/open. The record indicated that Resident 8 began taking divalproex sodium on 9/30/25, and continued to, as of 1/8/26.During an attempt to interview the facility's clinical pharmacist (CP), the facility was unable to arrange an interview with CP during survey hours.During a concurrent interview and record review with Nurse Practitioner D (NP D) on 1/8/26 at 3:34 pm, NP D identified and confirmed the current medication orders for Resident 8 included Divalproex Sodium, and also confirmed the active diagnoses for Resident 8. NP D stated I see no seizure diagnosis for this Resident. NP D went on to say [Resident 8] has no history of seizures, that medication should have been for behavior. NP D also stated the order for Divalproex Sodium was entered incorrectly.

Based on observation, interview, and record review, the facility failed to ensure that medications were stored at the correct temperatures. This failure had the potential for medications to not be therapeutically effective. Findings:A review of facility policy titled Medication Storage in the facility, dated 8/2014, showed Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier.During an observation of Medication Storage room [ROOM NUMBER] on 1/6/26 at 10:32 am, two types of rectal suppository medications were found inside the refrigerator, which had a reading of 34 degrees Fahrenheit. These medications were found to be:1) Acetaminophen (a medication used to treat fevers and mild to moderate pain) Suppository (a dissolving capsule inserted into the rectum, and releases medication), 650 milligrams (MG); packages for two residents found.A review of Manufacturer's Specifications for acetaminophen suppository, indicated Store at 20-25 degrees C (68-77 degrees F).2) Hydrocortisone AC Suppository (used to treat swelling, redness, and itching in the rectum and lower intestines) 25 milligrams (MG); package for one resident found.A review of Manufacturer's Specifications for hydrocortisone rectal suppository, indicated Store at 20-25 degrees C (68-77 degrees F).3) During an observation of Medication Storage Cart 1 on 1/6/26 at 11:15 am, one 120 milliliter (mL) amber colored bottle of liquid gabapentin was found in a drawer. This medication was being stored at room temperature (approximately 70 degrees Fahrenheit), in the facility hallway. A review of Manufacturer's Specifications for liquid oral gabapentin, indicated Storage & Handling: Store refrigerated, 2 C to 8 C (36 F to 46 F).During an interview with Licensed Vocational Nurse (LVN) H on 1/6/26 at 11:15 am, LVN H stated I think its ok after opening to store [liquid gabapentin] in the med cart.During an interview with Director of Nursing (DON) on 1/9/26 at 9:58 am, the DON stated, It's the responsibility of the pharmacy to label medications with temps and put away properly, but also nurses are responsible to check where meds should be stored.

Based on interview, record review, and policy review, the facility failed to ensure two of seven sampled residents (Resident 13, and Resident 65) medical records contained accurate documentation when their Physician Orders for Life-Sustaining Treatment (POLST - a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life) inaccurately indicated that Resident 13 and Resident 65 had advance directives (a written instruction, such as a living will or durable power of attorney for health care, recognized under State law, relating to the provision of health care when the individual is incapacitated [inability to make decisions]).These failures had the potential to result in delays or inaccuracies in Resident 13, and Resident 65's wishes being carried out if they were incapacitated.Findings: Review of a facility policy titled Advance Directives revised September 2022, indicated that Determining existence of advance directive 1. Prior to or upon admission of a resident, the social services director of designee (a person who has been officially chosen to do something) inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. And If a resident has an advance directive 1 . Copies of these documents are obtained and maintained in the same section of the residents medical record and are readily retrievable by any staff. Review of Resident 13's health record indicated that he was admitted to the facility on [DATE] with diagnoses with included stroke, and high blood pressure. Review of Resident 13's POLST dated 8/5/25 indicated that he had an advance directive. During a review of Resident 13's health record no advance directive was present. Review of Resident 65's health record indicated that she was admitted to the facility on [DATE] with diagnoses which included dementia (loss of memory and ability to make sound decisions), and atrial fibrillation (an irregular and often very fast heartbeat that can cause poor blood flow). Review of Resident 65's POLST dated 10/15/24 indicated that she had an advance directive. During a review of Resident 65's health record no advance directive was present. During an interview on 1/7/26 at 2:50 p.m. interview with the Director of Nursing (DON), the DON indicated that there were no advance directives for Resident 13 or Resident 65. The DON indicated that she could not find them in the electronic health record but would ask medical records to see if they could find them.During a concurrent interview and record review on 1/8/26 at 9:10 a.m. with the Social Services Director (SSD), the SSD confirmed that the presence of an advance directive was checked off on Resident 13 and Resident 65's POLSTs and that there were no advance directives in Resident 13 or Resident 65's medical records. The SSD indicated that prior to three months ago nursing staff were determining if newly admitted residents had an advance directive but that she did not know what process nursing staff was using to determine if residents had advance directives. During an interview on 1/8/26 at 9:25 a.m. with the Medical Records Director (MRD), the MRD indicated that the existence of advance directives in Resident 13 and Resident 65's POLSTs were documentation errors, that neither Resident 13 or Resident 65 had an advance directive. And that nursing staff had been responsible for determining if there was an advance directive. When asked if there was any further documentation or process done regarding the determination that there was an advance directive, the MRD indicated that there was nothing further done by nursing staff except asking if there was an advance directive during the residents' admission to the facility.

Based on observation, interview, and record review, the facility failed to ensure a plan of care for safety and supervision for one of three sampled residents (Resident 4), when Restorative Nursing Assistant (RNA) H left Resident 4 alone outside on a patio for 30 minutes, where Resident 4 fell and sustained a subdural hematoma (bleeding between the brain and its lining). This deficient practice resulted in Resident 4 experiencing a major head injury, emergency care at hospital, and a significant decline in their quality of life. Resident 4 was transferred to the hospital on [DATE] after he fell. Resident 4 returned to the facility on [DATE], with Hospice services (specialized end of life care). Resident 4 passed away at the facility on [DATE], 13 days following the fall.Refer to F609, F679 and F726.FindingsDuring a review of facility policy titled Assessing Falls and their Causes, revised [DATE], indicated falls are a leading cause of morbidity and mortality among the elderly in nursing homes. Falling may be related to underlying clinical or medical conditions, overall functional decline, medication side effects, and/or environmental risk factors. Residents must be assessed upon admission and regularly afterward for potential risk of falls. Relevant risk factors must be addressed promptly.During a review of Resident 4's Facility admission Record, indicated that Resident 4 was admitted on [DATE], with diagnoses that included Vascular Dementia (a condition where the brain doesn't get enough blood flow, causing problems with memory and thinking), hemiplegia and hemiparesis (weakness and difficulty moving one side of the body) following nontraumatic intracerebral hemorrhage (a stroke, where brain tissue is damaged by a leaking blood vessel), and muscle weakness.During a review of Resident 4's Minimum Data Set (MDS: a standardized resident assessment and care screening tool), dated [DATE], indicated that the Resident 4 had a Brief Interview for Mental Status score of 99 (a quick, verbal quiz that tests memory and shows how a person's brain is working) indicating the resident had been unable to fully participate in the assessment due to their mental state, and was likely confused. The MDS indicated that Resident 4's functional status required one-person assistance with bed mobility, and transfers. The MDS data indicated that Resident 4's ability to walk was unsteady. During a review of Resident 4's Care Plan on Fall, last revised on [DATE], indicated [Resident 4] had hx (history) of falls r/t (related to) weakness, poor balance, impaired in communication, impaired decision making ability, poor safety awareness, incontinence (unable to control urine flow or bowels), on cardiac meds (heart medications), on narcotics (strong pain medications) and diagnosis of CVA (a stroke, where brain tissue is damaged by a leaking blood vessel) with left sided weakness. This Care Plan on Fall indicated interventions for Resident 4 that included activities that minimize the potential for falls while providing diversion and distraction. [Resident 4] needs a safe environment with even floors free from spills and/or clutter.Educate [Resident 4]/family/caregivers about safety reminders and what to do if a fall occurs. This care plan also indicated [Resident 4] has an ADL (activities of daily living) self-care performance deficit r/t CVA with left hemiplegia, impaired cognition, impaired in communication, poor endurance, with interventions listed including Provide appropriate assistance in all ADLs. This Care Plan on Fall also indicated that staff should provide Resident 4 with prompt response to all requests for assistance. This Care Plan on Fall also indicated [Resident 4] needs a safe environment with even floors free from spills and/or clutter, adequate, glare-free light; a working and reachable call light, and the bed in low position.During a review of Resident 4's activity Care Plan Report, revised [DATE], indicated preferred activities are sitting in the sun. This Care Plan Report also indicated that Resident 4 needs activities that minimize the potential for falls while providing diversion and distraction. This Care Plan Report does not indicate how to provide those activities, or what kind of supervision was needed. During a review of Resident 4's Progress Note: Alert Note dated [DATE], indicated Resident was found on the ground outside the patio. Resident 4 was found to be unresponsive to verbal or tactile stimuli (trying to cause a patient to respond verbally or physically), he has a pulse and has shallow breathing. The Progress Note also indicated Resident 4 was unresponsive, had unstable vital signs, and was soon transported to local hospital for evaluation. This Progress Note also indicated according to investigation of fall, [RNA H] took [Resident 4] outside to the patio, and [Resident 4] was found on the ground afterward.During a review of local Hospital A records titled History and Physical Examination (H&P) by Medical Doctor (MD) X, dated [DATE], the H&P indicated that Resident 4 was taken via ambulance to Hospital A's emergency room immediately following the fall. The H&P indicated Resident 4 was assessed, and received advanced Computer Tomography (CT) (a special type of camera that takes detailed images of inside the brain and body) to look for injuries. The CT of the brain results indicated CT Brain without Contrast (imaging that does not use special contrast dyes inside the body) [DATE] Impression: 1. Small acute left frontotemporal (the area of brain between the ears and forehead) subdural hematoma causing 3 millimeter of left-to-right midline or subfalcine shift (a small bleed inside the brain, that pushes the brain against the skull). The H&P also shows Fall leading to subdural hematoma. This H&P indicated Resident 4's condition as poor prognosis.During a review of records titled Progress Note: Interdisciplinary Team (IDT- a group of professionals from different disciplines who collaborate to provide care for the resident) Note, dated [DATE], indicated that Resident 4 was brought back to facility on [DATE], after treatment at local hospital, and was placed on Hospice Care (treatment and care that focuses on comfort near the end of life). During a review of records titled Communication/Inservice 1:1, dated [DATE], indicated the Director of Staff Development (DSD) had provided specialized training to RNA H following Resident 4's fall incident on [DATE]. The Communication Inservice indicated the main topic of Supervision and Safety, and indicated if a resident is fall risk or disoriented, then supervision will be provided throughout the entirety of their time outside. During a review of facility records titled Fall Incident Occurrence [DATE], a written statement by the facility's Infection Preventionist Licensed Vocational Nurse (IP LVN) describing Resident 4's fall on [DATE], the IP wrote As I was running down the hallway with a staff member, I asked her what happened, and she said they found him outside on the ground. I asked her who took him outside and why wasn't there someone with him. She said she doesn't know. This written statement also indicated I questioned [RNA H] why she took [Resident 4] outside, why did she take him outside if she was not going to stay with him, why didn't she stay with him, why didn't she ask for someone to stay with him if she couldn't stay with him, why didn't she let someone know that she left him outside, and why didn't she let his nurse know. This written statement also indicated [RNA H] was very distraught and crying. She said she was sorry; she confirmed with me that she didn't think to let anyone know. This written statement also indicated IP explained to RNA H that confused residents cannot be left alone outside without a staff supervision. During a review of Registered Nurse C's (RN C) untitled written statement, dated [DATE], indicated [RNA H] did not tell me when she took [Resident 4] outside to the patio. And I did not know [Resident 4] was outside until his CNA told me that he is on the ground. During an interview with Facility Administrator (Admin) on [DATE] at 12:30 pm, Admin stated [CNA H] admitted there was nobody at the nursing station [after placing Resident 4 on patio alone]. Admin also stated that depending on the level of visual supervision, if staff had been at the nursing station, [the patio] would have been safe. During an observation on [DATE], at 12:40 pm, the facility's patio courtyard was approximately 15 feet wide and 25 feet long, and located in the center of the building. The patio was not covered, and open under the sky. The patio was found to have numerous potted plants, decorations, a metal table, umbrella, and metal chairs. The large double doors of the patio were clear glass, and located directly next to the central nursing desk. The doors were found to be moderately heavy, and did not open automatically. It was found that only approximately 50% of the patio could be visualized while sitting at any of the nursing station desks. The second nursing desk did not have clear line of vision onto the patio.During an interview with RNA H on [DATE] at 10:25 am, RNA H stated she had taken care of Resident 4 many times in the past. RNA H stated Yes, they had a high fall risk wristband on. RNA H stated that she took Resident 4 onto the facility patio in a wheelchair, and left him there alone. RNA H stated she did not see anyone at nursing station desks at that time. RNA H stated that Resident 4 was placed on patio at approximately 8:30 am on the morning of [DATE], and was found fallen on ground at approximately 9:00 am. RNA H stated she did make a mistake by leaving Resident 4 alone on patio.During an interview with Registered Nurse (RN) C on [DATE] at 10:07 am, RN C stated they had cared for Resident 4 many times in the past few years, and knew Resident 4's abilities and habits. RN C stated that Resident 4 was dependent on staff for all mobility, including in a wheelchair. RN C stated they were the assigned bedside nurse for Resident 4 on [DATE], the day of the fall incident. RN C stated that they had not been told that Resident 4 was sitting on the patio in his wheelchair. RN C stated that Resident 4 should have received more supervision on the patio, stating Yes, in my professional opinion, [Resident 4] should have had more supervision. During an interview with LVN E on [DATE] at 10:35 am, LVN E stated that Resident 4 did not have adequate supervision alone on the patio. LVN E stated that Resident 4's fall could have been prevented if we knew about it, or he was being supervised. LVN E also stated that verbal communication is the best way to provide safe and competent care to residents. During an interview with Certified Nursing Assistant J (CNA J) on [DATE] at 1:07 pm, CNA J stated they had worked at facility in the past, and had taken care of Resident 4 several times. CNA J stated that the morning of [DATE], they were assigned CNA for Resident 4. RNA H had been assisting Resident 4 at breakfast. CNA J was performing his other usual CNA duties, and an unknown staff member passed by and informed CNA J that Resident 4 was yelling on a patio. CNA J stated he did not know where the patio was located, and began looking for the patio in question. CNA J stated I started looking for [Resident 4] right away. CNA J stated that he found Resident 4 on the ground of central patio, next to his wheelchair, groaning. CNA J then called for help, and other staff came to assist. CNA J stated that prior to the fall, no staff member verbally informed him that Resident 4 was on the patio. CNA J stated that prior to the fall, he did not have verbal contact with RNA H, and said I didn't speak to [RNA H] until afterwards. During an interview with the IP LVN on [DATE] at 9:37 am, IP LVN stated she did interview RNA H immediately following the fall incident on [DATE]. IP LVN stated she asked RNA H Why didn't you let anyone know where he was? and that RNA H replied to IP LVN I didn't think to let anyone know. IP LVN stated that RNA H did not tell Resident 4's assigned staff of his location on the patio. IP LVN stated RNA H should have told more people, she should have known better. During an interview with Medical Doctor Z (MD Z) on [DATE] at 9:35 am , MD Z confirmed that they were one of the treating physicians for Resident 4, and performed the medical assessment on [DATE]. MD Z stated I identified a small bleed, a subdural hematoma. MD Z also stated Yes its absolutely a major injury, any bleed in the brain is a big deal. There was also midline shift (when bleeding and pressure inside skull becomes strong enough to push brain to one side), that was concerning. MD 1 stated that a major injury like this could negatively impact a person's quality of life. During an interview with Activities Director (AD) on [DATE] at 2:00 pm, AD stated that Resident 4's Care Plans had included going outside on facility patios, but that Activities Department had never done that. AD stated that Resident 4's Plan of Care did not include directions to staff on how to supervise Resident 4 outside on patios. AD confirmed that residents sitting outside on patio could not be visualized with direct line of sight at all times from AD's office, and stated that patio doors would have to be open to hear residents calling for help. During an interview with CNA Q on [DATE] at 1:25 pm, CNA Q stated that you can't leave [Resident 4], or someone like him. [Resident 4] who was disoriented. If [residents] are not alert, you should stay with them. If they have dementia, you don't leave them. CNA Q confirmed that staff cannot fully visualize or supervise residents from the nursing desk next to the patio. There's a portion of the patio you can't see. During an interview with CNA P on [DATE] at 2:30 pm, CNA P stated, its common sense that residents with dementia should not be out on the patio alone, especially during the hot months. CNA P stated, [Resident 4] needed total supervision at all times. CNA P confirmed while looking at the computer entering resident information, that there was not a clear line of site to the patio, and that the other station was even further from the door to the patio. CNA P confirmed you could not hear nor see residents out on the patio due to the level of noise at the nursing stations. CNA P confirmed that Resident 4 was totally dependent on staff for everything, wheelchair bound and could only use his right side. CNA P stated that Resident 4 enjoyed sitting on both patios in the facility.During a concurrent interview and record review with the Director of Nursing (DON) on [DATE] at 2:45 pm, DON reviewed the facility records and MDS reports for Resident 4, and confirmed that Resident 4 had been classified as a Moderate Fall Risk prior to his fall incident on [DATE]. DON also verbally confirmed that Resident 4 had been dependent on staff for all care and mobility. DON stated that residents with dementia, dependent residents, or resident with mobility issues only need to be supervised every 30 minutes while outside on patio. DON verbally confirmed that there was no method for residents on patio to call for help, such as a call light. DON confirmed the plan of care did not include how Resident 4 could safely be supervised when he requested to go outdoor patio. During an interview with Family Representative (FP) on [DATE], FP stated they found Resident 4 to have moderate to severe changes in condition following the fall on [DATE]. FP stated [Resident 4] doesn't talk as much, he's not aware anymore. When asked about the fall incident, FP stated It's my understanding that some nurse took [Resident 4] outside, left him there, and then he fell out and cracked his head. FP stated that while informing FP about the fall, the facility told FP We had eyes on the patio doors. FP stated, the facility shouldn't leave anyone unsupervised.During a review of records titled Progress Note: Alert Note, dated [DATE], indicated that Resident 4 had died at facility at approximately 9:21 pm that evening.

Based on interview and record review the facility failed to ensure one of four sampled residents (Resident 1) received respiratory care when a physician ordered Bilevel Positive Airway Pressure (BiPAP-a device that helps breathing) was not implemented for 14 days. This resulted in an emergent transfer to hospital for treatment for severe respiratory failure (not enough oxygen) for five days. Findings: A review of Resident 1 ' s hospital discharge summary dated 12/29/2023 at 1:08 pm, indicated she had been hospitalized for 9 days for treatment of acute respiratory failure with hypercapnia (respiratory system fails and carbon dioxide [a gas by product that is removed from the body by exhalation] builds up in the body), chronic obstructive pulmonary disease (COPD-a condition of the respiratory system causing shortness of breath, cough, fatigue and frequent lung infections), toxic metabolic encephalopathy (a condition of acute brain dysfunction resulting in seizures, behavior changes , memory loss, confusion and altered consciousness) and Congestive Heart Failure (CHF, weak heart causes fluid buildup). During her hospitalization she was started on BiPAP-a breathing machine. Resident 1 was transferred to a long-term care facility on 12/29/2023. During a review of hospital document titled Discharge Planning Needs sent to facility from hospital dated 12/29/2023 at 3:16 pm, by Case Manager Social Worker (CM/SW, coordinates care between hospital and care facility) indicated Resident 1 ' s discharge plan to facility was discussed with Resident 1 ' s family member how important it was for Resident 1 for the facility was to supply BiPAP for patient. A review of facility policy titled CPAP/BiPAP Support and Cleaning, dated March 2015, indicated only a qualified and properly trained nurse or respiratory therapist should administer oxygen through a CPAP/BiPAP mask. A resident ' s medical record should be reviewed to determine his/her baseline oxygen saturation (amount of oxygen that's circulating in your blood), respiratory, circulatory status. The physician ' s order should be reviewed to determine the oxygen concentration and flow and pressure settings for the machine. A review of hospital document titled Discharge Summary, and Order Sheet indicated that the primary discharge packet was sent via fax by the hospital and received by the long-term care facility at 3:01 pm and 3:05 pm on 12/28/2023. A review of hospital order sheet faxed to the long-term care facility dated 12/29/2023 at 11:25 am, indicated a hospital medical doctor ordered BiPAP on at bedtime and off for 6 hours during the day to keep her oxygen level above 90-92% (normal is 95-100%). A record review of an Admission assessment dated [DATE] at 5:42 pm, by Licensed Vocational Nurse (LVN) 1, no documentation of Resident 1 ' s need for BiPAP was noted. A review of Resident 1 ' s record dated from 12/29/23 to 1/16/24, indicated there was no documentation found that nursing staff called the physician to verify if Resident 1 was to continue the BiPAP machine. A review of a document titled Order Summary, indicated that there was an oxygen order dated 12/29/2023, for Resident 1 to receive 3 liters via nasal cannula (a flexible tube worn under the nose delivering oxygen) or shortness of breath, as needed. A review of document titled Weights and Vitals Summary for January 2024, Resident 1 had been receiving supplemental oxygen via nasal cannula from 1/6/2024 to 1/11/2024 during the day, and room air only from 1/11/2024 to 1/13/2024 at night. Resident 1 received BiPAP at bedtime only from 1/12/24 to 1/16/2024. A review of document titled Minimum Data Set (MDS is a tool for implementing standardized assessment and facilitating care management in nursing homes) dated 1/5/2024, by MDS Registered Nurse (MDS RN) no documentation for BiPAP was found in the record. A review of a Care Conference note dated 1/12/2024, a meeting was held between Responsible Party (RP, decision maker), Social Services Director (SSD), Director of Nursing (DON), and Administrator (Admin). RP expressed a concern that Resident 1 was not receiving BiPAP. After the care conference concluded, RP called SSD and repeated her concerns. SSD and Admin approached LVN 1 and questioned where the BiPAP machine was located. LVN 1 and Admin went to Resident 1 ' s room and could not locate the machine. LVN 1 located BiPAP in Resident 1 ' s closet in a pink bag. A review of a physician order dated 1/12/24, 14 days after admission, the BiPAP was ordered with settings for Resident 1, the oxygen saturation level should be at 90- 92%, at bedtime for sleep apnea (breathing starts and stops during sleep). During a review of a Progress Notes dated 1/15/2024, at 1:19 pm, Social Services Assistant (SSA) documented Resident 1 declined a room visit and stated she was not feeling well. There was no indication in the documentation that nursing staff performed an assessment of her overall status. During a review of document titled Change in Condition (SBAR) assessment dated [DATE] at 10:18 am, indicated the reason for the SBAR was Resident 1 was experiencing shortness of breath (SOB) and her oxygen saturation level was 76 % (oxygen saturation levels below 90% can lead to a serious deterioration in health status) when receiving oxygen via nasal cannula. The Medical Director (MDir) was notified. During a review a progress note on 1/16/2023 at 1:26 pm, RN 1 documented that an order was received to transfer Resident 1 to the hospital due to SOB. On 1/16/2024 at 2:50 pm, Assistant Director of Nurses (ADON) documented Resident 1 ' s oxygen saturation decreased. Nurse Practitioner (NP) notified; orders received to transfer Resident 1 to hospital. No further documentation was found in Resident 1 ' s record for ongoing assessment of oxygen saturation from 10:23 am until five hours later at 3:02 pm, done at the hospital. During an interview on 1/25/2024 at 10:40 am, the Admission Supervisor (AS) stated the process for admissions was the case manager at the hospital would send her the resident ' s referrals and orders. AS stated, after receiving the information she sends it to Director of Nursing (DON), Assistant Director of Nursing (ADON), nursing staff and therapy departments via email and uploads the orders into the Electronic Medical Record (EMR). AS stated, that on 12/28/2023, Resident 1 ' s orders came by fax on several pieces of paper. AS explained orders would be emailed to the admission nursing staff. AS stated, a separate fax was received from the hospital with orders containing the settings for a BiPAP machine. AS stated, she did not think she needed to give this to the nursing staff and faxed the order to Interactive Medical Services (IMS-medical device supply company). AS reported, she did not email, print, or upload the faxed BiPAP order and settings into the electronic medical record that admissions, nursing staff, and medical director have access to. During a phone interview on 1/25/2024 at 11 am, the Interactive Medical Services representative (IMS-R, a BiPAP equipment rental agency) stated Resident 1 ' s BiPAP machine was delivered to the facility with preset settings on 12/29/2023 at 3:04 pm and was signed for by Licensed Vocational Nurse (LVN) 2. During an interview on 1/25/2024 at 2:40 pm, LVN 2 stated she had six admissions on 12/29/2023, it was very hectic. LVN 2 stated that she felt so overwhelmed with six admissions that she told ADON she would quit if they accepted a seventh admission. LVN 2 stated she remembered signing for Resident 1 ' s BiPAP machine and putting it at Resident 1 ' s bedside. LVN 2 stated that DON and Admin left at 2 pm that day. During a concurrent interview and record review on 1/25/2024 at 12 pm, Assistant Director of Nursing (ADON) stated he entered BiPAP order and diagnosis on 1/12/2024. ADON confirmed Resident 1 ' s documented diagnosis for the BiPAP was COPD and hypercapnia which utilizes BiPAP to help rid the body of excess carbon dioxide. ADON confirmed Resident 1 ' s BiPAP machine was delivered on 12/29/2024, and that Resident 1 did not use the BiPAP as ordered until 1/12/2024. During an interview on 1/25/2024 at 12:17 am, DON stated her expectations was the nursing staff should have verified physician orders for the BiPAP during the admission process for Resident 1. DON further stated the licensed nursing staff should have followed up when the BiPAP machine delivered and set up in Resident 1's room. DON stated licensed nurses should complete and document all respiratory assessments in the record when there was a change in condition. During interview on 1/25/2024 at 1:55 pm, SSD stated Resident 1 ' s RP called her on 1/12/24, and inquired about the BiPAP machine that her mother should have had since admission. SSD stated she called the RP later stating the BiPAP was found and now at Resident 1's bedside. A review of a hospital discharge summary dated 1/31/24 at 10:16 am, the physician indicated Resident 1 was brought in by ambulance on 1/16/24, with increasing fatigue and altered mental status (changes in mood/cognitive function). Physician documented Resident 1 was found to have significant hypercapnia and was admitted to a step down unit for acute respiratory failure, COPD exacerbation, large pleural effusion (build up of fluid around and in lung tissue), pulmonary edema (too much fluid in lungs, and CHF exacerbation (worsening). Resident 1 was discharged from the hospital on 1/31/24, after five days. During a concurrent interview and record review on 2/7/2024 at 9:19 am, DON confirmed that in Resident 1 ' s Admission Assessment document dated 12/29/2023 there was no BiPAP noted. DON confirmed there was no BiPAP documentation on Resident 1 ' s Baseline Care Plan dated 12/29/2023. DON confirmed that Resident 1 ' s BiPAP was not ordered by MDir until 1/12/2024, 14 days after admission. DON confirmed Resident 1 ' s hospital Discharge Summary was not scanned into EMR. During a phone interview on 2/14/2024 at 9:47 am, Medical Records Director (MRD) stated on the day of Resident 1 ' s admission on 12/29/23, there were six admissions. MRD stated that three admissions were their average and there had only been two occasions in the last eight years where there were six admissions. MRD stated that the staff was panicked, left in a scramble, was not prepared for the influx of residents, and felt abandoned. MRD stated that the Admin, DON, the business representative, and admissions staff left early that day. When asked if she saw Resident 1 ' s order for BiPAP, she confirmed that she was unaware of the BiPAP order. During a concurrent interview and record review on 2/14/2024 at 11:30 am, MDS RN confirmed Resident 1 ' s BiPAP was not in initial care plan. MDS RN stated Resident 1 ' s hospital discharge summary should have been scanned into EMR and given to the admissions nurse. MDS RN confirmed it could not be found in EMR and stated she was unaware Resident 1 ' s BiPAP was ordered and delivered at bedside. During a phone interview on 2/14/2024 at 10:13 am, MDir stated he was not responsible for how many admissions a facility would receive, but that six admissions in one day would be unusual. MDir stated the admissions coordinator puts everything into the EMR (which he has access to) including discharge records from hospital, which he reads after admission is finalized. When told that AS had the order for the BiPAP prior to admission and that it did not come in until 14 days post admission, MDir stated AS should have relayed that to DON or ADON. MDir stated he did not know how any of that happened. Regarding Resident 1 not feeling well after not receiving ordered BiPAP for 14 days, MDir stated if she wasn ' t doing well, what could happen, did happen. Carbon dioxide goes up, then she would eventually become lethargic, and comatose.

Based on observation, interview, facility document and Policy and Procedure review, the facility failed to ensure acceptable parameters of nutritional status were maintained for one of 21 sampled residents (Resident 48) when: 1. A Change of Condition (COC) assessment was not completed, and the Physician was not notified of Resident 48's severe weight loss of 12.8 pounds (lbs.), 7.7 % between 1/6/23 and 2/5/23, 15 lbs., 9% between 1/6/23 and 2/7/23, and 17.2 lbs., 10.2% between 8/20/22 and 2/7/23, 2. Weekly weights were not completed as ordered on 1/26/23 for Resident 48, and 3. Interventions to mitigate the severe weight loss of 12.8 pound (lbs.), 7.7 % between 1/6/23 and 2/5/23, 15 lbs., 9% between 1/6/23 and 2/7/23, and 17.2 lbs., 10.2% between 8/20/22 and 2/7/23 for Residents 48 were not implemented in a timely manner. As a result of these failures, Resident 48's compromised nutritional status was not monitored and addressed timely which could lead to further medical complications including but not limited to skin breakdown. Findings: A professional reference review of American Academy of Family Physicians Journal titled, Unintentional Weight Loss in Older Adults, dated 2014 showed, Unintentional weight loss (i.e., more than a 5% reduction in body weight within six to 12 months) occurs in 15% to 20% of older adults and is associated with increased morbidity and mortality. In this population, unintentional weight loss can lead to functional decline in activities of daily living, increased in-hospital morbidity, increased risk of hip fracture in women, and increased overall mortality. Further, cachexia (loss of muscle mass with or without loss of fat) has been associated with negative effects such as increased infections, pressure ulcers, and failure to respond to medical treatments . https://www.aafp.org/afp/2014/0501/p718.html - afp20140501p718-b1. 1. A review of the facility P&P titled Acute Condition Changes - Clinical Protocol revised 3/2018 showed in part, 1. The physician will help identify individuals with a significant risk for having acute changes of condition during their stay .2. In addition, the nurse shall assess and document/report the following baseline information: a. Vital signs; .7. Before contacting a physician about someone with an acute change of condition, the nursing staff will collect pertinent details to report to the physician . Medical record review for Resident 48 was initiated on 6/22/23. Resident 48 was admitted to the facility on [DATE], with diagnoses including acute bronchitis (airways of the lungs swell and produce mucus in the lungs), peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement), and major depressive disorder (a mental condition characterized by a persistently depressed mood). Review of Resident 48's History and Physical Examination completed and signed by the Medical Director on 7/14/22, showed Resident 48's weight was 164 lbs., and rehabilitation potential was poor. Review of the facility document titled Order Summary Report for Resident 48 signed and dated by the Nurse Practitioner (NP) on 1/20/23, showed the following was ordered on 10/5/22, Regular Diet dysphagia (difficulty swallowing) advanced texture, thin consistency, on 7/26/22 food snack two times a day for supplement was ordered. Review of the facility document titled Order Summary Report for Resident 48 signed and dated by the NP on 3/6/23, showed the following was ordered on 1/26/23, Health shake (nutritional supplement) one time a day for supplement with breakfast. Review of the facility document titled Weights and Vitals Summary from 1/6/23 to 2/7/23 showed the following weights and comparison for Resident 48: *On 1/6/23 = 166 lbs., *On 2/5/23 = 153.2 lbs., -12.8 lbs., a 7.7% severe weight loss in one month [comparison weight on 1/6/23, 166 lbs.]; -15.6 lbs., a 9.2% severe weight loss in two months [comparison weight on 12/3/22, 168.8 lbs.]; -17.6 lbs., a 10.3% severe weight loss in five months [comparison weight on 9/1/23, 170.8 lbs.], *On 2/7/23 = 151 lbs., -15 lbs., a 9% severe weight loss in one month [comparison weight on 1/6/23, 166 lbs.]; -17.8 lbs., a 10.5% severe weight loss in two months [comparison weight on 12/3/22, 168.8 lbs.]; -17.2 lbs., a 10.2.% severe weight loss in five and a half months [comparison weight on 8/20/23, 168.2 lbs.]. Review of Resident 48's Quarterly Minimum Data Set (MDS, a standardized resident assessment) dated 1/21/23, showed under Section C, a BIMS (brief interview of mental status) score of 12 which indicated Resident 48 had moderate cognitive impairment, Section K of the MDS indicated Resident 48 weighed 166 lbs. and height was 62 inches, Resident 48 had not experienced a 5% or more weight loss in the past month or 10% or more weight loss in the past six months. Review of Resident 48's Quarterly MDS dated [DATE], showed under Section C, a BIMS score of 11 which indicated Resident 48 had moderate cognitive impairment, Section K of the MDS indicated Resident 48 weighed 154 lbs. and height was 62 inches, Resident 48 had experienced a 5% or more weight loss in the past month or 10% or more weight loss in the past six months, and was not on a physician-prescribed weight-loss regimen. Review of the Physician progress notes dated 2/1/23 electronically signed and dated by the medical director on 2/6/23 showed, Chief complaint: Monthly. Subjective: General: .no loss of appetite. Plan: continue to assess of change in condition, provide assistance as needed, follow up monthly and prn (as needed). Resident 48's body weight or oral intake was not mentioned in the monthly progress note. Review of the Physician progress notes dated 3/1/23 electronically signed and dated by the medical director on 3/9/23 showed, Chief complaint: Monthly. Subjective- General: no loss of appetite. Plan: continue to assess of change in condition, provide assistance as needed, follow up monthly and prn. Stable on current treatment plan at this time. Resident 48's body weight or oral intake was not mentioned in the monthly progress note. On 6/22/23 at 9:46 am, a review of Resident 48's electronic medical record and concurrent interview was conducted with Registered Nurse (RN) 1. When asked to explain the facility's process of significant weight changes, RN 1 stated nursing checked the weights in the computer, or the Restorative Nurse's Assistant (RNA) would let nursing know about a significant weight change. RN 1 stated RNA charting would also mention significant weight changes in the RNA progress notes. The RN 1 stated a change of condition (COC) assessment would be completed for significant weight changes. Nursing was responsible to notify the physician, the resident's responsible party, the Registered Dietitian (RD) and the Director of Nursing (DON) of the significant weight change. The IDT (interdisciplinary team-team members from different disciplines working collaboratively with a common purpose to set goals) would meet to discuss the plan of action for significant weight changes. RN 1 confirmed Resident 48 experienced the following severe weight loss: *On 2/5/23 = 153.2 lbs., -12.8 lbs., a 7.7% severe weight loss in one month [comparison weight on 1/6/23, 166 lbs.]; -15.6 lbs., a 9.2% severe weight loss in two months [comparison weight on 12/3/22, 168.8 lbs.]; -17.6 lbs., a 10.3% severe weight loss in five months [comparison weight on 9/1/23, 170.8 lbs.], *On 2/7/23 = 151 lbs., -15 lbs., a 9% severe weight loss in one month [comparison weight on 1/6/23, 166 lbs.]; -17.8 lbs., a 10.5% severe weight loss in two months [comparison weight on 12/3/22, 168.8 lbs.]; -17.2 lbs., a 10.2.% severe weight loss in five and a half months [comparison weight on 8/20/23, 168.2 lbs.]. RN 1 added if a resident experienced a significant weight change the RNA would reweigh the resident. RN 1 confirmed Resident 48 was reweighed on 2/7/23 and had lost an additional 2.2 lbs. in two days. RN 1 stated a COC assessment was completed on 1/31/23 for Resident 48 due to new onset of confusion, lethargy and poor PO (by mouth) intake. RN 1 confirmed a COC was not completed and the physician was not notified of Resident 48's severe weight of 12.8 lbs., 7.7 % between 1/6/23 and 2/5/23, 15 lbs., 9% between 1/6/23 and 27/23, and 17.2 lbs., 10.2% between 8/20/22 and 2/7/23. When asked what the acceptable time frame to notify the physician of a COC was, RN 1 stated the physician should be notified within 24 hours of the COC. On 6/22/23 at 11:00 AM, an interview and concurrent electronic record review for Resident 48 was conducted with the Assistant Director of Nursing (ADON). The ADON stated significant weight loss was considered a change in condition and the physician should be notified. The ADON confirmed Resident 48 experienced the following severe weight loss: *On 2/5/23 = 153.2 lbs., -12.8 lbs., a 7.7% severe weight loss in one month [comparison weight on 1/6/23, 166 lbs.]; -15.6 lbs., a 9.2% severe weight loss in two months [comparison weight on 12/3/22, 168.8 lbs.]; -17.6 lbs., a 10.3% severe weight loss in five months [comparison weight on 9/1/23, 170.8 lbs.], *On 2/7/23 = 151 lbs., -15 lbs., a 9% severe weight loss in one month [comparison weight on 1/6/23, 166 lbs.]; -17.8 lbs., a 10.5% severe weight loss in two months [comparison weight on 12/3/22, 168.8 lbs.]; -17.2 lbs., a 10.2.% severe weight loss in five and a half months [comparison weight on 8/20/23, 168.2 lbs.]. The ADON was asked to show documentation the physician was notified of Resident 48's severe weight loss in February 2023. The ADON reviewed the physician progress notes dated 2/1/23 and 3/1/23 and confirmed Resident 48's severe weight loss was not mentioned. On 6/22/23 at 11:30 AM, an interview and concurrent electronic record review for Resident 48 was conducted with the DON. The DON confirmed significant weight loss was considered a COC and the physician, responsible party, DON and ADON should be notified. The DON confirmed the following severe weight loss for Resident 48: *On 2/5/23 = 153.2 lbs., -12.8 lbs., a 7.7% severe weight loss in one month [comparison weight on 1/6/23, 166 lbs.]; -15.6 lbs., a 9.2% severe weight loss in two months [comparison weight on 12/3/22, 168.8 lbs.]; -17.6 lbs., a 10.3% severe weight loss in five months [comparison weight on 9/1/23, 170.8 lbs.], *On 2/7/23 = 151 lbs., -15 lbs., a 9% severe weight loss in one month [comparison weight on 1/6/23, 166 lbs.]; -17.8 lbs., a 10.5% severe weight loss in two months [comparison weight on 12/3/22, 168.8 lbs.]; -17.2 lbs., a 10.2.% severe weight loss in five and a half months [comparison weight on 8/20/23, 168.2 lbs.]. The DON was not able to confirm a COC assessment was completed or the physician was notified of Resident 48's severe weight loss in February 2023. The DON confirmed the physician should be notified of a significant weight change the same day the weights were taken. Cross reference to F580. 2. Review of the facility Policy and Procedure titled Weight Assessment and Intervention revised March 2022 showed, Weight Assessment- 2. Weights are recorded in each unit's weight record chart and in the individual's medical record. Review of the facility document for Resident 48 titled, Order Recap Report dated 1/26/23 showed on 1/26/23 the Nurse Practioner (NP) ordered weekly weights for four weeks to begin 1/31/23 then monthly. On 6/22/23 at 9:46 am, a review of Resident 48's electronic medical record and concurrent interview was conducted with RN 1. RN 1 confirmed an order for weekly weights for four weeks was written on 1/26/23, to be implemented on 1/31/23. RN 1 confirmed weekly weights were not completed for Resident 48 per the physician's order. On 6/22/23 at 10:29 AM an interview was conducted with RNA. RNA stated nursing was responsible to notify the RNA of weekly weight orders. RNA checked the weight binder for an order for weekly weights for Resident 48. RNA was not able to confirm she received an order from nursing to weigh Resident 48 weekly on 1/31/23. RNA stated communication between nursing and the RNA regarding weekly weight orders had been an ongoing problem. RNA stated any resident who lost five pounds, or more was automatically reweighed. RNA confirmed Resident 48 had lost more than five pounds on 2/2/23 and was reweighed on 2/7/23 but was not weighed again until March 6, 2023. On 6/22/23 at 11:30 AM an interview was conducted with the DON. DON confirmed Resident 48 had an order for weekly weights to begin on 1/31/23. The DON confirmed weekly weights had not been completed for Resident 48 as ordered. 3. Review of the facility Policy and Procedure titled Weight Assessment and Intervention revised March 2022 showed, Weight Assessment- 5. The threshold for significant unplanned and undesired weight loss will be based on the following criteria .a. one month - 5% weight loss is significant; greater than 5% is severe. b. three months - 7.5% weight loss is significant, greater than 7.5% is severe. c. six months- 10% weight loss is significant; greater than 10% is severe. Evaluation- 1. Undesirable weight change is evaluated by the treatment team whether or not the criteria for significant weight change has been met. Review of the facility document for Resident 48 titled, Order Recap Report dated 3/01/23- 6/30/23 showed on 3/17/23 the medical director ordered 7.5 mg (milligram) of mirtazapine (anti-depressant) AEB (as evidenced by) loss of appetite related to major depressive disorder. A review of Resident 48's electronic medical record was initiated on 6/22/23 at 9:15 AM. The facility document titled RD- Nutrition Note completed and signed by RD on 2/6/23 showed in part, -Resident 48's weight was 153.2 lbs. on 2/5/23. Resident 48's weight history showed, 1/6/23 weight: 166 lbs., 12/3/22 weight: 168.8 lbs., 11/5/22 weight: 171.4 lbs.; 7.8 % 13 lbs. significant weight loss in 30 days, 10.6 % 18.2 lbs. significant weight loss in 90 days. -Diet order: Regular diet, dysphagia advanced texture, thin consistency -PO (by mouth) intake: mostly less than 50% for 14 meals, refused six meals. -Supplements: Health Shake with breakfast - intake approximately 50% for four days. -Fluids 120-480 ml/meal for seven days -Weekly weights (end date 2/28/23) -Resident is [AGE] year-old female who presents with significant weight loss in one and three months. Current PO intake is poor, does not appear adequate to meet ENN (estimated nutrition needs). Noted COC 1/31/23 for lethargy, new onset confusion .spoke with resident who reports poor appetite and having no interest in food .Resident was unaware of recent weight loss, RD encouraged adequate intake of meals, fluids, oral nutritional supplements to help prevent further weight loss May consider recommending appetite stimulant if no improvement in PO intake Monitor through IDT weight meeting PRN (as needed). Monitor PO intake, weight, skin integrity, labs as available. RD will continue to monitor per facility protocol and remain available. Review of the facility document titled IDT Review completed and signed by the RD on 2/9/23 showed in part, -2/7/23 weight 151 lbs., significant weight loss 15 lbs., 9% in 30 days, 20.4 lbs., 11.9% in 90 days. -PO intake mostly less than 50% for 14 days, refused six meals. -Supplements: Health Shake with breakfast - intake approximately 50% for seven days. --Current PO intake is poor .Noted weight loss 2.2 lbs. in two days (2/5-2/7). -Order for weekly weights for four weeks (end date 2/28/23) -Consider appetite stimulant if medically appropriate, continue to monitor weight trends. Review of the facility document titled RD- Nutrition Note completed and signed by the facility RD on 3/16/23 showed in part, -Resident 48 weighed 154.2 on 3/6/23, 153.2 on 2/5/23, 166 on 1/6/23, significant weight loss in 90 days, -14.6 lbs., 8.6% -Intake was variable 25-100% -Regular diet, Health Shake w/ Breakfast, -Skin intact, weight stable for one month, -Rec MVI (multivitamin) with minerals Review of the facility document titled IDT weight meeting completed and signed by the facility RD on 3/16/23 showed in part, -weights per RD note 3/16/23. -Recommend prostat (protein supplement) 30 ml (milliliter) every day for 30 days, -MVI with minerals. -Continue monthly weights. Review of the plan of care initiated on 2/6/23 for Resident 48 showed in part: -Resident 48 presents with significant weight loss: -7.8% (13 lbs.) since 1/6/23, -10.6% (18.2 lbs.) since 11/2/22. -Poor appetite -interventions- weekly weights (end date 2/28/23) -Recommend send extra juice, and ice cream. Consider appetite stimulant if medically appropriate. Monitor through IDT weight meeting PRN. Review of the facility document titled Nutritional Recommendations by Registered Dietitian dated 2/9/23 showed, the RD recommended to consider appetite stimulant if medically appropriate. On 6/22/23 at 11:00 AM, an interview was conducted with the ADON. The ADON stated if a resident experienced a significant weight change, the IDT would hold a meeting to discuss the significant weight change. The ADON confirmed Resident 48 experienced severe weight loss of 12.8 lbs., 7.7 % between 1/6/23 and 2/5/23, 15 lbs., 9% between 1/6/23 and 27/23, and 17.2 lbs., and 10.2% between 8/20/22 and 2/7/23. The ADON stated the RD was aware of Resident 48's severe weight loss. On 6/22/23 at 3:00 PM an interview and concurrent electronic medical record review was conducted with the Lead RD. The Lead RD stated she was responsible to oversee facility RDs but did not evaluate facility RDs. The Lead RD stated the facility's previous RD's last day was 6/14/23. The Lead RD was asked to explain the process for RD recommendations. The Lead RD stated the RD entered resident recommendations electronically on the facility document titled Nutritional Recommendations by Registered Dietitian form each visit and emailed a copy to the DON, ADON and DSS. The goal to complete the RD recommendations was five days, maybe seven days maximum depending on the physician. The Lead RD was asked if the facility RD should follow up on RD recommendations that were not completed. The Lead RD stated the facility RD should follow up on RD recommendations that were not completed depending on the situation. The Lead RD stated the facility RD should speak with the Certified Dietary Manager (CDM) or DON to investigate why the RD recommendations were not completed. The Lead RD confirmed the facility RD recommended an appetite stimulant on 2/9/23 but the order for an appetite stimulant was not received until 3/17/23. The Lead RD was asked what the facility process was if a resident experienced a severe weight loss. The Lead RD stated the RD would assess the resident and recommend weekly weights as indicated. The Lead RD further stated a resident with a severe weight loss should be monitored according to the resident's situation and the RD's clinical judgement. The Lead RD added the facility RD should document the plan how often the resident would be monitored. The Lead RD confirmed the facility RD assessed Resident 48 on 2/6/23 but did not assess Resident 48 again until 3/16/23. The Lead RD was asked why the RD did not continue to monitor Resident 48 after the IDT discussed her severe weight loss on 2/9/23. The Lead RD stated she did not know why and did not want to speak for the facility RD. On 6/22/23 at 3:48 PM an interview was conducted with the ADON. The RD recommendations from 2/9/23 were reviewed with the ADON. The ADON kept a copy of the RD recommendations in a binder, and he stated he notified the physician of the RD recommendations. The ADON confirmed on 2/9/23 the RD recommended for an appetite stimulant for Resident 48. The ADON stated when the RD recommendations were completed, he wrote a check mark next to the RD recommendation. The ADON confirmed the RD recommendation for Resident 48 on 2/9/23 did not have a check mark meaning it was not completed. When asked why the recommendation for an appetite stimulant had not been ordered for Resident 48, the ADON stated he could not remember why the RD recommendation was not completed. The ADON confirmed there was no documentation the NP or physician were notified of the RD recommendation for an appetite stimulant. The ADON confirmed an order was received from the physician on 3/17/23 for an anti-depressant which was often used as an appetite stimulant. When asked what the expected time frame to complete RD recommendations was, the ADON stated the RD recommendations should be completed as quickly as possible. On 6/23/23 at 9:07 AM, an interview was conducted with Resident 48. Resident 48 was alert and able to answer questions. She stated the facility told her she had lost weight. Resident 48 stated she liked ice cream. Resident 48 was asked if she received snacks between meals, Resident 48 stated she only received snacks if she asked for them. Resident 48 complained she was tired all the time and was in constant pain. Resident 48 also stated she often had loose stools and had a sore on her tailbone. On 6/23/23 at 9:37 AM, an interview was conducted with the DON. The DON was asked who was responsible for the IDT weight meetings. The DON stated nobody was responsible or in charge of the IDT weight meetings. The DON stated the RD was responsible to determine what residents would be discussed in the IDT weight meeting. The DON was asked how long a resident with a severe weight loss and poor PO intake was monitored in the IDT meeting. The DON stated residents with significant weight loss were discussed until they were no longer a concern. The DON confirmed Resident 48 was discussed in the IDT meeting on 2/9/23 and not again until 3/16/23. On 6/23/23 at 11:55 AM an interview was conducted with the medical director. When asked how long a resident with severe weight loss and poor PO intake should be discussed with the IDT, the medical director confirmed a resident with severe weight loss and poor PO intake should be discussed with the IDT until the resident is stable.

Based on observation, interview, and record review, the facility failed to ensure that one resident (Resident 48) who entered the facility without a pressure ulcer (PU), did not develop a pressure sore and that the resident received necessary care and services to promote healing, when Resident 48 was at a risk for PU's upon admit and routine skin assessments did not identify the pressure ulcer at an early stage. Resident 48's PU was identified on 4/7/23 at stage 3 (full thickness tissue loss without muscle, tendon, or bone visible). Resident 48's PU was not evaluated and treated by a wound care physician for 40 days and progressed to a stage 4 PU (a pressure injury that extended through the skin to muscle, tendon, or bone) on 5/18/23. This failure resulted in Resident 48 developing a stage 3 pressure ulcer to her coccyx (a bone at the base of the spine), which was further staged at a stage 4 PU by a wound doctor (WD, a physician that specializes in healing wounds), accompanying a severe weight loss. Refer F692 Findings: A facility policy titled, Pressure Ulcers/Skin Breakdown - Clinical Protocol, with a revised date of April 2018, indicated, The physician will order pertinent wound treatments, including pressure reduction surfaces . The physician will help identify medical interventions related to wound management; for example . addressing comorbid (medical conditions that are simultaneously present in a patient) medical conditions, managing pain related to the wound or to wound treatment, etc. A review of the facility's records indicated Resident 48 was admitted to the facility on [DATE], with diagnoses that included difficulty in walking, cognitive communication deficit (difficulty with thinking and how someone uses language), age related osteoporosis (bone disease that can lead to a decrease in bone strength), muscle weakness, and Parkinson's disease (a progressive nerve disorder resulting in tremors, stiffness, dementia). A review of a minimum data set (MDS, a tool for implementing standardized assessment and for facilitating care management in nursing homes) dated 07/22/2022, upon admission to the facility, indicated, Resident 48 was at risk of developing pressure ulcers/injuries and did not have one or more unhealed pressure ulcers/injuries at that time of admission to the facility. A review of a weekly progress note dated 04/02/2023 at 3:10 PM, indicated, No new skin issues noted this week. A review of a nursing progress note dated 04/07/2023 at 4:13 PM, indicated, Writer was notified by CNA (Certified Nursing Assistant) who had worked with resident yesterday PM shift, of resident having an open area to their coccyx. Writer assessed the area and noted the following: - Open area to coccyx measuring 2.5 centimeters (cm, a unit of measure) x 2 cm with slough (dead tissue) present at wound bed . Upon inquiring from staff, resident has been known to remain in supine position (face up, laying on back) and refusing to be turned by staff . A review of a nursing progress note dated 04/07/2023 at 9:42 PM, indicated, Treatment (Tx) nurse notified resident has open area to coccyx measuring 2.5 cm x 2cm with slough present at wound bed . Tx done by Tx nurse . A review of a document titled, Weekly Non-Pressure Skin Report, indicated on the week of 04/19/2023 Resident 48 had a new, excoriation (a well-defined injury with sharp or linear edges) to her coccyx. There was no documentation provided for the week of 04/12/2023 on this document. A review of a document titled, treatment administration report (TAR), dated March 2023, indicated, No order data found for Treatment Administration Record. A review of a document titled TAR, dated April 2023, indicated treatment for the wound on the coccyx began on 04/08/2023 by the treatment nurse. A review of a document titled, Comprehensive CNA Shower Review, for Resident 48 dated between 03/10/2023 to 05/1/2023 indicated, out of nine sheets provided, the resident had one shower sheet that indicated she had a pressure ulcer. The shower sheet that indicated CNA A had observed a tear at the lower coccyx on Resident 48 on 04/18/2023, but the three sheets following that date did not have any indication of an open area, wound, or tear. A review of a nursing progress note dated 04/10/2023 at 9:37 AM, indicated Resident 48, Is incontinent of bowel and bladder and does not know when she needs her brief changed. She is almost entirely dependent for movement and positioning. Staff educated to check brief and reposition/offload points of pressure at least every 2 hours and as resident will tolerate. (Resident 48) is at risk for skin breakdown due to her age, impaired mobility, incontinence, muscle weakness, and other comorbidities . A review of a weekly progress note dated 04/16/2023 at 1:54 AM, indicated, there are no current skin alterations. The comments section of the document indicated, Resident stable this week. No new changes noted. All needs met by staff . A review of a MDS dated [DATE], indicated Resident 48 was frequently incontinent of bowel and bladder. The document further indicated that the resident does not have a current pressure ulcer/injury but was at risk of developing pressure ulcers/injuries. A review of section G of the MDS, for the resident's functional status, it indicated that resident 48 required extensive assistance with bed mobility, which included how the resident moved, turned, and repositioned body while in bed. Resident 48's toilet use documented within the MDS indicated that she required extensive assistance. A review of a document titled (Resident 48) monthly nursing home visit, dated 05/01/2023, indicated that Medical Director (MD) had seen the Resident during his nursing home visit to this facility. The note indicated that Resident 48 was stable on current treatment plan and had no new skin tears or wounds. A review of a radiology (medical imaging) results report dated 05/17/2023, indicated, The sacrum (bony structure at base of spine, connected to the pelvis that strengthens and stabilizes the pelvis) and coccyx are osteoporotic (A condition in which bones become weak and brittle) . Slight disruption of the posterior (near the back) soft tissues. The document indicated it was faxed to the nurse practitioner dated 05/17/2023. A review of a document titled, Change in Condition Assessment/SBAR, dated 05/17/2023 at 8:32 AM, indicated, Resident seen by (WD) for initial wound consultation today . Wound has changed from a stage 3 to a stage 4 . A review of a document titled, Braden Scale for Predicting Pressure Sore Risk Original, dated 05/18/2023, indicated Resident 48 had a Braden Scale (a scale that predicts risk for pressure ulcers), with total of 11 out of 23 (a lower score that indicated a higher risk for pressure ulcer development). The document indicated that Resident 48 had a very limited ability to respond meaningfully to pressure-related discomfort, and her skin was often moist, which required the bed linen to be changed at least once a shift. According to the document, Resident 48 had a very limited mobility range, which made her unable to significantly change her position frequently or independently. The friction and shear section indicated that Resident 48 had a problem and required moderate to maximum assistance in moving. A review of a document titled, Documentation Survey Report v2, between the dates of March 2023 and June 2023, indicated Resident 48 was incontinent of bowel and bladder often and required limited to extensive assistance to total dependence while performing bed mobility. A review of a nursing progress note dated 05/18/2023 at 12:17 PM, indicated WD assessed Resident 48's wound, and staged it as an unstageable pressure injury (tissue loss in which the extent of the tissue damage cannot be confirmed) to the coccyx. According to the progress note, the pressure ulcer measured 2cm x 1.5 cm, and WD performed a muscle debridement (removal of dead or infected skin tissue to help a wound heal) and staged the wound as a stage 4 pressure ulcer. Resident 48 was on a LALM (low air loss mattress, designed to let air out slowly to help keep the skin dry). Staff was to check brief and reposition/offload points of pressure at least every 2 hours and as resident will tolerate. A review of a weekly progress note dated 05/21/2023 at 12:20 AM, indicated, No new changes noted. No new skin issues noted this week . During a concurrent observation and interview on 06/20/2023 at 12:20 PM with Resident 48, she stated I have diarrhea today, they take their sweet time to change me. Resident 48 further stated she had a wound on her tailbone for approximately 3 months and wanted to be changed more frequently. Resident 48 appeared upset and pointed where her wound was located, pointing to her coccyx area. She stated she feared the wound getting worse and having feces seep into the wound and explained that made her feel very upset as she was not changed or cared for enough. During a concurrent interview and electronic record review on 06/22/23 at 11:30 AM, with the Director of Nursing (DON), she confirmed significant weight loss was considered a change of condition (COC) and the physician, responsible party, DON and ADON should be notified. The DON confirmed the following severe weight loss for Resident 48: On 02/5/23 = 153.2 lbs., -12.8 lbs., a 7.7% severe weight loss in one month [comparison weight on 1/6/23, 166 lbs.]; -15.6 lbs., a 9.2% severe weight loss in two months [comparison weight on 12/3/22, 168.8 lbs.]; -17.6 lbs., a 10.3% severe weight loss in five months [comparison weight on 9/1/23, 170.8 lbs.], On 02/7/23 = 151 lbs., -15 lbs., a 9% severe weight loss in one month [comparison weight on 01/6/23, 166 lbs.]; -17.8 lbs., a 10.5% severe weight loss in two months [comparison weight on 12/3/22, 168.8 lbs.]; -17.2 lbs., a 10.2.% severe weight loss in five and a half months [comparison weight on 08/20/23, 168.2]. The DON was not able to confirm a change of condition assessment was completed or the physician was notified of Resident 48 severe weight loss in February 2023. The DON confirmed the physician should be notified of a significant weight change the same day the weights were taken. During an interview on 06/23/2023 at 9:19 AM with CNA G, she stated the treatment nurse performs wound care on Resident 48. CNA G stated if the dressing on her coccyx was soiled by feces or urine, they would alert the treatment nurse so that they can come to change it, explaining that she will clean around the best she can. CNA G stated that Resident 48 could use the call light and informed staff that she needed to be changed, and staff would check on her every two hours, and further stated, She knows when she needs to be changed. She won't let her brief stay soiled or wet. During an interview on 06/23/2023 at 9:34 AM with CNA H, she stated Resident 48 would use call light to inform staff if she needed her brief changed. CNA H stated Resident 48 would inform the staff if she wished to be repositioned within the two hours, otherwise she was repositioned every two hours. During an interview on 06/23/2023 at 9:46 AM with LVN 2, she stated Resident 48 was repositioned and changed often. LVN 2 stated the pressure ulcer was unavoidable as Resident 48 was alert and informed staff of when she wanted to be changed. It was probably going to happen anyway with her condition. During an interview on 06/23/2023 at 10:00 AM with Treatment Nurse LVN (Tx LVN), stated when she was made aware of Resident 48's pressure wound it was already an open area. Tx LVN stated when Resident 48 was soiled she won't let staff know, which was a factor for the pressure ulcer having been unavoidable. She stated that Resident 48 had improvements to her pressure ulcer, and it was healing. Tx LVN stated Resident 48 received showers properly and she does not refuse her showers. She further stated that she was not sure if the wound starting at a stage 3 pressure ulcer was warranted or not, as nursing and CNAs should have noticed redness and abrasion (an area damaged by scraping or wearing away). Tx LVN stated if the pressure injury was reported timely, it would not have reached the level of a stage four pressure ulcer. During an interview on 06/26/2023 at 11:15 AM, the DON stated the treatment nurse would ask if Resident 48 could feel if she was soiled and to put on call light for staff to assist, and Resident 48 responded with no she can't. DON stated the procedure for a new wound of any kind was to have the treatment nurse look at it and treat it to see if it was resolvable prior to it becoming an actual pressure wound. Per DON, in this instance, the treatment nurse worked on the wound for a while and was not making progress and then the wound doctor was called. She stated during the time that the treatment nurse was working with the wound, it continued to worsen and there was not improvement. DON stated it was not a requirement to have the wound doctor look at the wound, I give her the freedom, if she isn't seeing progress then we can have the wound doctor. She stated the wound was not bad and it would be a matter of judgement that it worsened and timing of when the wound doctor came. DON stated usually if there are two weeks of no improvement with wounds, then it was escalated up to the wound doctor. She stated that this could have been a lack on the part of nursing and CNAs, as they should have done skin assessments and observed during showers. DON confirmed that Resident 48 did have diarrhea occasionally, a couple of times a week. She stated during IDT (interdisciplinary team) meetings, it was briefly discussed that the current wound care was appropriate and that the wound doctor did not need to be called. DON confirmed that there was not a policy talking towards when to reach out to a wound doctor, it is just nursing judgement. She stated that Resident 48 was on a LALM and provided the manufacturer's user manual for the Domus 4. A review of the user manual for Domus 4 (an LALM) dated 2018, indicated, This product is intended to help and reduce the incidence of pressure ulcers while optimizing patient comfort. It also provides following purposes: To help and reduce the incidence of pressure ulcers while optimizing patient comfort. For long-term home care of patients suffering from pressure ulcers. For pain management as prescribed by a physician.

Based on interview and record review, the facility failed to ensure medication orders were administered safely and within standards of practice, when insulin (medication that regulates blood sugar) dosage orders were modified by Licensed Nursing staff without notifying physician and receiving new orders for one of three residents (Resident 1). This failure resulted in a significant change of condition when Resident 1 had a severe low blood sugar level that required emergent life saving measures causing injuries and hospitalization . Findings: A review of facility policy titled, Administering Medications, revised [DATE], indicated If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's attending physician or the facility's medical director to discuss the concerns. A review of an admission record indicated Resident 1 was admitted to the facility on [DATE] at 5:09 pm, with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1 was able to make health care decisions. A review of a hospital discharge summary for Resident 1, dated [DATE] at 8:57 AM, indicated on [DATE] Resident 1 was seen at bedside, his blood sugars were in the 60's (low end blood sugar level). Monitor with low blood sugar protocol and 50 percent glucose (given for low blood sugar provides five times the amount of glucose in a normal adult's blood) was given. On [DATE], it indicated, Patient blood sugars are stable. Sliding scale (the dosage of insulin based on blood glucose level) will be continued. It was also documented that Resident 1 had uncontrolled Type 2 Diabetes. Resident 1 had blood glucose levels on [DATE] - 122 milligram (mg) per deciliter (dl), on [DATE] - 109 mg/dl, and on [DATE] - 148 mg/dl. The discharge medications included, [MEDICATION(S)] (fast acting insulin) KwikPen (insulin for Type 2 Diabetes) 100 units/ml injectable solution 42 units, subcutaneous (injection under the skin) at bedtime was ordered on [DATE]. A review of a Nursing Admission Assessment for Resident 1 dated, [DATE] at 5:09 PM, indicated under physical observation, there was no documentation for the most recent blood glucose taken. The assessment was signed by the Director of Nursing (DON) and completed on [DATE], seven days after admission. A review of a Care Plan dated [DATE], stated Resident 1 used insulin for blood sugar control, and documented the Goal was that the resident will not have complications related to diabetes through the review date. It was noted the Interventions/Tasks included Diabetes medication as ordered by doctor; Monitor/document for side effects and effectiveness. A review Resident 1's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . It indicated there were no orders for a sliding scale or blood glucose monitoring in the record. A review of Monitoring Parameters, recommended by Lexicomp (online drug guide, updated 2021), Glucose monitoring is recommended before meals and snacks, and at bedtime for diabetic patients on [MEDICATION(S)] insulin. A review of Resident 1's Order Recap Report, indicated on [DATE] (date of admission) there was a medication order for [MEDICATION(S)] KwikPen Solution Pen-Injector 100 UNIT/ML - Inject 42 Units subcutaneously at bedtime for Type 2 Diabetes. During a review of Resident 1's, ,d+[DATE] Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE], RN 1 indicated on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no schedule on the MAR for blood sugar checks. A review of Resident 1's Progress Notes, indicated: 1. On [DATE] at 7:40 PM, RN 1 documented a blood glucose of 224 mg/dl, and documented she administered 3 Units of [MEDICATION(S)] insulin at 7:40 pm, according to sliding scale because 42 units seems to be too high. RN 1 did not notify physician of concerns with insulin order and dose. 2. On [DATE] at 8:30 PM, RN 1 documented a blood glucose of 301 mg/dl, and indicated she administered 6 Units of [MEDICATION(S)] insulin 8:30 pm, according to sliding scale because 42 units seems to be too high. RN 1 did not notify physician of concerns with insulin order and dose. 3. On [DATE] at 9:43 PM, RN 1 documented a blood glucose of 224 mg/dl, and indicated she administered 4 Units of [MEDICATION(S)] insulin at 9:43 pm, according to sliding scale because 42 units seemed to be too high. RN 1 did not notify physician of concerns with insulin order and dose. A review of an online resource issued by the American Diabetes Association (2021), titled Standards of Medical Care in Diabetes, indicated that glucose monitoring for individuals with Type 2 Diabetes was Essential to preventing [CONDITION(S)] (a condition in which your blood sugar level is lower than normal) and critical to the management of diabetes. A review of Resident 1's Progress Notes, dated [DATE] at 3 AM, indicated a change of condition was documented, and the following report was made: Certified Nursing Assistant (CNA) notified, resident is not responding. Upon assessment resident cool to touch and he is very pale, eyes wide open, but no blinking response and no pulse noted, resident unable to communicate, not responsive to verbal and tactile stimuli, pulseless. Cardiopulmonary resuscitation (CPR) initiated. After 2 minutes into CPR, resident jerking and moaning, pulse noted. Blood sugar checked is 26 mg/dl. [MEDICATION(S)] (hormone given for severe low blood sugar level less than 50 mg/dl) 1 mg intramuscularly given, it was not effective, his blood sugar still low 22 mg/dl. Called ambulance and sent resident to Emergency Department (ED) for further treatment and evaluation. A review of an ambulance record titled, Patient Care Report, dated [DATE], indicated, first responders were dispatched to the facility for an unresponsive resident. Upon arrival the transport team found Resident 1 to be unresponsive with shallow breathing, and nursing staff documented the resident was last seen normal at 1 AM but at 3 AM staff found the resident unresponsive. The transport team reported Resident 1 had two simultaneous seizures [MEDICATION(S)] 10 seconds each, without regaining consciousness, en route to the hospital. A review of a hospital record titled, Emergency Medical System Radio Call Log, dated [DATE] at 3:05 AM, indicated that Resident 1 required advanced life support for [CONDITION(S)] ([CONDITION(S)] symptoms occur when blood sugar levels fall below 70 mg/dL), with a blood glucose level of 27 mg/dl and [CONDITION(S)]-like activity. During a review of a hospital record titled, ED Physician Notes, dated [DATE] at 7:41 PM, indicated that Resident 1 was brought back to the emergency room for Right-sided chest pain. The record also indicated that since the last visit (for [CONDITION(S)] on [DATE] at 3:17 AM), Resident 1 required a blood transfusion due to critically low hemoglobin and hematocrit values (Hemoglobin is a protein in red blood cells and Hematocrit is a measurement of the amount of red blood cells as related to total blood cell count.) It indicated Secondary to the CPR he received on [DATE], Resident 1 had the following injuries: 1. Multiple rib fractures on both sides (injury that occurs when one of the bones in your rib cage breaks or cracks). 2. [MEDICATION(S)] force trauma (an injury to the body caused by forceful impact, injury, or physical attack with a dull object or surface.) 3. Pulmonary contusion (bruising of a lung which causes bleeding and swelling). 4. Splenic infarct (a condition in which blood flow supply to the spleen is compromised, leading to partial or complete tissue death due to oxygen shortage). A review of a hospital record titled, Progress Note - Final Report,dated [DATE] at 11:13 AM, it was indicated that Resident 1 had experienced a hypoglycemic event (on [DATE]) likely due to inappropriate insulin dose. During a review of a facility record titled, Communication/Inservice 1:1, dated [DATE], indicated that RN 1 was Educated that when needing to change medication dosage or administration, it requires notification and confirmation from the doctor or his representative, i.e.: Nurse Practioner (NP) or Physician Assistant (PA). The Director of Nursing (DON) indicated RN 1 Failed to notify the doctor's office of her actions. During an interview on [DATE] at 3:05 PM, RN 1 stated the insulin order for Resident 1 was [MEDICATION(S)] 42 units and did not have a sliding scale ordered. She checked Resident 1's glucose level and it was 224 mg/dl on [DATE], and she decided to give only 4 units of insulin using a paper sliding scale (unable to provide to surveyor) at the nurse's station and did not call the physician or notify the Charge nurse (RN 2). A review an Interdisciplinary Note (IDT- group of health care disciplines that meet to discuss resident care needs), dated [DATE] at 1:59 PM, indicated that DON documented facility practice, hospital orders are continued until Medical Director or his staff see resident and make adjustments. During an interview on [DATE] at 10:30 AM, DON stated, Whatever orders come from the hospital, that's what we give. The admitting physician goes with whatever the hospital sends as medication orders. DON stated, The new nurse didn't call the physician about concerns with insulin order. DON stated they did not have a dedicated admission nurse, the RN on shift would be the one to admit a new resident. DON stated her expectation would be that Licensed Nurses would review medications upon admission and notify physician regarding concerns about medication orders as indicated in their policy. DON confirmed there was no order for a sliding scale insulin or blood sugar monitoring. DON confirmed RN 1 was not following physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on [DATE] at 11 AM, Nurse Practitioner (NP, admitted and followed Resident 1) stated I am responsible for loading resident information into our system. I would call about an insulin order without glucose check orders and would order glucose checks twice daily and a sliding scale. NP stated, We never give [MEDICATION(S)] without a sliding scale, I saw [MEDICATION(S)] but may not have read the entire text, because we would never order [MEDICATION(S)] without a sliding scale. I would definitely go through the admission record much more thoroughly going forward. NP confirmed no orders written for sliding scale insulin or blood glucose monitoring. NP stated nursing staff should have notified a physician or NP if changes of condition or new orders were needed to monitor Resident 1. During an interview on [DATE] at 12:40 PM, RN 4 stated her role as the Admission Nurse was to perform resident assessments, enter medication orders into electronic medical record, and review medications orders. RN 4 stated I do not remember admitting (Resident 1), but I was new at that time and getting use to the process. If I noticed the insulin order was without a sliding scale or had a concern with the dose I would call the physician as soon as possible.

Based on observation, interview, and record review, it was determined the facility failed to follow its infection control policies when: 1. The facility did not maintain an effective mechanism for accurately completing and tracking employee health data and records for eight of eleven staff (Activity Director (AD), Social Services Assistant (SSA), Treatment Nurse (TN), Licensed Nurse (LN) W, LN X, LN Y, One on One Staff (OO) A, and OOB) when records did not reflect current [MEDICAL CONDITION] (TB - an infectious disease caused by bacteria that usually attacks the lungs) screening and health exams. 2. The facility did not ensure the accuracy and reliability of PPDs (purified protein derivative, skin test used to diagnose TB) for six of six staff (Housekeeper (HK) A, HK B, LN F, LN B, Certified Nursing Assistant (CNA) M, and Cook (CK) A) records reviewed. 3. An oxygen concentrator (a medical device used to deliver oxygen) had a noticeable layer of dust and the oxygen tubing was outdated for one of 19 sampled residents (Resident 9). These failures had the potential to put residents, staff, and visitors at risk for exposure to life threatening communicable diseases and constituted an Immediate Jeopardy (IJ) situation. (Refer to F726, F835, F837, F838, F839, F841, F865, F867 and F868) Findings: A review of the facility policy entitled, Employee Health Records, revised 8/2012, indicated that health records were maintained for all employees, including [MEDICAL CONDITION] (TB) screening. A review of the facility policy entitled, [MEDICAL CONDITION], Employee Screening for, revised 8/11, indicated all employees shall be screened for [MEDICAL CONDITION] infection and disease. The policy indicated individuals who have had bacille Calmette-Guerin (BCG, TB vaccination) should still have an initial screening test. 1. On 8/30/18 at 8:53 am, during an interview and concurrent employee records review, ICN/DSD indicated that employee medical exams for (YEAR) had not been done, as the Medical Director/Physician (MD) had been out of town and there was no backup for when MD was not available. In a sample of eleven staff records reviewed, eight did not reflect current TB screening and health exams: AD - Date of Hire: 4/24/17 Health Exam & PPD not current for (YEAR) SSA - Date of Hire: 3/16/17 Health Exam & PPD not current for (YEAR) TN - Date of Hire: 6/13/11 Health Exam & PPD not current for (YEAR) LN W - Date of Hire: 3/11/16 Health Exam & PPD not current for (YEAR) LN X - Date of Hire: 3/2/16 Health Exam not current for (YEAR) LN Y - Date of Hire: 2/15/18 PPD not completed upon hire OO A - Date of Hire: 2/15/18 Health Exam & PPD not completed upon hire OO B - Date of Hire: 2/15/18 Health Exam & PPD not completed upon hire On 8/30/18 at 10:50 am, during an interview and concurrent employee record review, ICN/DSD indicated he was unable to provide a complete list of current TB testing and medical exams for staff, as the spreadsheet he used for tracking was not up-to-date. On 8/30/18 at 11:35 am, during an interview, ICN/DSD indicated that all employees should have current TB screening/testing and should not be working with residents if TB screening/testing was not current. On 8/30/18 at 12:54 pm, during an interview with ICN/DSD and DON, ICN/DSD indicated a face-to-face screening questionnaire for TB was only completed upon staff hire and should be done annually. On 8/30/18 at 3:41 pm, during an interview and concurrent employee health record review of five currently working licensed staff, Administrator (ADM) confirmed that four of the five employee health files reviewed were incomplete and did not contain health exams, TB questionnaires, or TB testing necessary to clear the employees for work. On 8/30/18 at 3:48 pm, during an interview with DON and ADM, ADM indicated the ICN/DSD was disorganized and may have completed the TB tests, but did not document them. On 8/30/18, an expanded sample review of employee records revealed that 23 of 24 facility staff working on 8/30/18, had deficient employee health records, including face-to-face TB screening questionnaire, PPD or chest x-ray (CXR) as appropriate, and health exam. Due to facility leadership staff having knowledge of the non-compliance concerning staff TB screening and health exams and when it was not consistently maintained or monitored to ensure an effective infection control program, an IJ was declared on 8/30/18 at 4 pm in the presence of ADM, Administrative Director, and DON. On 8/30/18 at 5:11 pm, Minimum Data Set (a tool used in assessing the functional capabilities of residents) Nurse (MDS O) confirmed that the 23 employee health records were incomplete and did not contain health exams, TB questionnaires, or TB testing necessary to clear the employees for work. On 9/4/18 at 9:28 am, during an interview, DON indicated that ICN/DSD had gotten behind in monitoring/managing the staff TB skin testing/medical exams, but had not asked for help, so DON was unaware the tests/exams were so far behind. On 9/4/18 at 11:03 am and 1:30 pm, during an interview and concurrent record review, ADM indicated a review of all employee health files had been completed on 8/31/18 and continued over the weekend. ADM stated employee records were audited for compliance for TB screening questionnaire, TB testing or CXR as appropriate, and health exam, and that any staff not in compliance were required to complete the required screenings and/or exam. A sample review of 31 employee records of staff working on 9/4/18, revealed compliance for TB screening questionnaire, PPD or CXR as appropriate, and health exam in all 31 records. The record sample included fifteen regular clinical staff, eleven non-clinical staff, two contract staff, and three registry staff (staff from an outside company that provide nursing care). On 9/5/18 at 9:15 am, during an interview and concurrent record review, ADM provided documentation of an in-service to ICN/DSD and MD, titled, Importance of TB Testing TB Screening Questionnaires and Physicals, presented on 9/3/18, which outlined their responsibilities in maintaining and monitoring compliance with facility staff TB testing/screening and health exams. The ADM stated she did not present any clinical training to the ICN/DSD due to not being a licensed health care professional. The ADM stated the licensed nurses were instructed to do the TB training on their own via an Internet website source. The ADM stated no facility training or competency had been done with ICN/DSD or all the licensed nursing staff, and confirmed this was part of the plan of action presented on 8/30/18 at 7:31 pm to abate the IJ. During an interview with Payroll Staff (PS), on 9/5/18 at 9:10 am, while describing the PPD testing received by the ICN/DSD, PS reported that a needle was placed into the skin. PS denied seeing any type of raised skin upon injection, indicative of an appropriately delivered injection of serum (Centers for Disease Control, [MEDICATION NAME] Skin Testing). PS reported that the ICN/DSD looked at her forearm during the reading of the test when it required touching the skin at the injection site. During an interview with the Medical Records Assistant (MRA) on 9/5/18 at 9:15 am, the ICN/DSD did not feel for a raised area at the PPD site, only visually examined the area which did not follow policy. During an interview on 9/5/18 at 10:15 am, LN V, who had just attended the inservice on TB, was unable to state what a positive skin test would be for the resident population in the facility. On 9/5/18 at 10:20 am, during an interview and concurrent record review, DON indicated she had provided an in-service on TB screening, PPD administration, and how to read PPD results, to facility licensed nursing staff on 9/5/18 at 9:30 am, with 15 licensed staff in attendance. A review of the content presented revealed an inaccuracy in information on positive PPD results and did not include a validation of competency for licensed staff. On 9/11/18 at 8:36 am, during an interview, DON indicated she had consulted with County Public Health (CPH), after the IJ was declared, on curriculum development for facility staff education on TB and PPD administration. DON indicated an in-service was provided to licensed staff on 9/7/18 with 14 licensed staff in attendance. DON indicated that CPH would be assisting in additional facility staff education by providing an in-service on 9/17/18. On 9/11/18 at 8:42 am, during an interview with DON and ADM, ADM indicated the decision was made to re-test staff with PPDs done by ICN/DSD within past year. DON and ADM confirmed that only MDS O and MDS D were authorized to administer/read PPDs until other licensed staff were educated and validated for competency. DON indicated that over 100 facility staff were re-tested , due to concerns with reliability of PPDs administered/read by ICN/DSD. A concurrent review of training curriculum revealed clarification of positive PPDs to be 10 millimeters (mm) or more induration (localized swelling). DON and ADM confirmed that only staff with up-to-date PPDs were allowed to work. On 9/11/18 at 9:27 am, during an interview, LN V confirmed she received education on 9/7/18 for PPD administration. LN V explained the process of administering/reading a PPD correctly. She indicated her PPD was read yesterday by MDS D and confirmed PPD was read correctly. On 9/11/18 at 9:33 am, during an interview, LN G confirmed she received education on 9/7/18 for PPD administration. LN G explained the process of administering/reading a PPD correctly. On 9/11/18 at 9:36 am, during an interview, LN B confirmed she received education on 9/7/18 for PPD administration. LN B explained the process of administering/reading a PPD correctly. On 9/11/18 at 9:41 am, during an interview, LN F confirmed she received education on 9/7/18 for PPD administration. LN F explained the process of administering/reading a PPD correctly. On 9/11/18 at 9:55 am, during an interview, Occupational Therapist (OT) indicated her PPD was read today and confirmed PPD was read correctly. On 9/11/18 at 10:02 am, during an interview, CNA L, indicated her PPD was read today and confirmed PPD was read correctly by MDS O. On 9/11/18 at 10:05 am, during an interview, MDS D confirmed she received education on 9/7/18 for PPD administration and explained process of administering/reading a PPD correctly. MDS D confirmed she had been administering and reading PPDs. On 9/11/18 at 10:10 am, during an interview, Maintenance Assistant (MA) indicated he had PPD administered within the last week. MA indicated the PPD was read by MDS D and confirmed PPD was read correctly. On 9/11/18 at 10:13 am, during an interview, Medical Records Assistant (MRA) indicated DON read her PPD on Sunday. MRA confirmed PPD was read correctly. On 9/11/18 at 10:18 am, during an interview, LN A confirmed she received education on 9/7/18 for PPD administration and explained process of administering/reading a PPD correctly. LN A indicated her PPD was read by MDS D on Monday and confirmed PPD was read correctly. On 9/11/18 at 10:23 am, during an interview, HK C indicated his PPD was administered on Saturday and read by MDS D yesterday. HK C confirmed PPD was read correctly. A review of Guidelines for Prevention and Control of [MEDICAL CONDITION] in California Long Term Health Care Facilities, (MONTH) 2013, the California Code of Regulations (CCR), Title 22 Section requires that all Healthcare Workers (HCWs) working in health care facilities, including Long Term Care Facilities (LTCFs), be screened for TB within 90 days prior to employment or within seven days after employment and at least annually thereafter by a person lawfully authorized to perform such a procedure. 2. During a review of employee health records on 8/30/18, the following included positive TB Skin Test (TST) results (>=10 millimeters (mm)), followed by an annual negative TST results of 0 mm: HK A HK B LN F LN B CNA M Cook (CK) A On 8/31/18 at 10:48 am, MD was interviewed about the above employee health records. He confirmed that once their TST was positive, it would not turn back to negative or 0 mm and could not explain it. MD stated that if the employee had received a BCG as a child, their TST could be a false positive and later become negative. He confirmed the above employees were from out of the country and could have had BCGs done as children. a. During an interview with MDS A on 8/31/18 at 10:08 am, she confirmed that HK A had a positive TST from 9/15/11 and negative CXR from 6/1/11. She confirmed there was a negative 0 mm TST in his record, dated 9/17/17, and therefore no reliable TB status for HK A currently. During an interview with HK A on 9/3/18 at 4 pm, he confirmed he had not had a skin test in the last two years but had done a CXR. b. A review of LN F's employee health record showed she had a CXR, dated 12/14/12, due to a positive TST. Her record also included a negative TST, dated 7/1/18, measured as 0 mm. During an interview on 9/3/18 at 5:30 pm, LN F was asked about the negative TST, dated 7/1/18. She stated she had not done another TST since the CXR done 12/14/12 and therefore the TST for 7/1/18 was a false test. c. A review of CK A's employee health record showed a CXR done 2/28/11 due to a positive TST. Her record showed a TST with 0 mm done 2/27/15 and another TST with 0 mm on 5/28/17; Both negative results. During an interview on 9/3/18 at 5:55 pm, CK A stated she had not done any TSTs since her CXR 2/28/11 and therefore, the TSTs in her record for 2/27/15 and 5/28/17 were false tests. d. A review of CNA M's employee health record showed a CXR done 11/9/12 following a positive TST. Her record also included a negative TST, dated 12/1/16, with 0 mm as a result. During an interview with CNA M on 9/5/18 at 9:30 am, she stated she did not remember having done a TST since her CXR. e. A review of LN B's employee health record showed a CXR done 1/25/12 for a positive TST. Her record also included a TST, dated 9/10/17, with a 0 mm result. During an interview with LN B on 9/5/18 at 9:32 am, she confirmed she had not done a TST since her CXR 1/25/12 and therefore the TST, dated 9/10/17, was a false test. f. A review of HK B's employee health record showed she had a CXR done 1/7/14 to rule out TB. Her record also had a TST, dated 12/1/16, that showed 0 mm. During an interview with HK B on 9/5/18 at 9:41 am, she stated she had not had a TST done since her CXR, therefore the TST dated 12/1/16 was a false test. The ICN/DSD was interviewed on 9/5/18 at 10:17 am. He stated he had not reviewed the employee health records or done face to face TB screening questionnaires, prior to having employees sign their consents for annual TSTs. ICN/DSD confirmed he did not identify who had a positive TST or CXRs in their employee health record. When asked how he read employee TSTs to know if they were positive or not, ICN/DSD stated he looked at them for a visible reaction. He confirmed he did not feel the TST sites for induration to determine whether the result was positive or negative. ICN/DSD stated that he should not have administered the TST to the above referenced staff (HK A, HK B, CNA M, LN F, LN B, and CK A) if they had prior positives and CXRs on file. He stated that his prior TSTs were done Haphazardly. ICN/DSD admitted he may not have done the tests at all. 3. An initial tour of the facility was conducted on 8/29/18 at 8:33 am with Treatment Nurse (TN). During the initial tour, oxygen concentrators were observed in resident rooms. In a concurrent interview, TN stated that the filters (to help prevent dust and debris from entering the machine to be breathed in) for the oxygen concentrators were changed each weekend by the treatment nurse on duty. During an observation on 8/29/18 at 12:05 pm, LN Z was observed exchanging an oxygen concentrator in Resident 9's room. The oxygen concentrator was noted to have a solid layer of brown dust where the filter should have been, and the attached oxygen tubing was labeled with tape and dated 8/11. During a concurrent interview, LN Z confirmed the oxygen tubing was to be changed weekly and that the tubing was two weeks old. LN Z also confirmed that the filter on the concentrator was missing and should not have had any dust. Resident 9's record was reviewed and indicated she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 9 had a physician's order, dated 3/2/17, for oxygen at 3-4 liters per minute via nasal cannula (a device used to deliver oxygen) continuously every shift due to [MEDICAL CONDITION]. During an interview on 8/29/18 at 4:15 pm with the ICN/DSD, he reported he was behind in providing education to the nurses about the cleaning of the oxygen concentrators. During an interview with the DON, on 8/30/18 at 8:45 am, she reported that when a treatment nurse did not work on the weekend, it was the medication cart nurse's responsibility to clean the concentrator filters and to change the oxygen tubing. The DON confirmed the removed concentrator had a layer of brown dust, no filter, and that the tubing was outdated.

Based on observation, interview, and record review, the facility failed to ensure the necessary care and services to attain or maintain residents' highest practicable well-being for three of 21 sampled residents (Residents 13, 15, and 16) by failing to: 1. Ensure documented coordination of care for Hospice (End of life comfort care) services for two of 21 sampled residents (Residents 13 and 15). 2. Maintain adequate intercommunication between the facility and the [MEDICAL TREATMENT] (the process of mechanically cleansing excess waste and water from the blood via access to the patient's vein) center for one of 21 sampled residents (Resident 16), by failing to ensure documented treatment sheets for 9 of 13 treatments in 12/2013, 5 of 13 treatments in 1/2014, and 6 of 11 treatments in 2/2014, and fluid Intake and Output (I&O) sheets for 23 of 26 days in 12/2013, 31 of 31 days in 1/2014, and 17 of 26 days in 2/2014. These failures had the potential for staff not to be accurately informed of resident conditions / changes and the potential for residents to not be provided necessary medical care to prevent serious complications. Findings: 1. On 5/21/13, Resident 15 was admitted to the facility with [DIAGNOSES REDACTED]. A review of Resident 15's Minimum Data Set (MDS-an assessment tool), dated 12/2/13, indicated she had moderate memory problems, required full assistance for her personal needs and to walk. Resident 15 was able to make her needs known. A review of Resident 15's physician's orders [REDACTED]. A review of the "Hospice Binder" showed notations for every month since admission up to December 2013, there were no other entries after 12/23/13. The last three entries, 10/31/13, 12/13/13, and 12/23/13 indicated "No change in care." In an interview on 2/26/14 at 4 pm, Registered Nurse J, she stated that when the hospice nurse has new information or wants to make a change in a resident's care, they verbally tell the staff. The information or change in care does not always make it to the hospice binder documentation. 2. Resident 13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A MDS, dated [DATE], indicated that Resident 13 was alert and oriented and able to make her own decisions. Resident 13 had began receiving Hospice Services on 2/21/14. Resident 13's record was reviewed and contained a physician's orders [REDACTED]. On 2/24/14 at 5:10 pm, during an interview and record review with the Director of Nurses (DON), the DON confirmed that medication and oxygen order had been changed by the Hospice agency staff on 2/21/14, and confirmed that there was no documentation in Resident 13's record from the nurse who signed the change in the order. The DON confirmed that there were no indications that any other Hospice staff had been in to visit Resident 13 and that she did not know when or which Hospice staff were scheduled to visit Resident 13. DON confirmed that there was no hospice plan of care in the record. On 2/26/14 at 4:30 pm, during an an interview the Director of Hospice (DOH) confirmed that the nurses usually complete there documentation the day after a visit and then fax it to the facility. The DOH stated that a nurse, had been out on 2/24/14 and that a certified nurse assistant, social worker and clergy had been out on 2/25/14. The DOH concurred that there was no record of these visit in Resident 13's record and that the facility staff did not have the information available to coordinate care. 3. Resident 16's record was reviewed on 2/26/14. Resident 16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/26/14 at 11:30 am, during an observation and interview, Resident 16 confirmed that he went to [MEDICAL TREATMENT] three times a week. Resident 16 was noted to have a white foam drinking cup at his bedside, and he confirmed that he drinks independently. Resident 16's record contained a physician's orders [REDACTED]. Resident 16's record contained a [MEDICAL TREATMENT] communication sheet that instructed the facility to "Complete top portion of form prior to residents [MEDICAL TREATMENT] treatment. Send with the resident or fax to the [MEDICAL TREATMENT] center." The form instructed the [MEDICAL TREATMENT] center to: Complete lower half of form at end of treatment. Copy for [MEDICAL TREATMENT] record and send original back to the nursing facility." On 2/26/14 at 4:50 pm, during an interview and record review, the DON confirmed that of the last 37 [MEDICAL TREATMENT] treatment days the record was missing 19 communication sheets. The DON stated that it was the facilities practice to call the [MEDICAL TREATMENT] facility when the resident did not return with the communication sheet, however, the DON confirmed that there had not been follow up. Resident 16's fluid intake and output (I&O) record was reviewed. Resident 16's I&O sheets indicated that Resident 16's total fluid intake on 2/23/14 was 2010 cc, and on 2/24/14, was 2020 cc (Over the prescribed fluid restriction). Resident 16 did not have an I&O record sheet completed for 23 of 26 days in 12/2013, 31 of 31 days in 1/2014, and 17 of 26 days in 2/2014. Resident 16's record contained a "[MEDICAL TREATMENT] Flow Sheet." The sheet instructed nursing staff to document when resident left for [MEDICAL TREATMENT], when the resident returned, blood pressure, heart rates, check the dressing and monitor for bleeding on return and two hours after return. Resident 16 did not have the [MEDICAL TREATMENT] flow sheet completed for nine of 13 [MEDICAL TREATMENT] treatments in 12/2013, five of 13 [MEDICAL TREATMENT] treatments in 1/2014, and six of the 11 [MEDICAL TREATMENT] treatments in 2/2014. On 2/27/14 at 10: 30 am, during an interview and record review, the DON confirmed the above missing documentation. An undated facility policy titled, "Care of a [MEDICAL TREATMENT] Resident" was reviewed. It directed the facility after [MEDICAL TREATMENT] to take blood pressure, and respiration and pulse rate. The policy instructed that fluid restrictions will be provided, as prescribed by a physician's orders [REDACTED].

Based on observation, interview, and record review, the facility failed to ensure two of 13 sampled residents (Residents 7 and 13) received the necessary care to maintain their highest practicable physical, mental and psychosocial well being when: 1. Resident 7 did not receive care to prevent recurrent ongoing [MEDICAL CONDITION] (convulsion, episode of abnormal brain electrical activity when body shakes rapidly and uncontrollably), following a fall with loss of consciousness and head injury. The facility delayed treatment when Resident 7's ongoing [MEDICAL CONDITION] were untreated for [REDACTED]. This caused Resident 7 harm from continuous [MEDICAL CONDITION], muscle injury resulting in rhabdomylosis (potential life threatening condition from rapid destruction of skeletal muscle that can destroy the kidneys which filter the blood). 2. Resident 13's Hospice (end of life comfort care) services were not documented for coordination and this failure had the potential for Resident 13 not to receive adequate comfort care and symptom management. Findings: 1. Resident 7 was originally admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 7 had no history of [MEDICAL CONDITION]. Following admission to the acute care hospital, on 5/26/14, Resident 7 was readmitted to the facility, on 6/6/14, with [DIAGNOSES REDACTED]. On 6/10/14, the facility's, "Change in Resident Condition policy," undated, read, "A. Acute Medical Change 1. Any sudden or serious change in a resident's condition manifested by a marked change in physical or mental behavior, will be communicated to physician with a request for physician visit promptly or acute care evaluation. The licensed nurse in charge will notify the physician AT ONCE." Resident 7's Change of Condition Form, dated 5/23/14 at 2 pm, showed she was found unresponsive, lying on the floor with her head between the bed and the dresser, with swelling to the right side of her head, Resident 7 regained consciousness, and her physician was notified. On 6/10/14 at 3:10 pm, Licensed Nurse (LN) L stated that Resident 7's head became swollen after the fall, she was fatigued, exhausted and that her lips were flapping/vibrating when breathing, like someone following a [MEDICAL CONDITION]. Resident 7's nurse note, dated 5/24/14 at 2 pm, showed she was observed to have jerking movements for 25 seconds. Resident 7's Neurological (brain, spinal cord and nerves physical responses) Assessment Flowsheet, dated 5/23/14, did not include the 2 pm [MEDICAL CONDITION] activity (jerking movements), on 5/24/14, which was to be noted under the Observations column. During the [MEDICAL CONDITION], the monitoring documentation was downgraded from monitoring every four hours to once per shift following the facility's neurological assessment protocal. Resident 7's nurse note, dated 5/24/14 at 6 pm, (four hours later) showed swelling to the right side of her head. Resident 7's nurse note, dated 5/25/14 at night (no time noted), documented no new injuries noted due to fall. Resident 7's "Change of Condition Form," dated 5/25/14 at 12 noon, showed she had two [MEDICAL CONDITION], was unable to move the right side of her body and a new physician's orders [REDACTED]. Resident 7's physician's orders [REDACTED]. On 6/10/14 at 3 pm, Licensed Nurse (LN) D stated that Resident 7's lips turned purple and her arms and legs shook during her [MEDICAL CONDITION]. LN D stated she had [MEDICAL CONDITION] on 5/25/14 at 9 and 10 am and at 12 noon. LN D stated the facility did not have [MEDICATION NAME] in the emergency kit to administer to Resident 7 for her [MEDICAL CONDITION], so the order was written to administer [MEDICATION NAME] "when available." Resident 7's nurse note included an entry, dated 5/25/14 at 1 pm, that right sided weakness was noted. An entry, on 5/25/14 at 10 pm, included 2 episodes of jerking movements, continued episodes of incontinence (loss of bladder control), yet noted no injury related to fall 5/23/14 with loss of consciousness and swelling. The 10 pm entry included the notation, "Started on new med [MEDICATION NAME]" The medication was unavailable at this time. Resident 7's nurse note and medication administration records, dated 5/26/14, noted the first dose of [MEDICATION NAME] given at 3 am, 15 hours after physician's orders [REDACTED]. During an interview with Registered Pharmacist (RPh) on 6/11/14 at 2:53 pm, he confirmed Resident 7's [MEDICATION NAME] was not delivered until 1:16 am on 5/26/14. RPh stated they received the original order for Resident 7's [MEDICATION NAME] at 11:53 am on 5/25/14, but it was unclear. RPh stated the order appeared to be for five 300 milligram (mg) tablets, twice daily (BID) and [MEDICATION NAME] did not come in 300 mg or 500 mg tablets and only came in 100 mg tablets. RPh stated five of them (1500 mg total) would be an excessive dose so they called the facility for clarification at 1:30 pm on 5/25/14. RPh stated his pharmacy called the facility three to five times throughout the day because of the "hanging order." RPh stated at 11 pm, they received the clarified order of 500 mg [MEDICATION NAME] BID twice daily and it was a "pretty high" dose at 1000 mg split into two doses. RPh stated it was not a good choice and a better choice would have been [MEDICATION NAME] (anti-anxiety medication used to stop [MEDICAL CONDITION] in [DIAGNOSES REDACTED]) which the facility already had in their emergency kit. On 6/11/14 at 2 pm, Nurse Consultant (NC) confirmed Resident 7 should have been medicated within four hours of initial [MEDICAL CONDITION] activity on 5/24/14. Resident 7's nurse note, dated 5/26/14, read, "jerking movement every 5 minutes noted. MD (medical doctor and Resident 7's physician) notified. MD ordered, "send resident to ER (emergency room ) for eval (evaluation) and treatment." On 6/11/14, Resident 7's two page Resident Transfer Form (document with resident's pertinent medical information, prepared by the facility for the acute care hospital to effectively diagnose and treat), dated 5/26/14, did not include any information from the facility about the 5/23/14 fall with head injury or loss of consciousness, just prior to her new onset [MEDICAL CONDITION]. On 6/11/14 at 10 am, LN M confirmed that Resident 7's Transfer Form, dated 5/26/14, should have included information about her recent fall and head injury, just prior to the onset of her [MEDICAL CONDITION]. Resident 7's acute care hospital emergency room note, dated 5/26/14 at 6:53 pm, included an entry showed no medical history was given to the hospital, by the facility. On 6/18/14 at 1 pm, the MD was told Resident 7's fall with loss of consciousness was omitted from her Resident Transfer Form. MD confirmed her fall with loss of consciousness was "pertinent history" for the acute care hospital's admission on 5/26/14. MD confirmed Resident 7 seizing for 15 hours was "not exactly good for you." MD stated the facility had not requested he come in and evaluate Resident 7, following her fall or request that she be sent to the acute care hospital. On 6/11/14 at 2:58 pm, when the Director of Nurses (DON) N was asked if the facility had followed their Change in Resident Condition policy or if they had asked the physician to come in and evaluate Resident 7 following her fall, DON N did not answer the question. Resident 7's acute care hospital reports for her admission on 5/26/14 were reviewed. Her head injury and loss of consciousness after her fall on 5/23/14 was not included in the history of any of the different physicians' reports: emergency room Report dated 5/26/14; Neurology Consult, dated 5/27/14; Neurology Progress Reports, dated 5/28, 5/29, 5/30/14; and Transfer Summary, dated 6/6/14, showed Resident 7's physicians were not aware of her recent head injury. On 6/18/14 at 1:40 pm, the Neurologist (NR, physician that [DIAGNOSES REDACTED]. NR stated this indicated he had not been made aware of it and it was pertinent to Resident 7's case. NR stated that Resident 7 should have had her [MEDICATION NAME] administered as ordered (not 15 hours later) and that it was not good for Resident 7 to have been left untreated for [REDACTED]. 2. Resident 13 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 13 was admitted to Hospice on 5/1/14. Resident 13's record was reviewed on 6/11/14. The Hospice plan of care indicated physician orders [REDACTED]. There was no documentation found in Resident 13's record for a skilled nursing Hospice assessment visit from 5/4/14 to 5/12/14 (eight days) and from 5/14/14 to 5/23/14 (ten days). During a concurrent interview and record review on 6/11/4 at 8:15 am, the Director of Nursing (DON) confirmed there was no documentation in Resident 13's record indicated a weekly Hospice visit from 5/4/14 to 5/12/14 and 5/14/14 to 5/23/14. During a telephone interview on 6/11/14 at 10:45 am, with the Hospice Supervisor (HS), she stated a skilled nurse did make a Hospice visit on 5/10/14 and explained they fax their visit notes within two days of the visit. The HS confirmed there was no skilled nursing Hospice visit from 5/14 to 5/23/14 a 10 day gap and they did not follow the plan of care as ordered by the physician. During an interview with DON on 6/12/14 at 9:30 am, about the plan of correction for Hospice communication, she stated there was no system in place to track the documentation or scheduled visits for Hospice services. The agreement dated 6/6/08, between the Hospice provider and the facility indicated under records, each clinical record shall completely, promptly, and accurately document all sources provided to, and events concerning, each Residential Hospice Patient (including evaluations, treatments, progress notes, authorizations, to admissions to Hospice and or Nursing facility and the physician orders [REDACTED].

Based on observation, interview, and record review, the facility failed to ensure that two of 21 sampled residents (Residents 4 and 14) who entered the facility without pressure sores, did not develop new pressure sores: 1. Necessary care planned interventions to prevent the development of new pressure sores were not implemented for Resident 14 resulting in the development of two avoidable Stage III pressure sores (Full thickness skin loss). 2. Resident 4 developed an avoidable, Stage IV pressure sore on her coccyx, was not provided sufficient nutritional assessment / interventions to promote wound healing, and was subsequently hospitalized for [REDACTED]. These failures resulted in increased medical treatment, a decline in functional ability, pain, and the potential for infection and/or further decline in physical and psychosocial well-being for Residents 4 and 14, and had the potential for other residents to develop avoidable pressure sores. Findings: 1. Resident 14's record was reviewed. Resident 14 was admitted to the facility on [DATE] for rehabilitation after a hip surgery with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS, a resident assessment tool), dated 2/5/14, identified that Resident 14 had two stage 3 pressure sores that were not present on admission, and that she was totally dependent on staff for toileting, hygiene, and transfers. A "Potential for Skin Integrity Impairment Care Plan," updated 12/18/13, identified that she had a high risk for skin breakdown. The care plan did not include any interventions to reduce the risk of a pressure related injury from a her knee immobilizer (a splint device that is attached by Velcro straps completely around the leg and runs the length of the leg from just below the hip to just above the ankle) that she had continuously worn since her admission to the facility. The care plan interventions to prevent skin breakdown included daily skin checks during routine daily care and weekly skin checks by licensed staff. A Physician's telephone order for Resident 14's right femur fracture care, dated 12/18/13, read "PT (physical therapy) - Strict non weight bearing to right leg; may remove knee immobilizer for knee ROM (range of motion)...May remove knee immobilizer for hygiene, bathing and therapy." On 1/14/14 a new physician's orders [REDACTED]. May remove immobilizer for Knee ROM x 42 days." The order for removing the immobilizer during bathing and hygiene was no longer written in the physician's orders [REDACTED]. A "Condition Change Form," dated 1/27/14 and timed at 10 am, read, "Dry black eschar (dead skin tissue) on resident's right lower lateral (outer) leg (2 areas) near ankle area...leg brace may be applying pressure to the area, brace adjusted and taken off while in bed." The form read that the physician was notified and in agreement with the plan. The physician's orders [REDACTED]. No care involving assessment of the skin beneath the brace was documented in Resident 14's record, prior to the skin breakdown. On 2/26/14 at 1:05 pm, Licensed Vocational Nurse/Treatment Nurse (LVN TN) stated that he was the nurse who did weekly skin checks on Resident 14, as well as, documented her pressure sores. He stated that when he had done a full weekly skin check, prior to the pressure sores, he did not notice any redness or skin problems related to the knee immobilizer on her lower leg. He stated he was notified of the skin problem on 1/27/14 by the physical therapy department. LVN TN stated, "It just appeared overnight." Two "Wound/Skin Healing Records," dated 1/27/14, identified two new areas of skin breakdown. The wound records read wound "Site 1" (higher up the right lower leg) measured 2.5 centimeters (cm) long by 1 cm wide, with a dark area surrounding it and covered with eschar. A second wound record, for "Site 2" (the second new wound on the lower right leg nearest to the ankle) measured 1.5 cm long and 1 cm wide with a surface of dry eschar. No depth measurements were documented for either of the new wounds on 1/27/14. A "Wound Care Specialist Initial Evaluation," dated 1/30/14, read that Resident 14 had two "Stage 3 Pressure Wounds (sores)" on her right calf (lower leg). The evaluation identified the cause of the two pressure sores as "Etiology (cause) ...Pressure" and "Duration: greater than 3 days" for both sores. The 1/30/14 Wound Care Specialist (physician) report indicated that the sore at "Site 1" was measured at 2.8 cm long by 1.5 cm wide by 0.1 cm deep before removal of dead tissue. After dead tissue removal the report read that the sore was 0.2 cm deep. The evaluation for "Site 2" read 1.2 cm long by 0.6 cm wide by 0.1 cm deep with no dead tissue. Both sites had a moderate amount of serous (clear) drainage. A "Wound Care Specialist Evaluation," dated 2/13/14, read that "Site 1" measured 2.9 cm long by 1.1 cm wide by 0.4 cm deep. Surgical wound debridement (removal of dead tissue) was done on this site on 1/30/14 and 2/13/14 causing a deepening of the base of the wound to 0.4 cm on 2/13/14. The evaluation for "Site 2" read 1.8 cm long by 0.7 cm wide by 0.1 cm deep with no dead tissue. Both sites read that they had a moderate amount of serous (clear) drainage. A note that a two by two inch dressing was applied to Resident 14's leg brace on 2/13/14 was made by the specialist. On 2/27/14 at 7:24 am, an observation of a measurement of Resident 14's pressure sores with LVN TN was conducted. Wound Site 1 measured 2.85 cm long by 1.3 cm wide by 0.2 cm deep and Site 2 measured 1.4 cm long by 0.9 cm wide by 0.0 cm deep. There was no dead tissue observed on either wound and no signs of infection. LVN TN stated that the wounds had showed some improvement from the date of discovery. On 2/27/14 at 11 am, Certified Nurses Aide (CNA) H stated that she had taken care of, or had assisted in, Resident 14's hygiene and bathing needs several times in the period prior to the discovery of her pressure sores on her right leg by the physical therapy department on 1/27/14. CNA H stated that the she was instructed to keep the immobilizer on at all times. She stated that Resident 14 was receiving bed baths two or three times per week and a skin check sheet was completed. CNA H stated that it was not common practice to remove the knee immobilizer for bed baths or hygiene care and that the skin sheets did not reflect the condition of her skin below the knee immobilizer. On 2/27/14 at 11:30 am, the Director of Nursing (DON) and Registered Nurse Consultant (CRN) stated that Resident 14's preventative skin care plan should have included preventative interventions related to the risk of pressure sores from the knee immobilizer. DON stated that she had relied upon the CNA shower skin sheets and skin checks done by licensed staff to identify skin problems before they progress. DON and CRN stated that Resident 14 should not have sustained her pressure sores. On 3/5/14, the facility Administrator was contacted and requested to provide Resident 14's treatment records (TR) for 1/2014. After two faxes and three contacts with the facility, the facility was unable to provide the requested documents. Refer to F 514. 2. Resident 4's record was reviewed. Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 4 had just recovered from a pressure sore obtained in July 2013. On 2/25/14 at 4:00 pm, Resident 4 was observed in her bed. She was awake but confused. Resident 4 was noted to be attempting to reposition herself in bed. When Resident 4 attempted to sit on her bottom, she said, "ouch" and put her hand on her bottom. On 2/26/14 at 9:00 am, Resident 4 was observed during a dressing change and treatment to the pressure sore on her coccyx (tailbone). The treatment was being provided by Licensed Vocational Nurse, Treatment Nurse (LVN TN). The pressure sore was determined to be a Stage III wound and was measured by the LVN TN as 3.0 cm (centimeters) wide by 4.0 cm long by 0.4 cm deep. A review of a care plan titled, "Nutritional / Dehydration / Fluid Maintenance Care Plan," initiated 7/10/13 and last reviewed 12/3/13, indicated that Resident 4's daily nutritional needs would be met, that 75% or more of meals would be encouraged, and if the intake was less, that substitutes were to be offered to ensure adequate nutrition. A review of a document titled, "Weight Review," dated 12/3/13, indicated that that Resident 4 was experiencing a gradual weight loss and that Resident 4's protein requirements were 1 gram per kilogram of weight. Review of laboratory values of Resident 4's serum (blood) [MEDICATION NAME] (protein) level while at the facility indicated a low level on 12/13/13 of 3.3 milligrams per [MEDICATION NAME] (mg/dl- unit of measure). Normal values were identified as 3.5-5.7 mg/dl. A review and calculation was conducted by this surveyor of documented daily percentages of Resident 4's nutritional intake during the month of December, 2013. The daily percentage was calculated for the three meals consumption per day, times 30 days. The calculation indicated that for in 12/2013, Resident 4 consumed an average daily percent of 58.6% of her meals. Based on a weight of 118 # (54 kilograms) with an allowance of 1 gm of protein/kg, this calculated to a protein intake of 30 grams, far below the minimum recommendation of 54 grams of protein per day. There were no RD assessments provided between the time of 12/3/13 and 1/28/14. For the month of December 2013, Resident 4 did not meet the goal of 75% for 30 of 31 days, per the plan of care and there was no nursing documentation that this concern was discussed with the RD. A review of Nurses Notes, dated 11/28/13 through 1/12/14 was conducted and indicated the following: On 12/9/13 at 7:00 pm, Resident 4 "needed total assist for bed mobility, eating, ..." On 12/16/13 at 1:30 pm, Resident 4 required extensive assistance with activities of daily living (ADLs). On 12/30/13 at 8:30 pm, a weekly progress note indicated that "Resident (4) was in bed and stays in bed throughout shifts. Was a 1:1 feeder (requiring feeding assistance of one person) on puree diet (a special consistency, blended foods, for persons who have difficulty swallowing or chewing). On 1/1/14 at 9:00 am, a status change note indicated that Resident 4 was found with "an open area on coccyx. Pink wound bed, no drainage. Responsible Party was notified." Not until the date of 1/1/14, when a Stage II pressure sore was identified, was every two hour turning addressed in nursing notes. The notes did not indicate that Resident 4 was a high risk resident for a pressure sore. A review of a facility addendum plan of care, no title, identified a concern or a problem as "admitted with actual skin breakdown; Specify: Hand written was "open area to coccyx" and appeared to be dated 1/1/14 (strikeover). This document included low air loss mattress and turning and repositioning every two hours as interventions to be provided. A review of Wound/Skin Healing Records for Resident 4 indicated, on 1/1/14, a "1.0 x 1.0" wound with location identified as coccyx, pink wound bed, no drainage. On 1/8/14, Resident 4's wounds was described as "1.0 x 1.0, Stage II (partial thickness skin loss involving the epidermis (outer layer of skin), dermis (the second layer of skin), or both), scant serous exudate (drainage), pink/beefy red skin bed, surrounding tissue and skin edges normal for skin, and pain as demonstrated by guarding of the tailbone area. This notation area indicated that dietary staff was notified on 1/1/14, and the family and physician were notified on 1/8/14. This is the last description of the pressure sore, prior to 1/13/14, when Resident 4 was transferred to an acute care hospital. A review of a "Wound Care Specialist Initial Evaluation," a tool utilized by the wound physician, dated 1/8/14, indicated that Resident 4 had a Stage II pressure wound of the coccyx of at least 7 days duration. The size of the wound was identified as 1.0 x 1.0 x 0.02 cm (centimeters). Deconditioning and Immobility were identified as Musculoskeletal System problems. A review of a document in Resident 4's records, no title, dated 1/9/14, not signed, but validated by Responsible Party (RP MH) that she submitted this to the facility indicated, "I called the meeting early." This document indicated RP MH's care concerns for Resident 4 and addressed the pressure sore as "bedsore-how often turned; before the meeting in the same position 7:30-11:00." A review of a facility interdisciplinary team (IDT) meeting document, dated 1/9/14, no time, did not address the pressure sore for Resident 4 or interventions to be provided to ensure that the pressure sore did not worsen. A review of physician's orders [REDACTED]. A review of Resident 4's "Potential for Skin Integrity Impairment Care Plan," originally dated 7/9/13 and last updated 1/12/14, indicated that a high risk Braden Score (skin assessment tool) was 0-15. Under "Approaches/Interventions," options for turning were not checked off. The approach to instruct the Resident in turning and position change was checked off (Resident 4 had dementia and required cues and assistance to turn). Pressure reducing devices were not checked off. The care plan included a goal that 75% of all meals would be consumed and nutritional intake would be monitored and a referral would be made to the Nutrition / Hydration / Skin Committee, as indicated. The care plan did not address what actions were to be taken when the stated goal for nutritional intake was not met. (Adequate nutritional intake help promote wound healing). On 1/13/14, Resident 4 was transferred to a hospital emergency room for evaluation of a change in condition. A review of the acute care facility photographs of Resident 4's pressure sore, dated 1/13/14 and timed 1:00 pm, indicated a pressure sore on the sacrum of Resident 4 with eschar and dark colored tissue surrounding the eschar area of the sore. This date and time are when Resident 4 was in the emergency room of the acute care facility after transfer from the skilled nursing facility. On 1/13/14, hospital laboratory values were reported for Resident 4 as follows: Serum [MEDICATION NAME] value was reported at 3.7 mg/dl, a low normal value in the presence of dehydration; a total protein level of 7.7 mg/dl (abnormally low). Resident 4 suffered unplanned weight loss, malnutrition, a Stage IV pressure ulcer, and dehydration which resulted in her hospitalization on [DATE]. A review of a hospital Nursing Assessment, dated 1/14/2014 and timed 10:25 am, indicated the Wound Care Certified Nurse documented that Resident 4 was admitted on [DATE] with an unstageable pressure sore, location on the coccyx, size 4.8 x 6.2 centimeters, no depth identified because of eschar making the wound bed unidentifiable. Resident 4 was re-admitted to the facility on [DATE] with a different staging for the pressure sore (unstageable-more severe) and this stage was identified in the acute care hospital on admit 1/13/14. Upon re-admission to the facility on [DATE], Wound/Skin Healing Records indicated Resident 4's wound was described as a coccyx/sacrum wound, size of 3.5 x 4.5, UTD, soft black eschar, with infection. There were no units of measure given for the sizes of the wounds on any of these documents. In the section, Plan of Care Updated, yes or no was not marked or checked. A review of a document, Wound Risk Notes, dated 1/17/14, not timed, and signed by Resident 4's physician at the facility, identified the pressure sore as "acquired in house, Stage unable to determine (UTD), acquired on admission -No." This document indicated options to identify risk factors inclusive of active [DIAGNOSES REDACTED]. A review of a "Registered Dietician Nutrition Assessment," dated 1/18/14, indicated that Resident 4 weighed 52 kilograms and protein needs for Resident 4 were based on a protein factor of 1.0- to 1.2 (calculation used to determine protein needs based on actual weight) for maximum protein needs identified at 52 to 62 grams of protein per day. The C RD based this calculation on a Stage II wound or mild depletion. However, Resident 4 at the time of this assessment had a Stage IV pressure ulcer on her coccyx with debridement of muscle and a healing Stage III pressure ulcer on her left ear, as well as continued identified weight loss. The correct protein factor would have been at a minimum of 1.5 gm (for Stage III or IV wound or moderate depletion) and a maximum of 2.0 gm/kg (for multiple severe wounds and as recommended by the wound care doctor). This would have provided a minimum daily requirement of 78 gm and a maximum requirement of 104 gm of protein per day. (The dietary consult from the wound care doctor was provided five days prior to the assessment by the C RD on 1/28/14). Further documentation indicated that the C RD spoke with a wound treatment nurse who identified the wound as a Stage II pressure ulcer to the coccyx with a size of 1.0 centimeters x 1.0 centimeters. This information was incorrect as Resident 4 was discharged from the acute care hospital with an unstageable pressure ulcer. A review of a "Wound Care Specialist Evaluation," dated 1/23/14 (6 days after re-admit to the facility), indicated the wound was "unstageable (due to necrosis (dead tissue) of the medial coccyx of at least 21 days duration." This same document indicated that a surgical debridement (cutting away of tissue under sterile technique with a scalpel blade) was performed to determine the margins of viable (living) tissue. The size of the wound was identified as 4.5 x 5.5 x 0.1 cm (centimeters). Additionally, the "Wound Care Specialist Evaluation," dated 1/23/14, indicated the wound was a Stage IV pressure sore ( Full thickness skin loss (3 layers) with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures) of the medial coccyx of at least 28 days duration. This note indicated surgical debridement of muscle. The size of the wound was identified as 4.6 x 5.2 x 0.7 cm. This note indicated the depth of the wound to be much deeper than the previous note. On both 1/23 and 1/30/14, the wound care physician recommended that Resident 4's protein requirement be adjusted up to 2 gms/kilogram of body weight. (Helps to promote wound healing). A review of a "Registered Dietician Nutrition Assessment," dated 1/28/14, Resident 4's pressure sore was identified as Stage IV, involving muscle. The C RDs note indicated that Resident 4 was consuming only 69% of her diet which would equal 71 gm of protein a day, below the recommended amount of protein needed to promote wound healing. On 2/4/14, the C RD notes identified two pressure ulcers, but the C RD did not increase the protein recommendations, as suggested by the wound care physician. Another C RD note, dated 2/11/14, indicated that Resident 4 was to be receiving approximately 170 gm of protein, but with an average intake identified as 63% per day, Resident 4 would have only received 107 gm of protein per day. A review of a facility policy titled, "Care For The Resident That Is High Risk For Skin Breakdown" indicated, under Purpose, "1. To protect the at risk patient from impairment in skin integrity, 2. To ensure documentation- (See Skin Care Documentation). treatment and evaluation by responsible persons." Under Procedure, "Prevent Pressure- a) Mattress- apply appropriate device as needed; b) Positioning in bed- Turn and reposition the resident at least every 2 hours using support pillows and cushions..." A review of a facility policy titled, "Skin Integrity" indicated, under Policy, Residents who have suffered loss of skin receive appropriate treatment; and under Procedure, Licensed Nurses were to inspect areas for potential breakdown on a daily basis, implement a program of repositioning at least every two hours, document the condition of the areas being treated once a week including size, depth, drainage, healing, medication, and devices used to reduce pressure, and update the resident care plan. During interviews conducted on 2/26/14 at 12:45 pm and 2/27/14 at 12:15 pm, Responsible Party MH (RP MH) stated that she had observed the pressure sore on Resident 4's coccyx during a dressing change on 1/11/14. She stated she was shocked and upset because she had just seen the pressure sore (PU) the day before with LVN TN and it was not as large as it was on this day. RP MH further stated that she had concerns that staff were not turning Resident 4 and had verbalized these concerns to the facility and documented her request for an interdisciplinary meeting on 1/9/14. RP MH stated that Resident 4 was unable to feed herself. RP MH stated that she had only one discussion with a RD on 2/4/14. RP MH stated that the pureed diet was needed for Resident 4 because her dentures did not fit well. RP MH expressed her concerns with Resident 4's poor nutrition, but could not get any answers from facility staff. RP MH was concerned that the CNA staff were not feeding Resident 4 and stated that she was the one who asked to have laboratory work done for Resident 4 because of her unplanned weight loss. RP MH stated that she did not get any responses either from her written concerns or those expressed in the interdisciplinary meetings. RP MH had concerns for Resident 4 to be sitting in a wheelchair for prolonged periods of time because of the pressure ulcer that had developed on her coccyx. During an interview conducted on 2/26/14 at 5:15 pm, LVN TN stated that he was in the facility on 1/12/14 and was called into Resident 4's room by RP MH to assess the pressure sore. LVN TN stated that there was another treatment nurse on that day but RP MH wanted to speak with LVN TN about the pressure sore. LVN TN stated that he was shocked at the size and color of the pressure sore on Resident 4 and that there was a definite worsened change in its appearance. LVN TN stated that he did not document the change in the chart or notify the doctor. LVN TN validated there was no documentation in the chart from the other treatment nurse, (a registered nurse), in the chart regarding the worsening of the pressure sore. LVN TN stated, the wound "happened here and we are healing it." In an interview conducted on 2/26/14 at 12:15 pm, the Director of Nursing (DON) and the Consultant Registered Nurse (C RN) both stated they were aware of the pressure sore that Resident 4 had acquired at the facility. The DON could not provide documentation of what the pressure sore looked like when Resident 4 was transferred on 1/13/14 to the acute care hospital. In an interview conducted on 2/27/14 at 11:45 am, Consultant Registered Nurse (C RN) stated that nutritional intakes and outputs (I & O's) were to be done on all Residents at risk of weight loss or with a pressure ulcer. C RN could not provide evidence that I&O's were done for Resident 4 in January 2014 to ensure adequate nutrition that could promote wound healing. A record review indicated that there were no documented meal percentages for the month of January, 2014. There were no documented I&Os for the period of January 1/1/14-1/13/14. In an interview conducted on 3/5/14 at 10:43 am, the DON verified that I&Os were not done for Resident 4, during the time period of 1/1/14 and 1/13/14, meal consumption percentages were not conducted for the month of January, 2014, and the DON could not show evidence that Resident 4's facility acquired pressure sore and worsening of the pressure sore were unavoidable. During an interview conducted on 3/5/14 at 4:38 pm, the facility's C RD stated she started following Resident 4's nutritional care beginning in January 2014, and verified that Resident 4 had unexplained weight loss. C RD stated she was misinformed about the Stage of Resident 4's pressure sore in January 2014, and did not increase protein requirements, despite physician recommendations, until requested by RP MH in February 2014. C RD stated that RDs visit once a week, however, because of the number of residents in the facility, more frequent visits to complex residents, such as Resident 4, could not be done. C RD stated that the RD consulting firm requested more RD consulting visits, but the facility denied the request.

Based on interview, observation, and record review, the facility failed to provide sufficient fluid consumption for Resident 4 to prevent dehydration for Resident 4. This failure resulted in Resident 4 being transferred to a hospital emergency room for evaluation of a change in condition where she was found to be dehydrated, requiring intravenous fluids to correct acute kidney failure and abnormal blood chemistry caused by dehydration. Findings: Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 4 had a recent [DIAGNOSES REDACTED]. Observations were made of Resident 4 as follows: On 2/24/14 at 4:05 pm during an initial observation, Resident 4 was lying in bed on her left side (facing the wall), asleep, with a water glass noted on the bedside table approximately 3 feet away. There were signs posted in the room advising care providers that Resident 4 required to be fed all meals and all snacks, and to be given water "constantly." On 2/25/14 at 4:00 pm, Resident 4 was lying in bed, awake and confused but smiling at times. Resident 4's speech was unintelligible and non-sensical. A half eaten cup of sherbet was noted on the bedside table approximately 3 feet away. On 2/26/14 at 1:15 pm, Resident 4 was observed being served her lunch by a Certified Nursing Assistant (CNA). A glass of water and a jar of baby food was noted on the bedside table approximately 3 feet away from her. The CNA left the room to deliver more trays, then a few moments later returned, and the CNA was observed feeding the water and the baby food to Resident 4. Resident 4 was eating and drinking without any difficulty when fed by staff. A review was conducted of a facility policy titled, "Resident Assessment Protocol: Dehydration/Fluid Maintenance." The policy indicated under the heading "Problem," education for the care provider that dehydration occurred when fluid needs were not met for an individual resident, which could result in decrease skin turgor, decrease urine output, or vital sign changes (low blood pressure, increased temperature). Consequences of dehydration included "decreased functional ability, predisposition to falls, predisposition to infection, fluid and electrolyte disturbances, and ultimately death." The policy read, "Unfortunately, many symptoms of (dehydration) do not appear until significant fluid is lost. Early signs and symptoms tend to be unreliable and nonspecific." A review was conducted of a facility policy titled, "Resident Hydration and Prevention of Dehydration." Under the heading Policy Interpretation and Implementation, item 1 indicated that the Dietician will assess all residents for hydration adequacy at least quarterly, and more often as necessary per resident need. Resident 4 was sent to the acute care hospital on [DATE] with a resultant [DIAGNOSES REDACTED]. Resident 4 was not seen by a Registered dietician in the month of January until 1/28/14, 27 days after malnutrition, dehydration, worsening of a pressure sore, and continued unintended weight loss were identified. A review was conducted of a document titled, "Nutrition and Hydration Care; What Nursing Assistants Can Do." The document indicated that the care provider would take action if the resident did not drink six cups of liquid a day by: encouraging the resident to drink during every contact, offer two to four ounces of water frequently, make sure pitcher and cup are near enough and light enough for the resident to lift, and to offer the appropriate assistance needed if the resident cannot drink without help. A record review of a document titled, "Hydration' indicated under item 9, " those residents who refuse fluids, have a propensity for dehydration or evidence of need for increase fluids will be placed on a schedule for monitoring intake. Under item 10, Residents suspected of dehydration would be evaluated weekly for four weeks; the physician and the Responsible Party would be notified of signs of dehydration and a plan of care for dehydration would be implemented. There was no dehydration risk care plan implemented. A review of a care plan titled, "Nutritional/Dehydration/Fluid Maintenance Care Plan," initiation date of 7/10/13, last reviewed on 12/3/13, indicated that Resident 4 would maintain her goal weight and meet her daily nutritional needs as much as possible. This plan of care did not offer identifiable goals for actual free water versus other liquids to be consumed. This care plan did not offer information on what type of monitoring was to be provided other than intake and output to ensure that further weight loss would not occur. The care plan did not stipulate a schedule for monitoring or provision of fluids/food as instructed in the hydration policy. These care plans did not address the resident's minimum daily requirement of fluid intake. A review of a "Intake and Output Record," dated 1/18/14-2/14/14, indicated in the section, Fluid Needs - 1200-1800 (milliliters) per 24 hours. The minimum fluid requirement recommended by the registered dietician (RD) on 1/28/14 was for 1560 ml (milliliters) to 1820 ml/day. For the dates of 1/20, 1/24, 1/26, 1/30, 2/2, 2/4, 2/5, and 2/14/14, the basic fluid requirements were not met, as recommended by the facility's RD. The intake and output for the date of 1/31/14 was not completed. A review of a "Registered Dietician Nutrition Assessment,"dated 1/18/14, indicated that the minimum fluid intake for Resident 4 would be 1560 ml up to 1820 ml based on an actual weight of 52 kilograms. This recommended minimum fluid amount was not reflected on the intake and output sheets. The dietician's note indicated that Resident 4 was taking 69% of her diet. A review and calculation was conducted by this surveyor of documented daily percentages of meals taken for Resident 4 during the month of December, 2013. The daily percentage was calculated for the three meals consumption per day times 30 days. The calculation indicated that for the month of December, Resident 4 consumed an average daily percent of her meals at 58.6%. Resident 4 suffered dehydration which resulted in her hospitalization on [DATE]. There were no RD assessments for this high risk resident provided between the time of 12/3/13 and 1/28/14. This same record indicated for the month of December, Resident 4 did not meet the goal of 75% for 30 of 31 days as suggested by the plan of care. There was no documentation from nursing that this concern was discussed with the RD. A record review indicated that there was no documented intake and output for the month of January, dates 1/1/14-1/13/14, when Resident 4 was taken to the acute care hospital for documented dehydration and malnutrition. Laboratory values of Resident 4's serum (blood) [MEDICATION NAME] (protein) level while at the facility indicated a low level on 12/13/13 of 3.3 milligrams per [MEDICATION NAME] (mg/dl- unit of measure). Normal values were identified as 3.5-5.7 mg/dl. This laboratory value was done after the nutrition evaluation on 12/3/13, which identified Resident 4 of receiving adequate nutrition. Another serum [MEDICATION NAME] value, done on 1/13/13 at 11:46 am at the acute care hospital, was reported at 3.7, a low normal value in the presence of dehydration. Other abnormal laboratory blood values done at the acute care hospital on [DATE], indicated a total protein level of 7.7 mg/dl (abnormal low), serum sodium of 151 mg/dl (abnormal high), serum blood urea nitrogen (BUN- urea in the blood cleared by the kidneys) of 59 mg/dl (abnormal high), serum creatinine (chemical waste molecule created by muscle breakdown and filtered out through the kidneys- an elevation of this waste by-product is indicative of poor kidney function) of 2.9 mg/dl (abnormal high-3 x normal, indicative of acute kidney failure). The laboratory results also indicated a serum Troponin I (a cardiac enzyme released when the heart is stressed) level of 0.36 mg/dl, which the doctor identified as indicative of cardiac ischemia (reduced blood flow to the heart). Blood and Urine cultures were also drawn, which later came back negative, indicating that Resident 4 did not have an infection, even though treated with an antibiotic because of the abnormal values and a fever identified by a rectal temperature done the emergency room of 103.5 for which Tylenol was given. Resident 4 was also on a blood thinning drug called [MEDICATION NAME]. In the emergency room , Resident 4's [MEDICATION NAME] level was checked and found to be 6.2, which was dangerously high because it put Resident 4 at a risk for bleeding. Resident 4 was treated with vitamin K, given to help her clot. A review of a transfer summary, dated 2/1/14, dictated by Resident 4's doctor at the acute care hospital, indicated that Resident 4 was admitted to the hospital with [REDACTED]. The doctor identified Resident 4's illness as anorexia. Resident 4 was identified as having a large sacral sore which was referred to the wound team. Resident 4's doctor indicated that during the course of her acute care hospitalization , after hydration, her creatinine returned to normal the blood and urine cultures showed no infection. The doctor documented that Resident 4 had not eaten at the skilled nursing facility and began to go into progressive [MEDICAL CONDITION] which caused stress on her body, causing an elevation of white blood cells (blood cells that fight infection but will also rise with stress) found on her laboratory values. A record review of Resident 4's nursing notes, dated 12/2/13-1/13/14 indicated there was no indication of the types of fluids or foods that were offered Resident 4 during this time period. There was no indication of what encouragement of fluids meant. There was no indication that Resident 4 refused fluids. There was no monitoring of urine concentration, such as color or odor (can be an indication of dehydration). There was no fluid intake and output monitoring and the nursing assessments did not identify what type of monitoring they would continue to do and how that was being accomplished. These notes repeatedly referred to "water and call light within reach," but Resident 4 was incapable of using these physically or cognitively. During interviews conducted on 2/26/14 at 12:45 pm and 2/27/14 at 12:15 pm, RP MH stated that Resident 4 was unable to feed herself. There had been many communications from RP MH to facility staff regarding Resident 4. RP MH stated that she had only one discussion with a RD since Resident 4 had been admitted , recently on 2/4/14. RP MH stated there were many times when she would come to visit Resident 4 and the fluid and food would be sitting on the bedside table which was approximately three feet away from Resident 4 in her room. RP MH stated that Resident 4 did not remember to feed herself and because of increasing immobility issues, Resident 4 had difficulty holding her cup, but could do so with 1 to 1 assistance. RP MH was concerned that the certified nursing staff were not feeding Resident 4. RP MH stated that she and a family member had witnessed Resident 4 displaying thirst when offered water by them, as expressed by rapidly drinking water when it was offered, up to a glass and a half very quickly. RP MH stated that she did not get any responses either from her written concerns or those expressed in the IDT meetings. RP MH stated that the CNAs did not appear to know what Resident 4's care needs were and that she required to be fed. In an interview conducted on 2/27/14 at 11:45 am, Consultant Registered Nurse (C RN) stated that I & O's were to be done on all residents at risk of weight loss or with a pressure sore. C RN could not provide evidence that I & O's were done for Resident 4 in January 2014, prior to admission to the acute care hospital where she was diagnosed with [REDACTED]. On 3/5/14 at 12:24 pm, during an interview, the Director of Nursing (DON) validated that I&Os were not done for Resident 4 during the time period from 1/1/14 to 1/13/14. During a telephone interview conducted on 3/5/14 at 4:38 pm, Consultant Registered Dietician (C RD) stated that she could not recall many specifics regarding Resident 4 without the benefit of a chart review and said that she had begun seeing Resident 4 in January 2014. C RD could recall that Resident 4 had unexplained and gradual weight loss and she could not make a determination for why Resident 4 was losing weight. C RD could not say if CNAs were measuring the food and liquids correctly for Resident 4 and could not say how the food/fluid intake was tracked. C RD stated that dieticians visit once a week and that, because of the number of residents in the facility, more frequent visits to complex residents such as Resident 4 could not be done.

Based on interview and record review, the facility failed to ensure that one of four sampled residents (Resident 1) was assessed for injury and pain and then effectively medicated for pain, after an unwitnessed fall that resulted in a broken hip. This failure resulted in Resident 1 unnecessarily suffering pain for 12 hours. Resident 1 [MEDICAL CONDITION] could not be repaired and he was put on comfort measures (end of life care) and died on [DATE]. Findings: Resident 1's record was reviewed. Resident 1 was a [AGE] year old male who was admitted to the facility [DATE] with [DIAGNOSES REDACTED]. A review of the facility's Minimum Data Set (MDS, an assessment tool), dated [DATE], indicated that Resident 1 was not able to make his own decisions, needed the assistance of one person for mobility and was dependent on staff for transfers and toileting, requiring the assistance of two people. Resident 1 had a Care Plan for Pain/Discomfort, dated [DATE], that indicated that he would show facial grimacing, crying and moaning for his sign of pain. The approach/intervention was for the nurse to do a pain assessment, observe for non-verbal signs for discomfort/pain and offer pain medication, give as ordered, and monitor for effectiveness. A review of Resident 1's Fall Risk Care Plan, dated [DATE], indicated the resident was at high risk for Fall/Injury due to impaired, limited mobility, poor balance/unsteady gait, heart medications, and dementia. Some approach/interventions included to keep call light and personal items within reach, assist resident to toilet per toileting schedule, pain assessment and management, transfer safety with assist of 1 or 2, follow facility policy for all fall incidents. A nurse's note dated [DATE] at 5 am, indicated that a Certified Nurse Assistant (CNA) found Resident 1 on the floor next to his bed with a bleeding left elbow wound. It did not indicate that Resident 1 had been assessed for further injury or pain. A review of Resident 1's Medication Administration Record (MAR) for [DATE], indicated that he had no pain, but was given one dose of Tylenol (pain medicine) 500 milligrams (mg), and there was no time indicated for the administration of this medication on the MAR or a note to indicate the reason for or effectiveness of the Tylenol, and a new physician's orders [REDACTED]. Review of Neurological Assessment Flowsheet dated [DATE], indicated that Resident 1 was assessed at least every 30 minutes for pain and motor functions (ability to move arms and legs) starting at 5 am until 3:4. The documentation showed that Resident 1 had not been able to move his left leg and had pain throughout the assessment period.. During an interview on [DATE] at 1 pm with Director of Nursing (DON), she said the care expectation after a resident falls was that nurses perform a resident assessment and check range of motion. If a fracture were suspected, the resident was not to be moved, and nurses were to notify the doctor, and send the resident to the hospital. During an interview on [DATE] at 9:15 am, CNA I stated that she worked the day shift on [DATE]. She came in at 6:30 am and CNA G, who worked the night shift, gave her a report about Resident 1's fall earlier that morning. CNA I said Resident 1 was in a lot of pain when she tried to change him. He did not want her to touch him. He was not able to get out of bed. She had to feed him his meals and give him fluids because he could not do it for himself. CNA I stated that Registered Nurse (RN) C told her to not move him and he stayed in bed, on his right side, all day . During an interview on [DATE] at 3:25 pm, with RN F (the evening shift charge nurse), she stated that the day shift nurse reported Resident 1 was in a lot of pain. RN F's nurse's note for [DATE] documented, "Family was informed resident is in a lot of pain." The resident's pain was not described and RN F did not document the severity or location of Resident 1's pain. There was no indication that RN F treated Resident 1's pain. During an interview on [DATE] at 9:35 am, CNA D stated that she was the evening shift CNA on [DATE], and that Resident 1 had complained to her that he was in pain. During an interview on [DATE] at 7:30 am, RN A said that when Licensed Vocational Nurse (LVN) B told her Resident 1 had fallen out of bed on [DATE], she went to see him. Resident 1 was holding his knee and had a skin tear on his elbow. RN A said she could not recall if Resident 1 could move his leg. RN A said she called the doctor and orders were received for elbow wound care, X-ray of left elbow and leg, and [MEDICATION NAME]. RN A said Resident 1 was confused and mumbling, and she gave him some Tylenol. A review of RN A's nurse's note, dated [DATE] and timed 4 am, indicated that Resident 1 was found on the floor next to his bed, bleeding from his left elbow, requiring sterile strip application to close the wound. Resident 1 was given Tylenol 500 mg. Resident 1's physician was called and gave an order for [REDACTED]. RN A's nurse's note did not describe the resident's injury, address the severity level of his pain, or his level for consciousness. During an interview on [DATE] at 10:20 am, LVN E stated that he was the day shift medication nurse, responsible for administering medications to residents, while the charge nurse did all of the assessments and charting. LVN E said that he told the day shift charge nurse that Resident 1 was in pain. LVN E said he also helped the X-ray technician turn Resident 1 for the X-rays, and Resident 1 was in a lot of pain when his leg was moved. There was no indication that LVN E treated Resident 1's pain. During an interview and concurrent review of the Emergency Kit and medication sign out sheets on [DATE] at 2:35 am, the Assistant Director of Nursing (ADON) verified that there was no entry that indicated Resident 1 had received any [MEDICATION NAME] for his pain on [DATE]. During an interview on [DATE] at 8:50 am with Certified Nurse Aide (CNA) G, she stated she was working [DATE]. She didn't hear Resident 1 fall, but was across the hall from his room and heard Resident 1 moaning. She found him lying on the floor, bleeding from his left elbow. RN A and Licensed Vocational Nurse (LVN) B came into the room. CNA G stated, "RN A never touched him and did not do any assessment." Resident 1 screamed and yelled when she tried to take his slippers off and change his brief. CNA G said she approached RN A three times to tell her Resident 1 was hurt and needed to go to the hospital, but RN A seemed irritated and walked away. CNA G said she then went to LVN B to tell her that Resident 1 was hurt and needed to go to the hospital, but LVN B said that Resident 1 was not her resident and she could not interfere. CNA G gave report to the day shift CNA, CNA I, and told her what had happened and that Resident 1 was in pain. During an interview on [DATE] at 8:55 am with CNA H, he confirmed that he was asked to put Resident 1 back to bed on [DATE], and said at that time, Resident 1 was grimacing, holding his knee, and seemed to be in pain. During an interview on [DATE] at 9:35 am with LVN B, she said she entered Resident 1's room with RN A in the early morning of [DATE]. She said Resident 1 had a skin tear on his elbow and the elbow was starting to swell. She did not see an assessment done by RN A. She was unable to remember if Resident 1 could move his leg. Resident 1 was in pain and he had painful facial expressions. LVN B stated she told RN A that if Resident 1, "...was a change in condition she could send him to the ER." RN A did not think that Resident 1's pain was abnormal. The CNA's did ask me to send Resident 1 to the emergency room (ER). I told them that RN A was in charge of him and she was talking to the doctor on the phone. RN A gave him some Tylenol and said that if there were any changes in Resident 1's condition that the day shift nurse could send him to the ER. During an interview on [DATE] at 10:30 am, RN C said that she was the charge nurse on [DATE] and had received report from RN A from the night shift. RN C told the CNAs not to turn Resident 1 (who was at risk for pressure sores) and to keep him comfortable. She said Resident 1 told her he had pain. RN C's nurse's note of [DATE] documented that Resident 1 "complained of pain," but did not include severity, location or frequency of pain evaluations. There was no indication that RN C treated Resident 1's pain. During an interview [DATE] at 12:00 pm with RN AC, she said that the night nurse made the arrangements for the X-rays and did all of the paperwork involving the physician orders. She said that RN A should have put the [MEDICATION NAME] order on the MAR's when the order was obtained. RN AC confirmed that she and LVN E were told in report about the [MEDICATION NAME] order. On [DATE], a portable X-ray was done at about 2 PM. The X-ray results showed that Resident 1 had an interrogate left femoral fracture (left [MEDICAL CONDITION]) with 90 degree angulations (abnormal bend in a broken bone), and mild swelling. During a record review on [DATE] at 4 PM, physician's orders [REDACTED]. The ambulance arrived at about 4:30 PM to transport Resident 1 to the ER. Upon arrival to theER on [DATE] at 4:45 PM, the hospital ER records documented that Resident 1 had an unwitnessed fall at the facility and was not able to move his left hip. Resident 1 was found to be in acute pain and distress and diagnosed with [REDACTED]. Resident 1 was admitted to the hospital for further care and treatment. The admitting physician's assessment indicated that Resident 1 was moaning constantly, grimacing, and in obvious distress with a left [MEDICAL CONDITION]. In an interview and concurrent record review on [DATE] at 10:45 am with the DON, she stated that the [DATE] nurse's notes regarding Resident 1's unwitnessed fall with injury, and the period of time afterwards, prior to hospitalization , were inadequate. DON confirmed that the nurses had not documented pain assessment, reason for or effectiveness of Tylenol administration on the MAR, and was not able to produce any further documented evidence to show that Resident 1's pain had been assessed and treated. The DON confirmed that [MEDICATION NAME] had not been transcribed on to the MAR and had not been administered to Resident 1. The DON stated that the licensed nurses had not signed the MARs, and that the notations indicating no pain for [DATE], were not accurate. The DON was unable to find documented evidence of any Interdisciplinary Team (ID) notes to address Resident 1's unwitnessed fall, injury, or pain, and further stated that the ID notes were inadequate. A review of undated facility Fall Documentation Guidelines indicated that the initial nurse's note will document the absence or presence of complaints of pain, status of range of motion and a completed full body check. Follow up notes were to include complaints of pain and signs of injury. A review of the facility's undated Fall Monitoring Policy, indicated after a resident has fallen, a comprehensive assessment of the resident will be done by a licensed nurse. A review of the facility's undated Pain Assessment Policy indicated the policy's purpose was to improve or maintain the quality of life for facility residents by properly assessing their level of pain, providing adequate intervention to manage the pain and then evaluating its effectiveness. The policy required that the facility ensure that the residents have the routine assessments for pain and receive adequate management of that pain.

Based on observation, interview, and record review, the facility failed to provide care and services to prevent the avoidable worsening of a pressure sore for one of 12 sampled residents (Resident 9) when: The facility failed to ensure that a physician ordered treatment and a special bed were provided; The facility failed to ensure that the residents plan of care reflected current orders and to review and revise the care plan with interventions to prevent pressure sore progression; The facility failed to ensure accurate and complete comprehensive nursing assessments of Resident 9's skin and pressure sore condition; The facility failed to notify the physician, update the plan of care, and provide additional care and interventions when Resident 9 had changes in the condition (progressive worsening) of his left heel pressure sore. As a result, Resident 12 suffered an avoidable left heel pressure sore progression, that required surgical intervention, preventing the resident from reaching his highest practicable level of physical and emotional well-being, which had the potential to cause the resident increased pain and infection. Findings: Resident 9 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident 9's record was reviewed. The "Nursing History and Admission Notes," an assessment form, dated 2/12/13, reflected that Resident 9 was admitted with a pressure sore to his left heel that measured 2.0 by 1.5cm (centimeters, there are 2.5cm in one inch). The nursing assessment described the pressure sore as "eschar tissue," a dark brown or blackish area of dead tissue. On 2/12/13, Resident 9's physician ordered, "LAL Mattress (low air loss/air mattress that reduces pressure)" and "Float heels with pillows while in bed." (A pillow placed under the lower legs to elevate the heels off the mattress). "Resident 9's nursing notes contained documentation on 2/12/13, that "LAL mattress will be applied." Resident 9's Treatment Administration Record (TAR) documented, "LAL mattress float heels with pillows while in bed," as an "FYI" (for your information only). It was not reflected on the TAR as a physicians order. Resident 9's "Wound/Skin Healing Record" reflected that the left heel pressure sore measured 2.0 by 1.5cm on admission 2/12/13, and one month later on 3/14/13, the record showed that Resident 9's pressure sore had increased in size to 3.5 by 4cm. On 3/20/13 at 8 am, Resident 9 was observed with Certified Nursing Assistant (CNA) A, lying in his bed with his heels directly on the mattress and not floated. Resident 9 was lying on a regular bed mattress and not the LAL mattress, that his physician had ordered a month ago, on 2/12/13. CNA A confirmed that Resident 9's heels were not floated, and that he was not on a LAL mattress. On 3/20/13 at 11:30 am, an interview was conducted with the Registered Nurse Supervisor (RNS). The RNS confirmed that Resident 9 had a physician ordered treatment to float his heels on pillows while in bed and for a LAL mattress since 2/12/13, and those services had not been provided. The RNS confirmed that Resident 9's pressure sore to his left heel had worsened, as evidenced by the increased size, which could have been avoided had the facility implemented the physician ordered treatment and applied the LAL mattress. From 2/12/13 to 3/1/13, the facility had not accurately, completely, or comprehensively assessed Resident 9's pressure sore, updated the plan of care with additional interventions, or notified the physician of changes in wound size and characteristics. The facility could not produce any evidence that the LAL mattress had been provided or that the resident's heels were floated consistently, as ordered.

2 Based on observation, interview, and record review, the facility failed to provide care and services to prevent the avoidable worsening of a pressure sore for one of 12 sampled residents (Resident 9) when: The facility failed to ensure that a physician ordered treatment and a special bed were provided; The facility failed to ensure that the residents plan of care reflected current orders and to review and revise the care plan with interventions to prevent pressure sore progression; The facility failed to ensure accurate and complete comprehensive nursing assessments of Resident 9's skin and pressure sore condition; The facility failed to notify the physician, update the plan of care, and provide additional care and interventions when Resident 9 had changes in the condition (progressive worsening) of his left heel pressure sore. As a result, Resident 12 suffered an avoidable left heel pressure sore progression, that required surgical intervention, preventing the resident from reaching his highest practicable level of physical and emotional well-being, which had the potential to cause the resident increased pain and infection. Findings: Resident 9 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident 9's record was reviewed. The Nursing History and Admission Notes, an assessment form, dated 2/12/13, reflected that Resident 9 was admitted with a pressure sore to his left heel that measured 2.0 by 1.5cm (centimeters, there are 2.5cm in one inch). The nursing assessment described the pressure sore as eschar tissue, a dark brown or blackish area of dead tissue. On 2/12/13, Resident 9's physician ordered, LAL Mattress (low air loss/air mattress that reduces pressure) and Float heels with pillows while in bed. (A pillow placed under the lower legs to elevate the heels off the mattress). Resident 9's nursing notes contained documentation on 2/12/13, that LAL mattress will be applied. Resident 9's Treatment Administration Record (TAR) documented, LAL mattress float heels with pillows while in bed, as an FYI (for your information only). It was not reflected on the TAR as a physicians order. Resident 9's Wound/Skin Healing Record reflected that the left heel pressure sore measured 2.0 by 1.5cm on admission 2/12/13, and one month later on 3/14/13, the record showed that Resident 9's pressure sore had increased in size to 3.5 by 4cm. On 3/20/13 at 8 am, Resident 9 was observed with Certified Nursing Assistant (CNA) A, lying in his bed with his heels directly on the mattress and not floated. Resident 9 was lying on a regular bed mattress and not the LAL mattress, that his physician had ordered a month ago, on 2/12/13. CNA A confirmed that Resident 9's heels were not floated, and that he was not on a LAL mattress. On 3/20/13 at 11:30 am, an interview was conducted with the Registered Nurse Supervisor (RNS). The RNS confirmed that Resident 9 had a physician ordered treatment to float his heels on pillows while in bed and for a LAL mattress since 2/12/13, and those services had not been provided. The RNS confirmed that Resident 9's pressure sore to his left heel had worsened, as evidenced by the increased size, which could have been avoided had the facility implemented the physician ordered treatment and applied the LAL mattress. From 2/12/13 to 3/1/13, the facility had not accurately, completely, or comprehensively assessed Resident 9's pressure sore, updated the plan of care with additional interventions, or notified the physician of changes in wound size and characteristics. The facility could not produce any evidence that the LAL mattress had been provided or that the resident's heels were floated consistently, as ordered.

Based on interview and record review, the facility failed to implement its Hydration/Dehydration assessment and care policies by failing to provide two of 13 sampled residents (Residents 4 and 8) with sufficient fluid intake to maintain proper hydration (adequate intake of fluids), monitor fluid intake and output, and identify and treat signs/symptoms of dehydration, to prevent dehydration (a significant shortage of body fluid). These failures resulted in Residents 4 and 8 requiring evaluation and treatment at an acute care hospital: Resident 4 was evaluated by a emergency room physician to be dehydrated, in critical condition, requiring extensive intravenous fluid (IVF) replacement and admission to the critical care unit; Resident 8 required treatment for [REDACTED]. Findings: On 8/21/12, the facility's Resident Assessment Protocol (RAP): Dehydration/Fluid Maintenance document (undated), defined dehydration as a condition when loss of water or fluid far exceeds fluid intake and included a change on mental status and/or decreased urine output as symptoms. Consequences included a predisposition to infections, fluid and electrolyte imbalances, and ultimately death. The RAP read, "Nursing facility residents are particularly vulnerable to dehydration...identification of the most crucial symptoms of the condition are most difficult to identify among the aged...if resident cannot drink a minimum recommended 1500 cubic centimeters (cc or ml) of fluid every 24 hours." The facility's Hydration-Clinical Protocol, dated 4/07, was reviewed and showed that staff would identify individuals with signs an symptoms or abnormal labs ([MEDICAL CONDITION], elevated blood sodium caused by relative deficit of free water in the body and often synonymous with dehydration) that might reflect existing fluid and electrolyte imbalances (abnormalities of sodium, potassium, chloride, and other substances crucial for regulation of body functions that regulate body functions). The protocol showed the physician and staff would identify individuals at risk of dehydration and/or not eating or drinking well and provide fluids. The facility's Resident Hydration and Prevention of Dehydration policy, dated 4/07, was reviewed. The policy showed that to prevent dehydration, nursing would assess for signs and symptoms of dehydration daily, nurse aides would provide and encourage intake of fluids, document intake in the medical records, and report intake of less than 1200 milliliters (ml) daily to nursing staff. The policy indicated that if potential inadequate intake and/or signs and symptoms of dehydration were observed, intake and output (I/Os) would be monitored and care planned, nursing would monitor and document fluid intake, and physicians would be notified. 1. Resident 4 was admitted to the facility on [DATE], following gall bladder removal surgery on 12/27/11. His [DIAGNOSES REDACTED]. On 8/21/12, Resident 4's indwelling Urinary Catheter (FC, Foley catheter tube drains urine from bladder) care plan, dated 1/2/12, showed his I/Os would be monitored for 30 days. Resident 4's Bowel Function care plan, dated 12/31/11, showed nursing would encourage him to drink fluids and monitor and record the number of bowel movements for amount and consistency. Resident 4's Registered Dietitian (RD) Nutrition Assessment, dated 1/3/12, showed he weighed 85 kilograms (kg) and had fluid needs of 2550 ml daily, with 1320 ml included in foods and 1280 ml included in additional fluids. A nurses note, dated 1/7/12 and timed 10 pm, showed that Resident 4 complained of an upset stomach and had an episode of diarrhea. Resident 4's Daily Care Flow Sheet for January 2012 showed that on 1/8/12, he refused breakfast and dinner, and had poor intake (consumed 25-50 %) of his lunch; on 1/9/12 had poor intake of breakfast, fair intake (50-75%) at lunch, and refused dinner; on 1/10/12 had fair intake at breakfast and poor intake at lunch and dinner. The facility's Intake and Output Vitals Sheets for Resident 4 showed his fluid intake was 720 ml on 1/8/12, 920 ml on 1/9/12, 1140 ml on 1/10/12, and 300 ml on 1/11/12 (significantly below the estimated fluid needs of 2550 ml daily recommended by the facility's RD). His urine output showed 550 ml on 1/7/12, 150 ml on 1/8/12, 400 ml on 1/9/12, 5 ml on 1/10/12, and 25 ml on 1/11/12 (minimum urine output is 1020 ml in 24 hours (hr); 0.5 ml/kg/hr). Resident 4's Bowel Record for January 2012 showed he had diarrhea with 6 loose bowel movements (BM) on 1/8/12, 16 loose BMs on 1/9/12, 16 loose BMs on 1/10/12, and 2 loose BMs on 1/11/12. (Loose BM/diarrhea poses increased risk for dehydration). On 8/22/12 at 9:15 am, Licensed Nurse (LN) A was interviewed. She stated she did not know what Resident 4's fluid intake need was, that the resident needed FC urine output of 30 ml/hr or 240 ml/8hr shift. Resident 4's I/O record for 12/31/11 to 1/13/12 was concurrently reviewed with LN A. She confirmed that the Weekly Intake & Output Evaluation section at the bottom of the form was blank and that the sections for fluid needs, average intake, average output, and signs of dehydration items were not completed. LN A confirmed they had not followed Resident 4's care plan or the facility's Resident Hydration and Prevention of Dehydration policy by monitoring his I/Os or signs of dehydration. The facility's Acute Gastrointestinal Illness Case Log showed Resident 4 was admitted to the hospital on [DATE], during a Norovirus outbreak (stomach flu that includes diarrhea and vomiting) that occurred between 1/5 and 1/9/12 at the facility. A nurses note entry, dated 1/11/12 and timed 3 am, showed Resident 4's blood pressure had dropped to 57/34 (normal is 90/60 or above), his heart rate had increased to 116-120 beats per minute (normal is less than 100), and his urine output was only 25 ml. An entry at 3:50 am showed Resident 4 was sent to the emergency room . On 8/21/12, the acute care hospital's admission history and physical (H&P), dated 1/11/12, showed Resident 4 was "severely dehydrated" and "severely hypovolemic (low blood volume)" and in hypotensive shock (when organs and tissues receive inadequate flow of blood and can lead to death). Resident 4's acute care hospital emergency room records for 1/11/12 showed that he required three liters of intravenous fluid (IVF) replacement as follows: One half liter of IVF at 6 am; One liter of IVF that completed at 6:33 am; One liter of IVF that completed at 7:26 am; One half liter of IVF that completed at 9:22 am; The nurses notes for 1/11/12 showed that Resident 4 continued to show signs and symptoms of dehydration (low urine out put, low blood pressure, elevated heart rate, dry mucous membranes) and to require IVF replacement as follows: At 7:48 am, Resident 4 had zero urine output from his FC at 7:48 am; At 10:39 am, Resident 4 continued to have signs of dehydration (mucous membranes in his nose, throat, and mouth were dry); At 11:10 am, Resident 4 received a fifth liter of IVF; At 12:06 pm, Resident 4's urine output continued to be low at 90 ml since 10:30 am; At 12:13 pm, the resident had low blood pressure at 85/33; At 2:03 pm, the resident required a sixth liter of IVF; At 2:20 pm, the resident continued to show signs of dehydration (mucous membranes were dry, his heart rate was fast, and his FC output was minimal); Resident 4 received approximately one and one half liter of additional IVF in medication solutions administered; On 1/11/12 at 9:46 am, an emergency room physician's orders [REDACTED]. On 8/21/12 at 3:30 pm, Resident 4's nurse notes from 1/8 to 1/10/12 were reviewed concurrently with the Director of Nursing (DON) and compared with Resident 4's Activities of Daily Living charting (ADL, includes Daily Care Flowsheets, Intake and Output Vitals Sheets, and Bowel Records) for the same period. The DON confirmed that the nurse notes read, "No loose stools" and that there were no signs of dehydration identified on 1/8 and 1/9/12. The DON stated that the nurse notes charting did not make sense (accurately reflect identifiable risks and signs/symptoms of dehydration) when compared to the ADL charting. On 8/21/12 at 4:30 pm, Resident 4's Nutritional/Dehydration/Fluid Maintenance care plan, dated 1/2/12, was concurrently reviewed with the DON. She stated that it had not been completed for the dehydration. The DON stated that short term Dehydration care plans were to be done on all residents during the Norovirus outbreak, however, she was not able to locate a short term Dehydration care plan for Resident 4. On 8/21/12 at 5 pm, the DON confirmed that Resident 4's Intake and Output Record for 12/31/11 to 1/13/12 was not completed and that the Weekly Intake & Output Evaluation section at the bottom of the form was blank. She stated that nursing should have compared Resident 4's fluid needs as determined by the RD, and completed the blanks for fluid needs, average intake, average output, and signs of dehydration items, that were all left blank. 2. Resident 8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The facility's Minimum Data Sheet (MDS-a resident assessment), dated 10/31/11, described her as having both short and long term memory problems with moderate cognitive impairment (ability to think, reason, and make decisions). Resident 8's record included a care plan for Alzheimer's Dementia, dated 11/3/10, that showed the facility would monitor her appetite and hydration. Resident 8's record included a care plan, dated 11/21/11, that had a long term goal to maintain adequate nutrition and hydration. Resident 8's December 2011 physicians orders included an order, dated 2/2/10, that read, "Encourage resident to consume 1800-2000 ml fluid daily." The list of Resident 8's [DIAGNOSES REDACTED]. A Nutrition Progress Note, dated 8/2/11, showed Resident 8 was getting approximately 744 ml fluid in her food when eating 93%, and 1340 ml of additional fluid with her meals. There were no RD assessments found in Resident 8's chart from 8/9 to 12/20/11 to indicate that she had been evaluated (for 120 days). Resident 8's weight record showed her weight dropped from 145.6 pounds (lbs) in November 2011 to 131.2 lbs in December 2011 (14.4 lbs or 9.9% in 90 days, which is significant), indicating her intake was not adequate. There was no notation to show Resident 8's physician or the RD had been notified of her weight loss or decreased intake. On 8/23/12 at 10:40 am, Resident 8's Daily Care Flow Sheet for December 2011 showed she had poor intake for breakfast, lunch, and dinner on 12/3 and 12/4/11. Her intake for breakfast on 12/5/11 was good at 75-100%, poor at lunch and she refused dinner. On 12/6/11 she had poor intake for breakfast, good intake at lunch, and was then sent to the emergency room . Assistant Director of Nursing (ADON) B concurrently confirmed Resident 8's intake was poor on 12/3, 12/4, 12/5, and 12/6/11. Resident 8's December 2011 Daily Care Flow Sheet showed she frequently emptied her bladder; 9 times on 12/1, 7 times on 12/2, 8 times on 12/3, 8 times on 12/4, 8 times on 12/5, and 5 times on 12/6, prior to her emergency room admission. On 8/22/12 at 3:45 pm, the Medical Records Director (MRD) stated there were no Intake and Output (I/Os) records for Resident 8 and the facility was not monitoring them on her. On 8/22/12 at 4 pm, Administrative Nurse (AN) E stated the facility should have been monitoring Resident 8's I/Os and was not following her care plan. AN E confirmed that without monitoring Resident 8's I/Os, there was no way to identify her potential inadequate intake and dehydration. On 8/23/12 at 1:10 pm, facility Vitals Sheets for 12/5 and 12/6/11 were concurrently reviewed with Licensed Nurse (LN) F. Although Resident 8's vital signs were documented in the top section of the form, there were no I/O entries for Resident 8 in the bottom section titled, "Resident Intake and Output." LN F confirmed that Resident 8's I/Os were not monitored or documented on the Vitals Sheets for 12/5 and 12/6/11. LN F stated that Resident 8 had the potential for inadequate intake, I/Os should have been done, and the facility had not followed their policy. A nurses note, dated 12/5/11 and timed 5:30 am, showed Resident 8's condition was declining; respirations were rapid at 28 (normal 12-20) and that her blood oxygen saturation was low at 88% (normal 96-100%) on room air. A second nurse notes timed at 10 am showed Resident 8's heart rate was 111 and fluctuated to 120 beats per minute (normal is less than 100), her blood oxygen saturation was low at 91% on 3 liters of oxygen/minute, via nasal cannula, and that a chest X-ray was ordered. The chest X-ray report, dated 12/5/11, showed "mild" [MEDICAL CONDITION]. A nurses note on 12/6/12 at 4 pm showed that following laboratory and electrocardiogram test results, Resident 8's physician sent her to the emergency room for evaluation and treatment. Resident 8's lab report, dated 12/6/12, showed her sodium level was high at 155 ([MEDICAL CONDITION], normal 136-145), her potassium was high at 5.3 (normal 3.5-5.1), and her chloride was high at 121 (normal 98-107). On 8/22/12, Resident 8's acute care hospital admission H&P, dated 12/6/11, showed that Resident 8 was brought to the emergency room for altered mental status and abnormal laboratory test results. The H&P revealed Resident 8 was hypernatremic (high blood sodium and related to altered mental status), had a urinary tract infection, pneumonia, and rapid heart rate. On 8/22/12, Resident 8's acute care hospital discharge H&P, dated 12/11/11, showed her discharge [DIAGNOSES REDACTED]., dehydration, toxins, heart failure). On 8/28/12 at 2:30 pm, the MRD confirmed that the facility had not followed their policy to document Resident 8's I/Os.

Based on interview and record review, the facility failed to provide wound assessment and treatment from December 2011 to March 2012, as ordered by the physician and indicated in the plan of care, for one of 13 sampled Residents (Resident 16). Failure to provide wound assessments and treatments resulted in the development of infection to Resident 16's left thigh wound. Findings: Resident 16 was admitted to the facility on [DATE], following surgical repair of a fractured left distal femur (upper leg bone close to the knee) and diabetes (affects wound healing). On 8/16/12, Resident 16's admitting physicians wound care orders, dated 11/29/11, included, "Bruising to incision area. Monitor Incision to (26 cm (centimeters)) Lt (left) femur q (every) shift. Apply [MEDICATION NAME], cover c (with) dry dsg (dressing) then put ABD (army battle dressing; large absorbent pad) pad." Resident 16's November 2011 Treatment Administration Records (TARs) revealed that the admitting physician's 11/29/11 wound care orders were transcribed incorrectly as follows: "Clean Incision (26 cm) to left femur with [MEDICATION NAME], cover c dry dsg and put ABD pad over it q day (not every shift as ordered); and "Monitor bruising to incision site, Lt femur every q 3rd day until resolved." (Incision was ordered monitored each shift, bruise to "right" thigh was to be monitored every 3 days). Resident 16's December 2011 TARs revealed that the 11/29/11 order to monitor her incision was incorrectly transcribed again as follows: "Monitor bruising to incision site Q 3rd day for s/s (signs and symptoms) of infection." There were no documented nursing staff initials on 12/5, 12/19, 12/25, 12/26, 12/27, 12/28, 12/29, 12/30, or 12/31/12 to indicate that the incision was cleansed with [MEDICATION NAME] and/or covered with the ABD. Resident 16's record included two different physician's telephone orders, dated 12/8/11. The first read, "D/C (discontinue) Staples, apply [MEDICATION NAME] (enables sticking of steristrip bandages), steristrips; keep area dry and clean, monitor QSH (every shift) for s/s of infection." An adjacent notation read D/C 12/8/11 (discontinue the order). The second physician's telephone order, dated 12/8/11, read, "Monitor incision site QSH for s/s of infection." A third physician's telephone order, dated 12/31/11, read, "Apply steristrip now & prn (as needed) to Lt surgical site to thigh. Monitor Q shift for s/s of infection." Resident 16's record included an additional handwritten December 2011 TAR showed the PM (afternoon) shift for 12/16/11 and the AM (morning) shifts for 12/19 and 12/31/11 were not initialed by a licensed nurse to show that the wound had been kept clean and dry and monitored for s/s of infection. There was no documentation to show that the steristrips were checked or changed between 12/8 and 12/31/11 (for 23 days). The original admitting physician's wound care orders, dated 11/29/11, had handwritten notations of "D/C 12/30/11" written alongside them, although no physicians orders were found to discontinue the original 11/29/11 wound care orders. On 8/16/12 at 1 pm, the facility was not able to provide TARs to demonstrate documented monitoring or wound care to Resident 16's incision from 12/31/11 to 1/5/12 (5 days). Medical Records Director (MRD) stated that there was no documentation of monitoring or treatment to Resident 16's incision between 12/31/11 and 1/5/12 and could not confirm the physician's orders [REDACTED]. Resident 16's record included a Doctor's Progress Note, dated 1/5/12, that revealed the facility had called Resident 16's surgeon to report drainage from her surgical incision. The note showed that she was brought to the office very somnolent (sleepy), with slurred speech, and requiring maximum assistance for transfer, with no family or facility staff accompaniment. The note revealed that Resident 16 was diagnosed with [REDACTED]. The wound was scrubbed, surgically prepped, re-incised (cut open), cultured (CX, specimens obtained for lab testing) for infection, irrigated, packed, and dressed. Resident 16's orthopedic surgeon's orders, dated 1/5/12, changed her antibiotics for the incisional infection and issued new wound care orders that read, "Wound care to left leg: Change dressing daily: removed packing-irrigate wound c 100-200 cc (cubic centimeters/millimeters) of normal saline-pack c [MEDICATION NAME] (antiseptic)/NS (normal saline) damp 1" (inch) Kerlix (bandage used for packing wound) or plain packing strip-cover c 4 x 4 (gauze pad) and ABD." Resident 16's January 2012 TARs included the new 1/5/12 wound care orders. The boxes for 1/8 and 1/9/12 were not initialed by licensed staff to show the wound care was done daily, as ordered by the surgeon. Following discharge from the acute care hospital on [DATE], Resident 16's physician ordered wound care BID (twice daily) to her left thigh as follows: Irrigate wound with sterile water; Wet to dry dressing twice daily; Follow up with orthopedic surgeon in 2 weeks. There was also an order [REDACTED]. Resident 16's January 2012 TARs included the 1/18/12 BID orders to irrigate and dress the wound. There were no initials by licensed staff to show the wound care was done for the AM shift on 1/19, 1/29, 1/31 nor during the PM shift on 1/20, 1/21, and 1/28/12. The 1/18/12 order to monitor her incision BID for s/s of infection was not initialed as completed on 1/19, 1/29, 1/30, and 1/31/12 during the AM shift; or on 1/27 and 1/28/12 during the PM shift. Resident 16's February 2012 TARs included the 1/18/12 wound care orders, incorrectly transcribed as follows: "Apply Q 2 days wound care BID to left thigh. Irrigate wound w (with) sterile water set to dry dressing." There were no initials to show the wound care was done during the AM shift on 2/2, 2/12, 2/14, and 2/28/12 or during the PM shift on 2/2, 2/22, and 2/23/12. The 1/18/12 orders to monitor the incision were incorrectly transcribed to the February 2012 TARs as follows: "Monitor daily. Wound on left thigh BID for s/s of infection." There were no initials by licensed staff to show that the wound was monitored for s/s of infection during the AM shift on 2/2, 2/12, or 2/29/12 (3 times); or during the PM shift between 2/2 and 2/29/12 (28 days/times). Resident 16's March 2012 TARs included the same incorrectly transcribed orders for wound care and s/s of infection monitoring as that of February 2012. There were no initials documented by licensed staff to indicate that the wound care was done during the AM shift on 3/1/12 or during the PM shift on 3/2 and 3/3/12. There were no documented licensed staff initials to show the incision was monitored for s/s of infection during the AM shift on 3/1/12 or all PM shifts from 3/1 to 3/6/12. The wound orders were discontinued on 3/7/12. On 8/16/12 at 12:10 pm, during a concurrent record review and interview, the Director of Nursing (DON) stated that Resident 16's wound had become infected by 1/5/12. The DON confirmed that Resident 16's Weekly Body Audit, dated 12/27/11 (one week prior to infection) indicated a healed incision was an inaccurate assessment and that the incision was not healed. The DON was not able to explain the repeated transcription errors of the physicians orders for Resident 16's incision care or why the orders were not implemented. She was not able to explain why Resident 16's incisional wound care orders on her TARs for December 2011 and January/February/March 2012 were not initialed as done by licensed staff and could not confirm that the physician's orders [REDACTED].