Every finding on record at Champion Rehabilitation and Nursing Center

Based on interview and record review, the facility failed for one Resident (#13), out of a total sample size of 24 residents, to collaborate with the dialysis center on the Resident's care and services. Specifically, the facility failed to ensure the facility's Dietitian monitored Resident #13's Dialysis lab communication report cards and addressed abnormal laboratory results. Findings include:Review of the facility's policy titled End Stage Renal Disease, Care of the Resident with, revised September 2010, indicated but was not limited to the following:-Residents with end stage renal disease (ESRD) will be cared for according to currently recognized standards of care.-Staff caring for residents with ESRD, including residents receiving dialysis care outside the facility, shall be trained in the care and special needs of these residents.-Education and training of staff include, specifically: The nature and clinical management of ESRD (including infection prevention and nutritional needs). Resident #13 was admitted to the facility in December 2024 with current diagnoses which included: End stage renal disease (ESRD), anemia (condition in which blood doesn't have enough healthy red blood cells or hemoglobin, a protein that carries oxygen in the blood), diabetes, and malnutrition. Review of the Minimum Data Set (MDS) assessment, dated 7/7/25, indicated Resident #13 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating Resident #15 was cognitively intact. Further review of section O0110K1B indicated he/she was receiving dialysis. During an interview on 9/11/25 at 3:01 P.M., Resident #13 said he/she rarely talks to the Dietitian in this facility, he/she doesn't even know her name. Resident #13 said he/she does get lab results from dialysis and knows sometimes things are too high or low, but he/she doesn't know what to do to improve the numbers. Resident #13 said the Dietitian has never reviewed the report cards from the Dialysis Center or made recommendations to improve the results with dietary changes. Review of Physician's Orders indicated Resident #13 was not taking renal vitamins and was on a regular texture, thin consistency, with cold cereal at breakfast. Resident was not on a renal diet. The most recent blood lab results in the medical record were dated January 2, 2025.Review of Resident #13's Dialysis Communication binder Lab Report Card indicated, but was not limited to the following:-September 2025:a. Hemoglobin 8.8 Low (8/27/25 9.4 and 8/20/25 10.1). Your red blood cell count is lower than desired, which may mean you're anemic. This can cause you to feel tired and drowsy. The desired values for hemoglobin are between 10-11 G/DL. The doctor may change your EPO dose. Take your renal vitamins every day (after treatment from your dialysis). b. Albumin 3.6 indicating it is low (8/6/25 3.8 and 7/9/25 3.7). Your protein stores are low. Protein is important for wound healing and helps prevent infection. The goal is 4.0 or greater. The best way to get more protein in your diet is by eating more egg, chicken, turkey, fish, lean beef, fresh pork, lamb or veal. Plant proteins: Beans, legumes, nuts, seeds, and soy (tofu). Be sure to eat enough calories. You may also need nutritional supplements, talk to your dietitian about which one may be best for you.-August 2025: No report-July 2025: Albumin 3.7 indicating it is low. Same recommendations as above. -June 2025:a. Hemoglobin 8.9 indicating it is low. Same recommendations as above.b. Albumin 3.6 indicating it is low. Same recommendations as above.c. Phosphorus 3.2, indicating it is low. Your phosphorus is low. If your calcium level is less than 8.9 mg/dl, you can have extra dairy such as cheese, yogurt, pudding, ice cream or milk in your diet. Talk with your dietitian.-May 2025: No report -April 2025a. Hemoglobin low 9.0. Same recommendations as above.b. Albumin low at 3.8. Same recommendations as above.c. Phosphorus high 6.4. Limit dairy, peanut butter, nuts, seeds, sardines, liver, sausage, beer, bran, cornbread, dark [NAME], dried beans and peas. Take your binders renvela, auryxia, or velphoro. Review of Nutritional Risk Evaluation Quarterly, dated 6/25/25, indicated but was not limited to the following:-Review of lab values for fasting blood sugar, A1C, pre-albumin, Albumin, potassium, BUN, creatinine, sodium, Hematocrit and hemoglobin, and other labs, indicating no lab values were entered. -Supplements: Nepro twice daily and cold cereal for breakfast.-Weight status: Significant weight gain, +17.7%, 25 plus lbs. (pounds) within six months.-Identified cause of weight change: fluid status-Nutrition plan indicated continued diet as ordered, continued Nepro as ordered, weigh as ordered by MD, Monitor labs, skin, and oral intakes.- Weight gain fluctuation due to fluid. -Resident #13 continues to tolerate his/her regular diet as ordered with good oral intake of mostly 50 to 100% of meals.- Appropriate to continue Nepro twice a day 8 oz as ordered to aid in both weight maintenance and increased oral intakes. -Resident is at potential nutritional risk due to the diagnosis of previous malnutrition, ESRD, type ll diabetes, dysphagia, high cholesterol, and atrial fibrillation. -Registered dietitian available as needed.Review of nutritional risk evaluation quarterly, dated 3/28/25, indicated but was not limited to the following:Review of lab values for fasting blood sugar, A1C, pre-albumin, Albumin, potassium, BUN, creatinine, sodium, Hematocrit and hemoglobin, and other labs, indicating no lab values were entered. -Supplements: Nepro twice daily. -admission weight:156.8 lbs. -Supplements: Nepro twice daily and Proheal liquid one time per day.-Weight status: Stable, had a gain this quarter now stabilizing. -Nutrition plan: Resident #13 is currently on regular diet. Will monitor for need for diet change given ESRD on hemodialysis (HD). He/She is receiving Nepro twice a day for nutrition support. Resident #13's wounds have improved, can discontinue liquid protein. No labs to review period had significant weight gain this quarter but has since stabilized too. No new nutrition interventions at this time.- Registered dietitian available as needed. During an interview on 9/16/25 at 4:30 P.M., the Dietitian said she follows Resident #13 quarterly and does not review Resident #13's monthly lab report cards from the dialysis center. The Dietitian said she was not aware of any of the recommendations on the Report cards and if something was abnormal, she would expect the dialysis dietitian to review the results because they do all his/her lab work. The Dietitian said she does not communicate on a regular basis with the Dialysis dietitian and has not spoken to her for months. The Dietitian said Resident #13 was not on renal vitamins and was not on a renal diet. She said she would only put a resident on renal diet if their labs were off and their sodium or potassium were high. The Dietitian then said she does not review Resident #13's lab results because they are done at dialysis and they don't send over the results.

Based on observation, record review, and interview, the facility failed to ensure it provided an environment free of potential safety hazards for seven Residents (#27, #55, #81, #8, #30, #98, and #15), out of a total sample of 26 residents. Specifically, the facility failed:1. For Residents #27, #55, and #81, to ensure safe smoking practices were implemented; 2. For Resident #8, to complete a smoking evaluation prior to him/her smoking on facility property; and 3. For Residents #30, #98, and #15, to ensure falls were investigated thoroughly and interventions were developed and implemented to prevent future falls and/or mitigate risk of injury. Findings include: 1. Review of the facility's policy titled Resident Smoking Policy and Procedure, dated 2020, indicated but was not limited to the following: -The facility shall conduct an assessment to determine whether the resident requires a smoking apron and shall document this in the resident's care plan and in a smoking log to be kept on each residential floor. -Residents may not provide other residents with cigarettes or other smoking paraphernalia and may not light a cigarette for another resident. Review of the Smoking policy and Resident Agreement, undated, included but was not limited to: -Staff members that are supervising the smoke break will provide each resident with their smoking apron if assessed to require one, one cigarette at a time, and will assist with the lighting of each cigarette individually. -Residents may not share their cigarettes with anyone -No resident may assist another resident with lighting or disposing of a cigarette. Staff will maintain/control of all smoking materials. -Supervising staff must actively monitor all smoking activity (i.e., cueing of residents when to flick ashes, assisting with disposal of cigarettes in receptacle, etc.) A. Resident #27 was admitted to the facility in June 2024 with diagnoses including chronic obstructive pulmonary disease. Review of the Minimum Data Set (MDS) assessment, dated 6/27/25, indicated the Resident scored 13 out of 15 on the Brief Interview for Mental Status (BIMS) assessment indicating the Resident is cognitively intact. Review of Resident #27's care plan indicated but was not limited to the following: Focus: Resident is a supervised smoker, revised 9/10/24 Goal: Resident will comply with the facility smoking policy. Revised 7/10/25 Interventions: ensure resident is aware of facility smoking policy, date initiated 6/28/25 -supervised smoker, date initiated 9/10/24 On 9/10/25 at 9:42 A.M., the surveyor observed Resident #27 outside in the designated smoking area with two other residents. The surveyor observed Resident #27 light the other residents' cigarettes which they kept in their mouths while Resident #27 lit them. The surveyor observed Resident #27 light six cigarettes during this designated smoking time. On 9/10/25 at 1:18 P.M., the surveyor observed Resident #27 sitting outside in the designated smoking area with three other residents. Resident #27 used the lighter to light his/her cigarette and three other residents' cigarettes. The other Residents put the cigarettes in their mouth and Resident #27 would light their cigarette with the handheld lighter. In total, the surveyor observed Resident #27 light a total of eight cigarettes during this smoking break. During an interview on 9/10/25 at 1:20 P.M., Certified Nursing Assistant (CNA) #1 said she provides two cigarettes to each resident during the smoking break, and she stays inside and supervises. She said she provides the lighter to Resident #27, and he/she lights all the residents' cigarettes. She said she does not need to light the cigarettes since Resident #27 is independent with smoking. During an interview on 9/10/25 at 1:22 P.M., Resident #27 said since he/she is responsible, the staff give him/her the cigarette lighter to light other residents' cigarettes. The Resident said a lot of staff do not like coming outside because of the smoke, so they will sit inside and watch. Resident #27 said they were not aware of any smoking policy the facility had. Resident #27 said he/she is independent with smoking and is able to light other residents' cigarettes for them. During an interview on 9/15/25 at 9:20 A.M., Nurse #5 said information can be located on a resident's care plan to indicate their smoking status. She said she is aware of an assessment being done on admission. She said she is aware Resident #27 lights the other residents' cigarettes and that he/she is supervised by staff while smoking. During an interview on 9/15/25 at 9:30 A.M., the Director of Nurses (DON) said Resident #27 should not be lighting any cigarettes. She said it poses a risk of an accident for the Resident to light other resident cigarettes and staff should be supervising this activity and preventing it from happening instead of permitting it. B. Resident #55 was admitted to the facility in March 2020 with diagnoses including paraplegia. Review of the Resident's care plan indicated but was not limited to the following: -Focus- Resident is a smoker who wishes to continue smoking, revised on 9/20/22 Goal- Resident will participate in the facility's smoking program and follow facility safe smoking rules through the review date, revised on 2/14/25 Interventions: Resident requires smoking apron, date initiated 2/12/22 Review of the MDS assessment, dated 8/11/25, indicated the Resident scored 15 out of 15 on the BIMS assessment indicating he/she is cognitively intact. On 9/10/25 at 1:18 P.M., the surveyor observed Resident #55 outside smoking with no smoking apron. On 9/11/25 at 9:18 A.M., the surveyor observed Resident #55 outside smoking with no smoking apron. During an interview on 9/11/25 at 9:18 A.M., CNA #2 said the residents that were out smoking at this time did not require the use of a smoking apron. On 9/15/25 at 9:37 A.M., the surveyor observed Resident #55 outside smoking. The surveyor observed a hole in Resident #55's shirt where cigarette ash was blowing onto it. During an interview on 9/15/25 at 9:30 A.M., the DON said that Resident #55 should be utilizing a smoking apron. She said the care plan reflects the Resident's need for a smoking apron and because of the Resident's positioning he/she is at risk for burning themself and their clothing with cigarette ash. C. Resident #81 was admitted to the facility in June 2024. Review of the MDS assessment indicated the Resident scored 13 out of 15 on the BIMS indicating he/she is cognitively intact. Review of Resident #81's care plan indicated: Focus: Resident likes to smoke, date initiated 9/18/24 Goal: Resident will remain safe while smoking through review period, date initiated 9/18/24 Interventions: Resident must wear smoking apron at all times while smoking, date initiated 9/18/24 During an observation with interview on 9/10/25 at 9:42 A.M., the surveyor observed Resident #81 smoking outside with no smoking apron. The surveyor observed cigarette ash on Resident #81's jeans. The Resident said he/she has trouble using the ashtray and will flick ash on the ground and sometimes it gets on his/her clothing. The Resident said he/she has many shirts with burn holes in them because of cigarette ash. The Resident said he/she isn't aware of anything the facility has for him/her to wear to prevent burns in his/her clothing. On 9/10/25 at 1:16 P.M., the surveyor observed Resident #81 outside smoking a cigarette with three other residents. Resident #81 was not wearing a smoking apron while smoking. During the observation, the surveyor observed ash drop onto Resident #81's pants. The surveyor observed three smoking aprons hanging near the designated smoking area. During an interview on 9/11/25 at 9:18 A.M., CNA #2 said the smoking aprons were utilized for Residents who needed to wear them to prevent cigarette ash from burning their clothes. She said Resident #81 did not require a smoking apron. She said she would be told by the nurse if the Resident needed one. During an interview on 9/15/25 at 9:20 A.M., Nurse #5 said the Resident's care plan would reflect the residents' smoking needs, she said she was not sure what Resident #81's care plan reflected. She said she didn't think anyone on the unit required a smoking apron. During an interview on 9/15/25 at 8:50 A.M., Resident #81 said the holes in his/her red and white striped polo shirt were from cigarette ash burning the material. Resident #81 also showed the surveyor a green shirt with two small burn holes in it. The Resident said the smokers go outside while the staff sit inside and watch, and another resident lights the cigarettes. During an interview on 9/15/25 at 9:30 A.M., the DON said that Resident #81 should be utilizing a smoking apron. She said the care plan reflects the Resident's need for a smoking apron and the holes in his shirts are evidence he/she needs one. 2. Resident #8 was admitted to the facility in May 2025 with diagnoses including tobacco use. Review of the MDS assessment, dated 8/27/25, indicated Resident #8 was cognitively intact as evidenced by a BIMS score of 13 out 15. On 9/10/25 at 9:27 A.M., and 9/11/25 at 9:21 A.M., the surveyor observed Resident #8 smoking in the Astoria Unit Smoking area. Review of Resident #8's medical record indicated but was not limited to: -Nursing Evaluation with [NAME], dated 5/20/25, Smoking Evaluation section indicated: -Does the resident smoke: No -Nursing Evaluation with [NAME], dated 6/25/25, Smoking Evaluation section indicated: -Does the resident smoke: No -Nursing Evaluation with [NAME], dated 8/28/25, Smoking Evaluation section indicated: -the assessment was incomplete, and the Smoking Evaluation section was left blank. Further review of Resident #8's medical record indicated he/she signed the facility's Resident Smoking Agreement on 5/21/2025. Review of Resident #8's care plans indicated but was not limited to: -Focus: Resident likes to smoke r/t History of Smoking, Date Initiated: 05/27/2025 -Goal: Resident will comply with the facility smoking policy. Date Initiated: 05/27/2025 Revision on: 06/22/2025 Target Date: 11/25/2025; Resident will remain safe while smoking through review period. Date Initiated: 05/27/2025 Revision on: 06/22/2025 Target Date: 11/25/2025 -Interventions all initiated 5/27/25: -Offer smoking cessation information -Ensure resident is aware of facility smoking policy -Provide resident with requisition to sign for facility to purchase cigarettes out of their resident account -Show resident where smoking is allowed and how to access. During an interview on 9/11/25 at 9:38 A.M., Nurse #2 said before a resident was able to go out to smoke, he/she would need to have a smoking assessment and would need to be screened for safety. She reviewed Resident #8's medical record and said he/she did not have a smoking assessment. She said smoking assessments were done upon admission, readmission, quarterly, with a change in cognition and if a non-smoker started to smoke. During an interview on 9/11/25 at 9:43 A.M., Unit Manager #2 said she was unaware of when Resident #8 started smoking but he did sign a Resident Smoking Agreement on 5/21/25 so it was probably around then. She reviewed Resident #8's medical record and said he did not have a smoking assessment but should have had one prior to going out to smoke. She said Resident #8 did not smoke on admission but probably started on 5/21/25 when he/she signed the Resident Smoking Agreement. During an interview on 9/15/25 at 2:17 P.M., the DON said prior to Resident #8 being able to smoke he/she should have been evaluated for safety after signing a Resident Smoking Agreement. 3. Review of the facility's policy titled Fall Risk Assessment, dated as last revised March 2018, indicated but was not limited to the following: -The staff with the support of the attending physician, will evaluate functional and psychological factors that may increase fall risk, including ambulation, mobility, gait, balance, activities of daily living (ADL) capabilities, activity tolerance, continence, and cognition. -The staff will seek to identify environmental factors that may contribute to falling, such as lighting and room layout. -The staff and attending physician will collaborate to identify and address modifiable fall risk factors and interventions to try and minimize the consequences of risk factors that are not modifiable. Review of the facility's policy titled Fall Risk and Fall Risk Managing, dated as last revised March 2018, indicated but was not limited to the following: -Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try and prevent the resident from falling and to try and minimize complications from falling. -Fall Risk Factors include Environmental factors, Resident Conditions, and Medical factors. -If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified and unavoidable. Review of the facility's policy titled Assessing Falls, and the Causes, dated as last revised March 2018, indicated but was not limited to the following: -After an observed or probable fall, clarify the details of the fall, such as when the fall occurred and what the individual was trying to do. Distinguish if they were rolling, attempting to stand, or trying to ambulate. -Evaluate the chain of events or circumstances preceding the fall. -The following should be documented in the medical record: resident condition, assessment data, interventions/first aid, fall risk assessment, appropriate interventions taken to prevent future falls. A. Resident #30 was admitted to the facility in December 2024 with diagnoses which included history of falling, muscle wasting/atrophy, muscle weakness, abnormal gait/mobility, and dementia. Review of the MDS assessment, dated 6/20/25, indicated he/she scored 10 out of 15 on the BIMS, indicating he/she had moderate cognitive impairment and had sustained a fall with injury. Review of the Comprehensive Care Plan indicated but was not limited to the following: FOCUS: The Resident is at risk for falls. INTERVENTIONS: -Anticipate and meet the resident's needs. (12/26/24) -Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. (2/25/25) -Ensure the resident is wearing appropriate footwear such as non-skid socks when ambulating or mobilizing in wheelchair. (2/25/25) -Add resident to early riser assignment (3/11/25) -Fall mat to right side of the bed. (3/12/25) FOCUS: The Resident has an ADL self-care performance deficit related to deconditioning. INTERVENTIONS: Two (one/forth) side rails to aid in bed mobility (1/8/25) FOCUS: At risk for injury related to the use of side rail/grab bars for impaired bed mobility. (4/11/25) INTERVENTIONS: Obtain informed consent regarding the risk of injury versus benefit of use. (4/11/25) Review of the Nursing Fall Risk Evaluations dated 12/19/24, 3/17/25, 4/21/25, and 6/16/25 indicated Resident #30 was a high risk for falls. Review of a progress note, dated 1/10/25, indicated Resident #30 transferred units. Review of the Nursing Progress Notes indicated Resident #30 sustained falls on 4/10/25, 4/14/25, and 5/25/25 with no new interventions implemented to mitigate future falls. Review of the nursing progress notes, incident reports, and care plan indicated but were not limited to the following: FALL 4/10/25: -Resident was observed on the floor, attempting to get up during routine rounds at approximately 11:30 P.M., he/she was assisted back to bed and side rails were recommended for added safety. -The Predisposing Environmental, Physiological, and Situational Factors were incomplete. -Care Plan was updated to include side rails. Further review of the Comprehensive Care Plan indicated side rails were added to the care plan in January 2025. Review of the Informed Consent for Use of Bed Rails indicated on 12/14/24 Resident #30 signed for bilateral side rails, at all times when in bed due to muscle weakness for increased bed mobility. Review of the Side Rail/Restraint Enabler Evaluation, dated 12/19/24 and 3/17/25, indicated he/she had bilateral side rails. -The investigation failed to indicate a root cause analysis of the fall. -The Care Plan was not updated with any new interventions to prevent future falls or mitigate risk of injury. (Side rails should have been in place since 12/2024) FALL 4/14/25: -Resident fell in the bathroom out of the wheelchair while a staff member was looking for soap and sustained a laceration on the left side of his/her head. He/she was transferred to the hospital for evaluation. -He/she returned to the facility on 4/21/25 and was diagnosed with an occipital parietal hematoma status post fall. -The Predisposing Environmental, Physiological, and Situational Factors were incomplete. -The investigation failed to indicate a root cause analysis of the fall. -The Care Plan was not updated with any new interventions to prevent future falls or mitigate risk of injury. FALL 5/25/25: -Resident was observed laying on the floor with blood coming from right ear at approximately 4:00 P.M., he/she reported slipping and striking head on the floor. He/she was transferred to the hospital for evaluation. -He/she returned to the facility later that evening after the laceration on his/her ear was closed with glue. -The investigation failed to indicate a root cause analysis of the fall. -The Care Plan was not updated with any new interventions to prevent future falls or mitigate risk of injury. The surveyor made the following observations: -9/10/25 at 9:15 A.M., Resident lying in bed with fall mat on the left side of his/her bed. -9/11/25 at 9:30 A.M., Resident lying in bed with fall mat on the left side of his/her bed. -9/16/25 at 10:45 A.M., Resident in the day room; The fall mat in his/her room was on the left side of the bed. The left side of his/her bed is between the A and B beds. The right side of his/her bed is between B and C beds. The right side is where his/her night stand, TV, and chair are located, where he/she typically transfers, and where the fall mat was care planned to be placed. The facility failed to ensure the fall mat was in the proper location. During an interview on 9/16/25 at 12:44 P.M., Nurse #4 said after a fall, the nurse should assess the resident, complete the incident report, obtain statements, and then add a new intervention to try and prevent another fall or injury. She said if a Resident has side rails there should be an evaluation, a consent form, an order, and a care plan. She was unsure why side rails were added after the fall on 4/10/25, because they should have already been in place. Additionally, she said if a Resident is care planned for a floor mat, it should be in place and was not sure why Resident #30's floor mat was on the wrong side. During an interview on 9/16/25 at 3:30 P.M., the DON said they review the falls every morning and weekly at the risk meeting. She said after a fall the nurse should be investigating what caused the fall or injury and then adding an intervention to try and prevent future falls and/or injury. She said she did not know why an intervention was added for side rails in April, because they should have already been on the bed. She said she thinks when Resident #30 transferred units they were not put on the new bed. The DON said she was unsure why the fall mat has been on the wrong side of the bed and was going to investigate it, because Resident #30 always gets in/out of bed on the right side which is between the B and C beds and that is where the fall mat should have been. Additionally, she said the investigations should be better. She said many were incomplete and they should be adding something to try and prevent more falls and injury, and they were not consistently doing that. She said when a resident is sent to the hospital, and they return the incident should be reviewed to ensure an appropriate intervention was added. She said for the last three falls no new interventions were added. B. Resident #98 was admitted to the facility in August 2015 with diagnoses which included muscle weakness, difficulty in walking, and dementia. Review of the MDS assessment, dated 7/28/25, indicated he/she scored 1 out of 15 on the BIMS, indicating he/she had severe cognitive impairment and had sustained a fall. Review of the Comprehensive Care Plan indicated but was not limited to the following: FOCUS: The Resident is at risk for falls. INTERVENTIONS: -Ensure the resident is wearing appropriate footwear. Non-Skid soled shoes or non-skid socks while ambulating. (revision 10/16/23) -Re-educate the resident about safety and remind them of what to do if a fall occurs. Encourage Resident to report falls promptly to staff. (revision 10/16/23) -Scoop Mattress. (3/26/25) -Ensure fall mat is between the beds. (6/20/25) -Implement use of side rails to bed to help aid in safe transfers. (8/26/25) -Offer resident a nap after lunch. (8/26/25) FOCUS: The Resident has an ADL Self Care Deficit INTERVENTIONS: Resident is assist to dependent on staff for toileting. (revision 1/11/23) FOCUS: The Resident has bladder incontinence related to confusion/dementia. INTERVENTIONS: Toilet resident after dinner and before bed to attempt to keep continent. (revision 1/11/23) Review of the Nursing Fall Risk Evaluations, dated 4/21/25, 7/21/25, and 8/24/25, indicated Resident #98 was a high risk for falls. Review of the Nursing Progress Notes indicated Resident #98 sustained a fall on 4/16/25, 6/20/25, and 8/24/25. Review of the nursing progress notes, incident reports, and care plan indicated but were not limited to the following: FALL 4/16/25: -Resident noted with bruising to right wrist, abrasions on right knee, bruise on right forehead and multiple bruises to his/her back. He/she reported they fell the other night, and a colored man helped them up. The incident report notes indicated Resident #98 said they were reaching for the remote, and maintenance fixed the remote to a chain. -The Predisposing Environmental, Physiological, and Situational Factors were incomplete. -The Care Plan was not updated. -The investigation failed to indicate a root cause analysis of the fall and injuries. FALL 6/20/25: -Resident was observed lying on the floor mat on the left side of his/her bed with one nonskid sock on and one off. He/she reported they were trying to get back into bed after toileting self at approximately 2:25 A.M. -Care Plan was updated to ensure fall mat is between the beds. (The left side of the bed is between the beds and where the fall mat was located at the time of the fall.) -The investigation failed to indicate a root cause analysis of the fall. -The Care Plan was not updated with any new interventions to prevent future falls or mitigate risk of injury. FALL 8/24/25: -Resident was found sitting on their buttocks in front of the bed and wheelchair at approximately 1:20 P.M. He/she reported they were transferring from wheelchair to bed and fell. -The Predisposing Environmental, Physiological, and Situational Factors were incomplete. -The incident report indicated education was provided. -The investigation failed to include any statements or indicate a root cause analysis of the fall. -The Care Plan was not updated with any new interventions to prevent future falls or mitigate risk of injury. The surveyor made the following observations: -9/10/25 at 10:00 A.M., out of bed in the day room; no floor mats in his/her room. -9/11/25 at 9:45 A.M., out of bed in the day room; no floor mats in his/her room. -9/16/25 at 10:45A.M., out of bed in the day room; no floor mats in his/her room. -Resident #98's roommate has one floor mat on the left side of his/her bed near the door (not between the two beds). During an interview on 9/16/25 at 12:44 P.M., Nurse #4 said after a fall, the nurse should assess the resident, complete the incident report, obtain statements, and then add a new intervention to try and prevent another fall or injury. She said the intervention on 6/20/25 doesn't make sense because the floor mat was in that location when they fell. Additionally, she said if a Resident is care planned for a floor mat, it should be in place and was not sure why Resident #98's room did not have any floor mats. During an interview on 9/16/25 at 3:30 P.M., the DON said they review the falls every morning and weekly at the risk meeting. She said after a fall the nurse should be investigating what caused the fall or injury and then adding an intervention to try and prevent future falls and/or injury. Additionally, she said the investigations should be better. She said many were incomplete and they should be adding something to try and prevent more falls and injury, and they were not consistently doing that. She said during review of the 4/16 incident report the statements were not clear and the investigation did not really identify what had happened in the days leading up to when the injuries were noted and he/she reported the fall. The DON said the intervention on 6/20 regarding the fall mat location doesn't make sense because that was where the mat was at the time of the fall. The DON said she was unsure why there was no fall mat in the room now and was going to investigate it, because Resident #98 is care planned for a fall mat between the beds. She said education is not effective because he/she does not retain the information, so that intervention on 8/24 was not appropriate as he/she is not educatable. C. Resident #15 was admitted to the facility in January 2025 with diagnoses which included: dementia with moderate psychotic disturbances, psychotic disturbance, and mood disturbance. Review of the MDS assessment, dated 8/1/25, indicated Resident #15 scored 2 out of 15 on the BIMS indicating Resident #15 had severe cognitive impairment. Review of Resident #15's incident Fall packet indicated he/she had 10 falls since 4/5/25, including the following dates: Fall #1: On 4/5/25 at 9:00 A.M., Resident put himself/herself on the floor to lie down. Call out to the MD to decrease Seroquel in the A.M. to improve sleep cycle. Review of Medication Review Report indicated the Seroquel was not decreased. No investigation, no witness statements, or updated interventions on the care plan were found. Fall #2: On 4/28/25 at 6:00 A.M., Resident found lying on the floor in his/her room. Note written indicated: The patient refused to stay in bed transferring independently between wheelchair and bed. The patient was also seen entering another patient's room. A verbal altercation occurred due to patient turning on/off lights in the room. At one point resident was observed sitting in the hallway and later observed lying naked in the hallway. Patient was redirected multiple times but was consistently difficult to redirect. Safety observations due to ongoing concerns. Will monitor closely. No investigation, no witness statements, or updated interventions on the care plan were found. Fall #3: On 5/3/25 at 9:40 A.M., Patient found lying on the floor with head against the door, resident states he/she bumped his/her head, area pink in color, small bump noted, no open area, no further injuries noted, resident assisted off the floor into a chair. One witness statement from a nurse was the same as description above. No investigation, no additional witness statements, or updated interventions on the care plan were found. Fall #4: On 5/5/25 at 7:15 P.M., Resident Alert, verbally responsive with baseline confusion, observed sitting up on his/her buttocks by the bathroom door in his/her room. Unable to describe the incident. The report indicated after a resident was assessed, he/she was walking aimlessly in the hallway. No investigation, no witness statements, or updated interventions on the care plan were found. Fall #5: On 5/27/25 at 9:45 A.M., Resident was walking in the dining room and lost his/her balance and fell, therapist called the nurse. Nurse came and resident was already sitting on a chair. Note dated 5/28/25, indicated per witness statement resident was attempting to sit on piano bench. No investigation, no additional witness statements, or updated interventions on the care plan were found. Fall #6: On 6/9/25 at 11:30 P.M., Resident was sitting upright on the floor beside his/her bed at 11:30 PM. Alert and confused at baseline. Resident to be monitored every 15 minutes for safety. Witness statement indicated an unidentified staff reported on 6/10/25, went on rounds found resident sitting upright on the floor beside his/her bed. The resident was alert and confused, which is his/her baseline. Resident will be monitored every 15 minutes for safety throughout the shift. Care plan was updated for floor mats, bilateral bedside while in bed. No investigation, no additional witness statements, or updated interventions on the care plan were found. Fall #7: On 6/21/25 at 11:30 P.M., Resident found lying on the floor on his/her right side in room [ROOM NUMBER]. Alert/confused and at baseline. After being assessed, the resident was assisted into a recliner and brought to the nursing station for monitoring. No investigation, no witness statements, or updated interventions on the care plan were found. Fall#8: On 7/16/25 at 11:55 P.M., Resident was found lying on the floor in the dining room. While he/she was standing up from the chair and starting to walk, he/she lost his/her balance and fell, said another resident. Resident could not explain how it happened. No investigation, no staff witness statements, or updated interventions on the care plan were found. Fall #9: On 8/5/25 at 10:45 P.M., This writer was in room [ROOM NUMBER], when a loud noise was heard outside room [ROOM NUMBER]. Writer can visibly see Resident #15 on the floor from the doorway. Resident was pulling on mechanical lift when he/she fell, witnessed by a resident in the hallway, he/she stated he/she fell on butt and didn't hit his/her head. No investigation, no additional witness statements, or updated interventions on the care plan were found. Fall #10: On 9/2/25 at 2:00 P.M., Resident was with activity group on the [NAME] unit on the 4th floor when he/she tried to get off the chair where he/she was sitting and lost his/her balance and fell, according to one of the activity staff members. No investigation, no additional witness statements, or updated interventions on the care plan were found. Review of the Comprehensive Care Plan indicated but was not limited to the following: -Focus: The Resident is at risk for falls Related to confusion, and wandering resident has episodes where he/she prefers to lie on the floor instead of the bed, date initiated. 1/24/25. -Goal: The resident will be free of falls through the review date. Revision on 7/28/25 with a target date of 9/4/25. -Interventions: a. Anticipate and meet the residents' needs. Date initiated 1/24/25. b. Attempt to involve in activities at change of shift. Date initiated 2/28/25. c. Be sure the resident's call light is within reach and e

Based on interview and record review, the facility failed to provide pneumococcal immunizations for three eligible Residents (#7, #15, and #30), out of a total sample of five residents.Findings include:Review of the facility's policy titled Pneumococcal Vaccine, last revised March 2023, indicated but was not limited to:-All residents are offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections.-Prior to or upon admission, residents are assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, are offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated.-Administration of the pneumococcal vaccines are made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination. Review of the CDC guidance titled Pneumococcal Vaccine Timing for Adults, dated October 2024, indicated but was not limited to the following:Adults 50 years or older:Shared clinical decision-making for those who already completed the series with PCV13 and PPSV23.Prior vaccines Shared clinical decision-making option for adults [AGE] years old or olderComplete series: previously received PCV13 at any age & PPSV23 at or older than 65 yrs and it has been more than five years since the series was completed.Together, with the patient, vaccine providers may choose to administer PCV20 or PCV21 to adults that are [AGE] years old or older who have already received PCV13 (but not PCV15, PCV20, or PCV21) at any age and PPSV23 at or after the age of [AGE] years old. a. Resident #7 was admitted to the facility in April 2025 and is currently [AGE] years old.Review of the immunization history for Resident #4 indicated but was not limited to:-Prevnar13 pneumococcal vaccination, administered 9/18/15-PPSV23 pneumococcal vaccination, administered 12/19/16During an interview on 9/15/25 at 3:21 P.M., the Infection Preventionist (IP) said Resident #7 was not up to date on their pneumococcal vaccine and was overdue for the PCV20 or PCV21 pneumococcal vaccine and should have been offered the pneumococcal vaccine but was he/she was not offered the vaccine.b. Resident #15 was admitted to the facility in January 2025 and is currently [AGE] years old.Review of the immunization history for Resident #15 indicated but was not limited to:-PPSV23 pneumococcal vaccination, administered 10/17/13During an interview on 9/15/25 at 3:21 P.M., the IP said Resident #15 was not up to date on their pneumococcal vaccine and was overdue for the PCV20 or PCV21 pneumococcal vaccine and should have received it.c. Resident #30 was admitted to the facility in December 2024 and is currently [AGE] years old.Review of the immunization history for Resident #30 indicated but was not limited to:-PPSV23 pneumococcal vaccination, administered 9/1/11During an interview on 9/15/25 at 3:21 P.M., the IP said Resident #30 was not up to date on their pneumococcal vaccine and was overdue for the PCV20 or PCV21 pneumococcal vaccine and should have received it. During an interview on 9/16/25 at 11:12 A.M., the IP said she was unable to locate the pneumonia vaccine consents for Resident #15 and Resident #30. She said residents who had received the pneumococcal vaccine in the past were not reassessed to see if they were up to date with CDC guidance and had not been offered the pneumonia vaccine.

Based on interview and record review, the facility failed to immediately notify the physician and/or registered dietitian of a significant weight loss for one Resident (#98), out of a total sample of 24 residents, to determine if a change in treatment was necessary. Findings include: Review of the facility's policy titled Weight Assessment and Intervention, dated as last revised March 2022, indicated but was not limited to the following:-Weights are monitored for undesirable or unintended weight loss or gain.-Any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietician in writing.-The threshold for significant unplanned and undesirable weight loss will be based on the following criteria: 1 month - 5% weight loss is significant and greater than 5% is severe; 3 months - 7.5% weight loss is significant and greater than 7.5% is severe; and 6 months - 10% weight loss is significant and greater than 10% is severe.-Undesirable weight change is evaluated by the treatment team. The evaluation includes the resident's target weight range, calorie/nutrient needs, clinical situation, and to what extent weight stabilization or improvements can be anticipated.-The physician and the multidisciplinary team identify conditions and medications that may be causing anorexia, weight loss, or increasing risk of weight loss. For example: cognitive decline, swallowing abnormalities, pain, medications, environmental factors, increased need for calories, nutrient loss, and inadequate availability of food/fluids.-Interventions for undesirable weight loss are based on careful consideration of the following: Resident choice/preference, nutrition needs, functional factors, environmental factors, chewing/swallowing abnormalities, medications, supplements, and end of life decisions/advanced directives. Resident #98 was admitted to the facility in August 2015 with diagnoses which included muscle weakness, difficulty in walking, diabetes mellitus, and dementia. Review of the Minimum Data Set (MDS) assessment, dated 7/28/25, indicated he/she scored 1 out of 15 on the Brief Interview for Mental Status (BIMS), indicating he/she had severe cognitive impairment and did not have weight loss. Review of Resident #98's weight record indicated but was not limited to the following:-3/10/25: 160.2 pounds (lbs.)-4/7/25: 161.4 lbs.-5/2/25: 161.8 lbs.-6/2/25: 157.6 lbs.-7/1/25: 157.7 lbs.-8/2/25: 156.6 lbs.-9/1/25: 139.2 lbs.-9/2/25: 138.4 lbs. Resident #98 had an 18.2 lbs. / 11.62% weight loss in one month and 13.61% in six months. Review of the medical record including Nursing, Physician/Nurse Practitioner (NP), and Registered Dietician (RD) progress notes failed to indicate the Physician and RD were notified on 9/2/25 of the severe weight loss in one month after the weight loss was confirmed by a re-weight. Review of the medical record indicated Resident #98 was seen by the NP on 9/3/25 related to recent falls. The progress note failed to address the severe weight loss. Further review of the medical record failed to indicate the RD or MD/NP had addressed/evaluated the severe weight loss since it was confirmed on 9/2/25 (14 days). During an interview on 9/16/25 at 12:44 P.M., Nurse #4 said if a resident's weight is down 3 lbs., they are supposed to get another weight to confirm and then notify the MD/NP. She said they don't notify the dietitian; she does her own thing. She said there is not a specific dietary communication process. She said weight loss is reviewed at risk meeting weekly. During an interview on 9/16/25 at 3:39 P.M., the Director of Nurses (DON) said when they do the weekly or monthly weights if there is a weight loss noted, they should be getting a second weight the next day to confirm, and then notify the MD/NP and RD. She said anyone with a significant weight loss should have that addressed by the MD/NP and RD. The DON reviewed the medical record and said there were not any notes to indicate the MD/NP or RD had seen him/her or addressed the weight loss.

Based on observations, interview, and record review, the facility failed to maintain acceptable parameters of nutritional status for one Resident (#98) with an unplanned significant weight loss, out of a total sample of 24 residents. Specifically, the facility failed to assess and evaluate after a severe weight loss (11.62% weight loss in one month and 13.61% in six months) had been identified for two weeks resulting in no interventions being implemented and he/she continued to lose weight. Findings include: Review of the facility's policy titled Weight Assessment and Intervention, dated as last revised March 2022, indicated but was not limited to the following:-Weights are monitored for undesirable or unintended weight loss or gain.-Any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietician in writing.-The threshold for significant unplanned and undesirable weight loss will be based on the following criteria: 1 month - 5% weight loss is significant and greater than 5% is severe; 3 months - 7.5% weight loss is significant and greater than 7.5% is severe; and 6 months - 10% weight loss is significant and greater than 10% is severe.-Undesirable weight change is evaluated by the treatment team. The evaluation includes the resident's target weight range, calorie/nutrient needs, clinical situation, and to what extent weight stabilization or improvements can be anticipated.-The physician and the multidisciplinary team identify conditions and medications that may be causing anorexia, weight loss, or increasing risk of weight loss. For example: cognitive decline, swallowing abnormalities, pain, medications, environmental factors, increased need for calories, nutrient loss, and inadequate availability of food/fluids.-Individualized Care Plans shall address to the extent possible: the identified causes of weight loss, goals and benchmark for improvement, and timeframes/parameters for monitoring and reassessment.-Interventions for undesirable weight loss are based on careful consideration of the following: Resident choice/preference, nutrition needs, functional factors, environmental factors, chewing/swallowing abnormalities, medications, supplements, and end of life decisions/advanced directives. Resident #98 was admitted to the facility in August 2015 with diagnoses which included muscle weakness, difficulty in walking, diabetes mellitus, and dementia. Review of the Minimum Data Set (MDS) assessment, dated 7/28/25, indicated he/she scored 1 out of 15 on the Brief Interview for Mental Status (BIMS), indicating he/she had severe cognitive impairment and did not have weight loss. Review of the Physician's Orders indicated but were not limited to the following:-Regular Diet, Mechanical Soft Texture, Thin Liquids, Lactaid Milk. (7/22/25)-Nutritional Treat 4 ounces three times a day (10/4/24)-Monthly weight on the 1st (1/31/23) Review of the Comprehensive Care Plan indicated but was not limited to the following:FOCUS: The Resident has a potential nutritional problem related to dysphagia, diabetes, and dementia.GOAL: Weight Maintenance and Adequate intake, at least 50% of all meals.INTERVENTIONS:-Add large portions. (11/23/24)-Monitor mood/medications and effect on weights/appetite. (7/26/16)-Offer prepared food and substitutes if refusal. (7/26/16)-RD Consults as needed. (4/24/23) Review of the weight record indicated but was not limited to the following:-3/10/25: 160.2 pounds (lbs.)-8/2/25: 156.6 lbs.-9/1/25: 139.2 lbs.-9/2/25: 138.4 lbs. Resident #98 had an 18.2 lb. / 11.62% weight loss in one month and 13.61% in six months. Review of the medical record indicated Resident #98 was seen by the Nurse Practitioner (NP) on 9/3/25 related to recent falls. The progress note failed to address the severe weight loss. Review of the medical record indicated Resident #98 was seen by the Registered Dietitian (RD) for their quarterly RD Nutritional Risk Evaluation, dated 7/16/25, which indicated Resident #98's weight was 158 lbs. and he/she had not had weight loss/gain. Supplements: Nutritional Treat 4 ounces. Nutritional Plan: no significant changes, No new nutritional recommendations. Further review of the medical record failed to indicate additional weight monitoring had been done since 9/2/25 (14 days), failed to indicate the RD or MD/NP had addressed/evaluated the severe weight loss since it was confirmed on 9/2/25 (14 days), and failed to indicate any interventions were considered to address the significant weight loss. Surveyor Observations during survey indicated Resident #98 ate their meals in the day room and consistently consumed less than half of the meal. During an interview on 9/16/25 at 12:44 P.M., Nurse #4 said if a resident's weight is down 3 lbs. they are supposed to get another weight to confirm and then notify the MD/NP. She said they don't notify the dietitian. She said weight loss is reviewed at risk meeting weekly. She said the RD should see anyone with weight loss but did not know what her schedule was. Nurse #4 said she did not know exactly what a Nutritional Treat was. She said she just gives Resident #98 a small 4-ounce shake. She said it doesn't appear Resident #98 had been seen by the MD/NP or RD since the weight loss was identified because there were no notes or orders, so when the psych MD was here yesterday, she asked them to see the Resident because he/she had lost a lot of weight, and she wasn't sure if Remeron would be appropriate. During an interview on 9/16/25 at 3:39 P.M., the Director of Nurses (DON) said when they do the weekly or monthly weights if there is a weight loss noted, they should be getting a second weight the next day to confirm, and then notify the MD/NP and RD. She said anyone with a significant weight loss should have that addressed by the MD/NP and RD in addition to the routine quarterly evaluation. She said they discuss weight loss at the weekly risk meeting. She said if someone has weight loss they should be monitored more frequently. The DON said the RD sends her a worksheet of who she reviewed for risk. The DON retrieved the worksheet from the meetings on 9/5/25 and 9/12/25 and said Resident #98 was on the list but all it said was 19lb. weight loss and to monitor. She said there were no additional notes or interventions noted. The DON reviewed the medical record and said there were not any notes to indicate the MD/NP or RD had seen him/her or addressed the weight loss. Additionally, she said there were not any additional weights documented. The DON called the unit and requested a weight be obtained for Resident #98 and then entered an order for weekly weights into the electronic medical record. The DON said the house supplement order should have had an amount to be administered, otherwise you have no idea what the resident is consuming. The DON said the Nutritional Treat is a Magic Cup, which is a fortified ice cream. She said the order should be clear so everyone knows exactly what they should be giving the resident. She said there is a concern with the communication to and from the dietitian and nursing. Review of the weight the DON requested with the surveyor present was entered into the medical record on 9/16/25 at 4:36 P.M., as 134.4 lbs. (down another 4lbs. / 2.89% in two weeks, 14.72% in the last three months, and 16.10% in the last 6 months). Additionally, review of the nursing note, dated 9/16/25 at 3:08 P.M., indicated the MD was in the facility, updated on the recent (9/15/25) psych visit, and evaluated Resident #98 (14 days after the weight loss was confirmed). The note indicated Resident #98 was not eating because he/she did not like the food and the MD suggested dietary evaluate the Resident and the kitchen be involved to identify preferences and dislikes to better support nutritional intake. During an interview on 9/16/25 at 4:45 P.M., the RD said she usually only sees a resident during their quarterly evaluation and if she has time, then she might see someone in addition to that. She said the Nutritional Treat was the same as a Magic Cup but said the order should be more specific if the nurses don't know what they should be giving. The RD said she has not seen Resident #98 since their last quarterly evaluation, which was in July. She said they have been stable for a very long time, so she didn't think the September weight was accurate. The surveyor confirmed with the RD that the weight on 9/2/25 was taken to confirm the weight from 9/1/25. She said yes, but she wanted another weight. She said she has been waiting for a reweight. When asked how that information gets relayed to nursing, she said it could be at the risk meeting, verbally, on a scrap piece of paper, or a sticky note. She said there was not a specific communication method. She said a reweight should be done as soon as possible, but within 1-3 days. When asked what she did for Resident #98 after the second risk meeting (9/12/25) when there was not a reweight in the computer, the RD said, nothing, she was still waiting for a reweight. She said she has not seen or spoken to Resident #98 since the weight loss was documented. She reviewed the weights in the computer and said they got a weight this afternoon, so now she will have to do something this week because Resident #98 lost more weight. She confirmed it had been two weeks since the almost 20 lb. weight loss was noted, and no interventions had been implemented. When asked why she hadn't gone to see/speak with Resident #98 immediately, she said she doesn't always have time because she is only in the facility two days a week.

Based on observation, interview, and record review, the facility failed to develop and implement a person-centered comprehensive care plan for three Residents (#43, #2, and #36), out of a total sample of 18 residents. Specifically, the facility failed: 1. For Resident #43, to develop and implement a care plan for the Resident's smoking needs; 2. For Resident #2, to develop and implement a care plan for epilepsy (seizure disorder); and 3. For Resident #36, to develop and implement a care plan for the Resident's suicidal ideation. Findings include: 1. Review of Resident Smoking Policy and Procedure, dated 2022, indicated but was not limited to the following: -Resident deemed to need assistance to smoke should have the designation noted in the care plan. -The determination of the smoking assessment should be noted in the Resident's care plan. Resident #43 was admitted to the facility in August 2021 with diagnoses which included: hypertension, ambulatory dysfunction, and asthma. Review of the Minimum Data Set (MDS) assessment, dated 7/30/24, indicated Resident #43 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment, indicating the Resident was cognitively intact. During an observation with an interview on 08/27/24 at 10:58 A.M., the surveyor observed Resident #43 outside in the designated smoking area with two other residents smoking cigarettes. The Resident said they go out four times a day to smoke and was not sure if his/her care plan indicated any special restrictions or instructions for smoking. During an interview on 8/27/24 at 11:00 A.M., Unit Manager #2 said she was not sure if there were any special instructions for Resident's smoking needs. She said information regarding needs and accommodations would be found in a smoking care plan. Review of the record indicated there was no smoking care plan developed. Further review revealed a smoking assessment was completed on 4/26/24 which indicated the Resident must be supervised by staff, volunteer or family member at all times when smoking. During an interview on 8/28/24 at 1:31 P.M., the Director of Nursing (DON) said any resident who smokes should have a care plan. She said the care plan links to the Kardex (summary of resident's care and preferences) so Certified Nursing Assistants (CNA) can see the individual information related to the resident's smoking needs. She said the Resident should have a smoking care plan and that it was missed. 48084 2. Resident #2 was admitted to the facility in April 2024 with diagnoses including epilepsy. Review of the MDS assessment, dated 7/31/24, indicated Resident #2 scored 9 out of 15 on the BIMS indicating he/she had moderate cognitive impairment and he/she had epilepsy. Review of the active Physician's Orders indicated the following: -Seizure Activity: monitor for signs and symptoms of seizure activity. Document seizure activity and update Doctor/Nurse Practitioner every shift. (6/19/24) -Gabapentin Oral Capsule 400 milligrams (mg) give one capsule two times daily related to epilepsy. (6/4/24) -Lamictal Oral Tablet 25 mg-give 50 mg by mouth one time a day related to epilepsy. (4/2/24) -Lamictal Oral Tablet 150 mg-give one tablet by mouth one time a day related to epilepsy. (1/29/24) -Levetiracetam (Keppra) Oral Tablet 500 mg-give three tablets by mouth two times a day related to epilepsy. (4/30/24) -Phenobarbital Oral Tablet 32.4 mg-give three tablets two times a day related to epilepsy. (5/5/24) Review of the comprehensive care plan failed to indicate a care plan for epilepsy had been developed. Review of the medical record including physician and nursing progress notes indicated Resident #2 had been transferred to the hospital multiple times for seizure activity and had been having increased frequency of seizure activity. During an interview on 8/29/24 at 1:15 P.M., Nurse #4 said Resident #2 keeps having seizures. We are trying to get an inpatient appointment, but it is taking a long time. She said she was not sure why there was not a care plan developed as there should be one with triggers on it. She said she knows that the door alarm is a trigger and will cause a seizure, so she keeps him/her away from the door and if he/she wants to go outside she knows to take him/her outside first. During an interview on 8/29/24 at 2:00 P.M., the DON said there should be a care plan with triggers and interventions in place and there was not. She said the MDS Nurse usually does the care plans but this one was missed. 46862 3. Resident #36 was admitted to the facility in June 2024 with diagnoses including dementia with behavioral disturbance, post-traumatic stress disorder (PTSD- occurs in some individuals who have encountered a shocking, scary, or dangerous situation), and personal history of suicidal behavior. Review of the MDS assessment, dated 6/17/24, indicated Resident #36 was cognitively intact as evidenced by a BIMS score of 15 out of 15. Review of Resident #36's Hospital Discharge Summary indicated Resident #36 reported symptoms for worsening depression and suicidal ideation. Resident #36 expressed he/she had a plan to end his/her life. Further review of Resident #36's medical record failed to indicate facility staff gathered information related to Resident #36's suicidal ideation to develop an individualized person-centered plan of care. During an interview on 8/28/24 at 10:31 A.M., CNA #4 said she took care of Resident #36 regularly. CNA #4 said she was unaware that Resident #36 had been hospitalized for suicidal ideation. During an interview on 8/28/24 at 3:20 P.M., Social Worker (SW) #1 said she was aware that Resident #36 had been discharged following a psychiatric stay. SW #1 said she was unable to review the hospital discharge summary for Resident #36. SW #1 said she should have developed a care plan to monitor for suicidal ideation to keep him/her safe. During an interview on 8/29/24 at 7:45 A.M., Unit Manager (UM) #3 said she was unaware of Resident #36's history of suicidal ideation. UM #3 said she had admitted Resident #36 however, she only writes the medications and reviews them with the physician. UM #3 said she did not have time to read through the whole discharge summary. UM #3 said Resident #36's care plan for suicidal ideation should have been developed and staff taking care of him/her should have been aware. During an interview on 8/29/24 at 11:09 A.M., the DON said Resident #36's care plan should have been developed to include suicidal ideation and staff educated to monitor for signs of worsening depression.

Based on record review and interviews, the facility failed to ensure three Residents (#36, #51, and #89), out of a total sample of 18 residents, received culturally competent, trauma-informed care in accordance with professional standards of practice. Specifically, the facility failed to assess and identify triggers of trauma to prevent potential re-traumatization. Findings include: Trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being. Trauma. SAMHSA-HRSA Center for Integrated Health Solutions. Substance Abuse and Mental Health Services Administration, 11/30/2016. Review of the facility's policy titled Trauma Informed Care and Culturally Competent Care, dated revised 8/2022, indicated but was not limited to: -Perform universal screening of residents, which includes a brief, non-specialized identification of possible exposure to traumatic events -Assessment involves an in-depth process of evaluating the presence of symptoms, their relationship to trauma, as well as the identification of triggers -Utilize licensed and trained clinicians who have been designated by the facility to conduct trauma assessments -Develop individualized care plans that address past trauma in collaboration with the resident and family, as appropriate -Identify and decrease exposure to triggers that may re-traumatize the resident -Ensure that residents have a sense of psychological, social, cultural, moral and physical safety 1. Resident #36 was admitted to the facility in June 2024 with diagnoses including dementia with behavioral disturbance, post-traumatic stress disorder (PTSD- occurs in some individuals who have encountered a shocking, scary, or dangerous situation), and personal history of suicidal behavior. Review of the Minimum Data Set (MDS) assessment, dated 6/17/24, indicated Resident #36 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Review of the Resident's Level I Preadmission Screenings and Resident Reviews (PASRR) completed on 7/12/24 indicated PTSD as a current diagnosis. Review of the Discharge Summary from Resident #36's hospitalization indicated the Resident reported symptoms of PTSD which included: nightmares, flashbacks, difficulty sleeping, and changes in mood. Review of Resident #36's medical record failed to indicate a trauma informed care assessment had been conducted since admission. Further review of Resident #36's medical record failed to indicate facility staff gathered information related to Resident #36's PTSD to develop an individualized person-centered plan of care that identified potential triggers of trauma and prevented re-traumatization. During an interview on 8/28/24 at 10:31 A.M., Certified Nursing Assistant (CNA) #4 said she took care of Resident #36 regularly. CNA #4 said she was unaware of any trauma indicators or triggers for this Resident and did not know about his/her trauma history. During an interview on 8/28/24 at 3:20 P.M., Social Worker (SW) #1 said she did not realize Resident #36 had a diagnosis of PTSD. SW #1 said she should have completed a trauma assessment. During an interview on 8/29/24 at 7:45 A.M., Unit Manager #3 said she was unaware of Resident #36's trauma history and could not identify triggers or interventions to prevent potential re-traumatization. During an interview on 8/29/24 at 11:09 A.M., the Director of Nurses (DON) said the Social Worker should complete an assessment to identify a history of trauma upon admission for all residents. The DON said Resident #36's trauma assessment was not done. 48084 2. Resident #51 was admitted to the facility in September 2021 with diagnoses including muscular dystrophy, depression, and anxiety. Review of the MDS assessment, dated 8/14/24, indicated Resident #51 scored 15 out of 15 on the BIMS indicating he/she was cognitively intact and had a diagnosis of PTSD. Review of the medical record indicated the diagnosis of PTSD was a new diagnosis added to the profile on 8/5/24. During an interview on 8/27/24 at 9:00 A.M., Resident #51 reported to the surveyor that he/she had experienced a traumatic event in July 2024. Review of the nursing progress notes indicated that in July 2024 Resident #51 was transferred to the hospital and was admitted for further care. Resident #51 returned to the facility in August 2024. Review of the medical record, including hospital paperwork and discharge summary, indicated Resident #51 was admitted with a chief complaint of Abuse/Trauma. He/she was medically/psychologically cleared in agreement to return to the facility as long as issues were addressed. He/she returned to the facility for continued medical management in August 2024. Review of the nursing note, dated 8/6/24, indicated Resident #51 was seen by psychiatric services on 8/5/24 and a new diagnosis of PTSD was to be added to the resident record. Doctor aware and diagnosis added with a start date of 8/5/24. Review of the comprehensive care plan indicated a care plan had been developed on 8/7/24 for PTSD, however the care plan failed to indicate resident specific triggers that may cause re-traumatization of the Resident. Review of the Psychiatric Evaluation and Consultation progress notes indicated he/she was seen on 8/5/24 for monthly follow up after returning from the hospital and no medication changes were made. Further review indicated he/she was seen again on 8/12/24 due to persistent breakthrough anxiety and a recommendation for an as needed antianxiety medication was made. Review of the Trauma Questionnaire, dated 8/2/24, indicated the facility failed to complete the questionnaire. The assessment was opened in the electronic medical record and was blank; none of the questions were answered. During an interview on 8/28/24 at 12:21 P.M., Social Worker #1 said the Trauma Questionnaire should have been completed and it was not. During an interview on 8/29/24 at 1:15 P.M., Nurse #4 said she did not know who did the Trauma Questionnaire or who put the specific triggers onto the care plan. During an interview on 8/29/24 at 2:00 P.M., the Director of Nurses (DON) said the Trauma Questionnaire should have been completed when he/she returned from the hospital and the new diagnosis was added. She said she opened the questionnaire so the Social Worker would complete it and it was not done. Additionally, the DON said his/her care plan is generic and should have resident-specific interventions and triggers to avoid on it and it does not. She said the questionnaire, had it been completed, would have provided staff with more information to add to the care plan to guide staff to provide resident centered care related to the new diagnosis of PTSD and the events surrounding the new diagnosis. 49424 3. Resident #89 admitted to the facility in July 2004 with diagnoses including suicidal ideation and major depressive disorder. Review of the MDS assessment, dated 7/19/24, indicated the Resident scored 12 out of 15 on the BIMS assessment indicating a moderate cognitive impairment. Review of the Resident's documentation from the hospital indicated the Resident had a past medical history of trauma. Review of the Resident's care plan failed to include any history of trauma, triggers, or interventions to eliminate or mitigate triggers that may cause re-traumatization of the Resident. Review of hospital discharge documents in Resident #89's chart indicated that he/she had endured a history of sexual and physical abuse and had nightmares and flashbacks associated with these and described sometimes waking up screaming from these memories. Review of the Resident's Level II PASRR completed on 7/10/24 indicated PTSD as a current diagnosis. During an interview on 8/28/24 at 11:33 A.M., Resident #89 said the facility staff never asked him/her any questions about their trauma history. The Resident said he/she would have told them if they asked as there are specific things he/she can identify that bother him/her. For example, he/she said they had increased anxiety when he/she was in the hospital and there was a man disrobing in the hallway. Review of the Behavioral Health Services evaluation, completed on 8/27/24, indicated the Resident had been in a serious accident, witnessed an extremely frightening situation, and had been in a situation that was extremely frightening. Review of the medical record failed to indicate that the facility staff had assessed the Resident for trauma or implemented a care plan related to his/her diagnosis of PTSD. During an interview on 8/28/24 at 12:21 P.M., the Social Worker said she cannot remember if Resident #89 was assessed for trauma, as she cannot find any supporting information to indicate it was completed. She said if a resident has a diagnosis or trauma history she should go back and obtain additional information and develop a care plan. She said there is no additional information in the Resident's medical record indicating he/she was asked about his/her trauma and triggers and she must have missed the information in the Resident's PASARR and the psychiatric hospital discharge summary.

Based on observations, interview, and policy review, the facility failed to store, prepare, and serve food in accordance with professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to perform hand hygiene during meal service on two of three units observed. Findings include: Review of the facility's policy titled hand washing/hand hygiene, revised August 2019, indicated but was not limited to the following: -The facility considers hand hygiene the primary means to prevent the spread of infections. -All personnel shall follow the hand washing/hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. -Use an alcohol-based rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: a. Before and after direct contact with residents; b. Contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; and, c. Before and after assisting a resident with meals. On 8/28/24 at 11:55 A.M., the surveyor observed a meal pass on the [NAME] Unit and observed the Nurses and Certified Nursing Assistants (CNA) serve food trays from the meal truck and deliver them to resident rooms. In delivering the trays, they moved overbed tables, assisted residents in positioning, and set up the meal on the overbed table. This process was repeated until the meal truck was empty. The surveyor observed the nurses and the CNAs to occasionally perform hand hygiene when exiting the residents' room prior to retrieving and delivering another tray to a different resident. On 8/29/24 at 7:58 A.M., the surveyor observed breakfast service on the [NAME] Unit and observed the CNAs remove food trays from the meal truck and deliver them to resident rooms. In delivering the trays, they moved overbed tables, assisted residents in positioning, and set up the meal on the overbed table. This process was repeated until the meal truck was empty. The surveyor did not observe any of the CNAs perform hand hygiene after exiting the residents' room and prior to retrieving and delivering another tray to a different resident. During an interview on 8/29/24 at 8:25 A.M., the Food Service Manager (FSM) said he noticed the CNAs were not performing hand hygiene during the meal service. The surveyor reviewed the observations of meal service on 8/28/24 in which the CNAs and the nurses did not consistently perform hand hygiene during meal pass. He said they should be performing hand hygiene every time they leave the residents' room.

Based on record review and interview, the facility failed to ensure for one Resident (#2), out of a total sample of 18 residents, recommended specialist appointments were scheduled. Specifically, the facility failed to ensure Inpatient Epilepsy (seizure disorder)and Neurology appointments were scheduled. Findings include: Review of the facility's policy titled Consultation Follow (sic), dated 2/2/24, indicated the facility will schedule the appointment and arrange transportation. Resident #2 was admitted to the facility in April 2024 with diagnoses including epilepsy. Review of the Minimum Data Set (MDS) assessment, dated 7/31/24, indicated Resident #2 scored 9 out of 15 on the Brief Interview for Mental Status (BIMS) indicating he/she had moderate cognitive impairment, he/she had epilepsy, and had been hospitalized recently. Review of the medical record indicated Resident #2 was having frequent seizures. Review of the Appointment Communication Form, dated 5/28/24, indicated Electro-encephalogram (EEG) (test to measure electrical activity in the brain) was completed and to follow up on 6/26/24. Review of the Appointment Communication Form, dated 6/26/24, indicated to consider inpatient evaluation at Epilepsy Center- patient refuses. Follow up as needed. Review of the nursing progress note, dated 7/1/24 (late entry), indicated 6/26/24 clinic recommendations-continue current medications-could consider inpatient evaluation at Epilepsy Center- patient refuses. Review of the nursing and physician progress notes failed to indicate facility staff had a discussion with the Resident regarding the inpatient Epilepsy Center upon return from the appointment (6/26/24 through 7/12/24). Review of the Physician progress note, dated 7/12/24, indicated patient seen for neurology follow up 6/26/24 to discuss EEG results, recommendations for additional follow up- nursing staff to schedule. Review of the Appointment book failed to indicate an appointment at the Epilepsy Center had been made or was in progress. Review of the medical record indicated a fax transmittal cover sheet, dated 7/15/24, was in the paper chart. The cover sheet indicated it was sent to the Neurology Office and indicated Resident #2 was seen on 6/26/24 and there was a recommendation to consider inpatient evaluation at Epilepsy Center but he/she had refused. He/she has been having more frequent seizures and is now in agreement. Please let us know what steps are needed to get him/her admitted . No confirmation page was attached. No additional documentation was attached. Review of the nursing progress note, dated 7/15/24, indicated a call was placed and a message left with the Neurology office to schedule an appointment at the Epilepsy Center. Further review of the nursing notes indicated Resident #2 continued having more frequent seizures. The notes failed to indicate staff had reached out to schedule an Epilepsy Center inpatient appointment. Resident #2 was hospitalized in July 2024 due to increased seizures and the physician wanted a full neuro evaluation. Review of the Hospital Discharge Summary, dated 7/24/24, indicated the following: -Continuing prior Neuro meds. Recommend Neurology follow up in 4 weeks and outpatient referral for Epilepsy Monitoring Unit (EMU-specialized unit that monitors brain activity to evaluate, diagnose, and treat seizures) Admission. If having recurrent seizure type episode at the skilled nursing facility, recommend these be recorded for outpatient Neurology. Review of the comprehensive care plans failed to indicate an Epilepsy care plan had been developed. Review of the nursing and physician's progress notes and physician's orders failed to indicate the recommendation to record seizure activity had been addressed. Review of the Appointment book failed to indicate the appointments had been made. Review of the nursing progress notes indicated Resident #2 had seizures on 7/28/24, 7/30/24, and 8/1/24. Further review of the progress note, dated 8/1/24, indicated a call was placed to the Neurology Office to inquire about the Epilepsy Center Appointment process. The note indicated the Neurology Office said the process had been started, a return call was pending, and a direct number for the Epilepsy Center was provided to the nurse. Further review of the nursing progress notes failed to indicate a call was placed to the Epilepsy Center regarding the appointment process/status. Further review of the Appointment Binder on the unit failed to indicate Resident #2 had any appointments for Neurology or the Epilepsy Center scheduled or pending return calls. Review of the nursing progress notes indicated Resident #2 had seizures on 8/18/24, 8/22/24 times 2, and 8/27/24. Further review of the nursing progress notes failed to indicate a call was placed to the Epilepsy Center regarding the appointment process or to the Neurology Office to schedule a follow up appointment. During an interview on 8/28/24 at 9:51 A.M., Nurse #4 said every appointment is logged into the Appointment binder and that is used to book transport as well. She was unsure if he/she had a Neurology or an appointment at the Epilepsy Center booked. During an interview on 8/29/24 at 1:15 P.M., Nurse #4 said she did not know why neither of the appointments were ever made. She said the Epilepsy Center sent a fax on 7/15/24 but they haven't called back. Nurse #4 said Resident #2 keeps having seizures and she did not know what the plan was. Nurse #4 reviewed the Discharge Summary with the surveyor and said she did not know anything about a Neurology follow up or recording the seizure activity and was not sure of the status of the other appointment. She said it should not take this long to make appointments and we should have followed up. Nurse #4 called the Neurology Office, with the surveyor present, and the office confirmed a Neurology Appointment was never made. Additionally, she said the Epilepsy Center will not take Resident #2's insurance, but we (facility) did not know that because we never spoke to the office. During an interview on 8/29/24 at 2:00 P.M., the Director of Nurses (DON) said she was not sure how the appointments were missed but the ball was dropped, and the process needs improvement. She said she did not know anything about the recommendation to record the seizure activity but would have to look into that as they would need a secured device. The DON said Resident #2 has had more frequent seizures (a few times a week now) and it is to the point that the Physician doesn't know what to do with him/her. She said we need to get those appointments made and if the Epilepsy Center won't take his/her insurance we will have to call the Physician and come up with a new plan. Additionally, she said the Neurology Appointment was booked today (after surveyor inquiry), but it should have been done when he/she came back from the hospital a month ago. She said making follow up appointments should not take this long. No additional information was provided to the surveyor prior to exit.

Based on observations, interviews, and record review, the facility failed to ensure the physician ordered therapeutic diet was followed for one Resident (#29), in a total sample of 18 residents. Findings include: Resident #29 was admitted to the facility in July 2015 with diagnoses which included: dysphagia oropharyngeal phase (an impairment in the ability to swallow), pneumonitis due to inhalation of other solids and liquids, gastrostomy status (presence of a feeding tube), and hemiplegia and hemiparesis following cerebrovascular disease affecting right dominant side. Review of Resident #29's Minimum Data Set (MDS) assessment, dated 6/11/24, indicated the staff assessed the Resident to be severely cognitively impaired. Review of the Physician's Orders for Resident #29 indicated the following: regular diet, puree texture, thin consistency. Review of the care plan for Resident #51 indicated the following: Focus: Resident #29 has an ADL self-care performance deficit. Goal: Resident #29 will maintain current level of function through the review date, revised on 3/26/24. Intervention: Resident requires tube feedings for nutrition, pureed diet for pleasure foods and requires continual supervision by staff. He/she may require physical assistance to eat by mouth. Review of the Nurse Practitioner's note, dated 8/1/24, indicated Resident #29 was to continue the current diet and monitor for signs of aspiration. Further review indicated that the Resident has been tolerating the pureed diet with thin liquids. Review of the Speech and Language Pathologist's (SLP) discharge summary, dated 4/6/23, indicated Resident #29 was to continue to require a pureed diet for safe swallowing; he/she continued to present with difficulty managing non-pureed solids at discharge. On 8/28/24 at 10:35 A.M., the surveyor observed Resident #29 in bed, awake, with a box of crackers on the bedside table and an opened sleeve of crackers in the bed. The Resident's privacy curtain was pulled past the Resident's end of bed. The surveyor observed the Resident with crackers in his/her mouth and he/she was actively chewing. During an interview on 8/28/24 at 10:41 A.M., Unit Manager #2 said she doesn't know where the information would be kept if the Resident could have crackers on their diet. She said she was aware that the Resident had them. She said that a staff member would have had to hand the crackers to the Resident and open them as he/she wasn't able to do that without assistance. Unit Manager #2 said the staff keeps an eye on the Resident by checking on him/her and walking by the room. Unit Manager #2 said Resident #29 is on a therapeutic diet and isn't aware of any exceptions to the puree diet order. During an interview on 8/28/24 at 3:17 P.M., the Director of Nursing (DON) said the Rehab Director could not find any documentation indicating the Resident could eat the crackers safely and unsupervised. During an interview on 8/29/24 at 8:15 A.M., the Rehabilitation Director said the Resident was last treated by SLP in 2023. She said not adhering to the therapeutic diet puts the Resident at risk for choking and aspiration. She said the Resident should be supervised and if there were exceptions for the Resident to eat foods outside of the therapeutic diet there would be a physician's order. During an interview on 8/29/24 at 1:24 P.M., Rehab Staff #1 said that a screen was placed for the Resident to be evaluated by SLP. He said that after the evaluation, he had concerns for aspiration due to the Resident's positioning, lack of dentition, and he recommended that the puree diet be adhered to for safety with no exceptions.

Based on observations, interviews, record review, and policy review, the facility failed to monitor the nutritional status for one Resident (#18) with an unplanned gradual weight loss, in a total sample of 18 residents. Specifically, the facility failed for Resident #18, to obtain weekly weights as ordered and to monitor the gradual weight loss of 9.68% over six months. Findings include: Review of the facility's Weight Management policy, undated, indicated the healthcare staff will perform the following best practice guidelines to manage risk of significant unplanned weight change: -residents are weighed a minimum of monthly with more frequent weights obtained as ordered or deemed necessary Review of the facility's Clinical Assessment policy, dated 3/17/23, indicated it was the policy of the facility to complete appropriate assessments on residents on admission, quarterly, significant change, annually and at any time an assessment would be indicated. The purpose of the assessments is to get an accurate picture/evaluation of the resident to ensure the development of an appropriate and comprehensive plan of care. Assessments to be completed on admission, quarterly and significant change include Nutritional Assessment. Resident #18 was admitted to the facility in September 2006 with diagnoses of anoxic brain damage, dysphagia (difficulty swallowing), and dementia. Review of the care plans indicated Resident #18 was nutritionally at risk due to diagnoses of anoxic brain damage and dysphagia. The care plan goals indicated the Resident would consume greater than 50 percent (%) of all meals and would maintain a weight of 185 pounds (lbs.) plus or minus 5 lbs., last revised April 2024. Review of the medical record indicated on 2/2/24, Resident #18 weighed 169.4 lbs. and on 8/1/24, the resident weighed 153 lbs., a loss of 9.68%. During an interview on 8/28/24 at 8:20 A.M., Certified Nursing Assistant (CNA) #2 said the intake for Resident #18 can vary, sometimes the Resident was alert, like today and sometimes the Resident was more tired. The CNA said the Resident's ability to self-feed also depended on how alert the Resident was. Review of the most recent Mini Nutritional Assessment, dated 3/25/24, indicated Resident #18 was at risk for malnutrition. Review of the most recent Nutritional Risk Evaluation, dated 3/25/24, indicated Resident #18: -weighed 168 lbs. -had a usual body weight of 175 lbs., plus or minus 5 lbs. (10 lbs. less than indicated on the care plan) -received double portions and super cereal (dietary supplement) with breakfast -weight history indicated weight was stable for one month with a loss of 4.5% in six months, insignificant. Review of the progress notes indicated the following: -on 3/1/24, the Nurse Practitioner initiated Mighty Shakes (dietary supplement) twice per day -on 3/12/24, the physician reviewed the Resident's weights and did not feel it was a true weight loss because of good intake of meals. Review of the Physician's Orders indicated an order to obtain weekly weights for Resident #18 was written on 3/5/24. Review of the electronic and paper medical record failed to indicate weights were obtained weekly. Review of the weight record indicated the following weights were obtained for Resident #18: 3/5/24: 168.3 lbs. 4/2/24: 170.0 lbs. 4/9/24: 170.2 lbs. 4/16/24: 169.4 lbs. 4/30/24: 166.6 lbs. 5/14/24: 165.4 lbs. 5/28/24: 162.6 lbs. 6/11/24: 160.0 lbs. 6/18/24: 197.6 lbs. (reweigh requested) 6/25/24: 161.0 lbs. 7/15/24: 156.8 lbs. 8/1/24: 153.0 lbs. 8/6/24: 154.1 lbs. During an interview on 8/29/24 at 8:45 A.M., CNA #1 said there was a list of residents who needed to be weighed weekly. She reviewed the list with the surveyor and said Resident #18 was not on the list. Review of the physician's Progress Note, dated 8/20/24, indicated Resident #18 had no signs of weight loss, despite the loss of 14.2 lbs. since the order for weekly weights was written on 3/5/24. Review of all assessments and progress notes on 8/27/24 indicated a Registered Dietitian (RD) had not completed an assessment or written a progress note for Resident #18 since 3/25/24. During an interview on 8/29/24 at 11:05 A.M., the RD said she had been covering the facility since June 2024. She said the facility process was for every resident to be assessed quarterly by an RD and she was unable to locate a quarterly assessment for Resident #18 since March 2024. She said the RD also pulled reports to check that all residents with orders for weekly weights were being weighed weekly. She said she did not know Resident #18 was not being weighed weekly. She said she had become aware of the insidious weight loss (gradual, unintended, progressive weight loss over time) for Resident #18 this week and had planned to see and assess the Resident this week. During an interview on 8/29/24 at 2:16 P.M., the RD said she had met with and assessed Resident #18 and would be adding additional interventions.

Based on observation, record review, and interview, the facility failed to ensure the environment was free from accident hazards for one Resident (#51), out of a total sample of 18 residents. Specifically, the facility failed to implement interventions on the comprehensive care plan to ensure safety precautions were taken for resident safety related to smoking, and to complete quarterly smoking evaluations. Findings include: Review of the facility's policy titled Resident Smoking Policy and Procedure, dated 2022, indicated but was not limited to the following: -The facility will maintain an environment that remains as free from accidental hazards as possible. The facility will ensure that each resident receives adequate supervision and assistance to prevent accidents. The facility will provide accommodation of individual needs and preferences without endangering the health or safety of any resident in the facility. -Residents deemed to need assistance should have this designation noted in the care plan. RESIDENTS: -Each resident should be individually assessed to determine whether or not he/she can safely smoke without supervision. -Residents are not permitted to have any smoking paraphernalia in their room or on their person. All smoking paraphernalia should be given to the nursing staff for safe keeping. -Residents who have been determined to require supervision must be actively supervised by a staff member while in the designated smoking area. CONTRACT: -Smoking materials are stored at the nurses' station or as per facility policy. -Use ashtrays provided to extinguish cigarettes. -Follow the plan of care established for the use of safety devices. Review of the facility's policy titled Clinical Assessment, dated 3/17/23, indicated but was not limited to the following: -Assessments to be completed on admission, quarterly, and significant change: Smoking - if applicable. Resident #51 was admitted to the facility in September 2021 with diagnoses including muscular dystrophy, ambulatory dysfunction, and generalized weakness. Review of the Minimum Data Set (MDS) assessment, dated 8/14/24, indicated Resident #51 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) indicating he/she was cognitively intact and he/she smoked. Review of the Smoking Evaluations in the medical record indicated evaluations were completed on the following dates: 11/30/21 and 3/27/23. The facility failed to complete quarterly assessments per policy. Review of the most current evaluation, dated 3/27/24, indicated Resident #51 was not able to light a cigarette safely, was not able to utilize an ashtray safely and properly, and was not able to extinguish a cigarette safely. Additionally, he/she must be supervised by staff and must wear a smoking apron. Review of the comprehensive care plan indicated the following: FOCUS: Resident #51 likes to smoke. (Initiated 11/30/21) GOAL: Resident # 51 will remain safe while smoking. INTERVENTIONS: -Resident #51 uses an adaptive ashtray to aid in smoking. (Ashtray that holds the cigarette in the ashtray away from the body, the cigarette is attached to a plastic tube with a mouth adapter that goes into the Resident's mouth to prevent ashes and the cigarette from falling onto lap if unable to hold the cigarette with own hands. (3/3/22) -Ensure Resident is aware of facility smoking policy. (11/30/21) -Smokers Apron. (11/15/22) Review of the active Physician's Orders indicated the following: -Adaptive Equipment: Smokers Apron (1/30/23) The surveyor made the following observations: -8/27/24 at 10:00 A.M., Resident #51 was sitting outside on the smoking patio with a staff member with the smokers apron on. Resident #51 had the cigarette hanging out of his/her mouth with his/her arms at their side under the smokers apron. No adaptive ashtray was in use. -8/28/24 at 1:40 P.M., Resident #51 was sitting in a wheelchair in his/her room with two cigarettes on his/her lap, waiting for staff to come back to take him/her outside. At 1:44 P.M., Certified Nursing Assistant (CNA) #6 arrived to bring Resident #51 to the smoking patio. -8/28/24 at 1:48 P.M., Resident #51 was sitting outside on the smoking patio with smokers apron on. Resident #51 had a cigarette hanging out of his/her mouth with his/her arms at their side under the smokers apron. No adaptive ashtray was in use. Nurse #3 was standing inside the building behind the glass doors to supervise smoking. Ashes from the cigarette fell from the cigarette that was hanging from his/her mouth onto the apron then Resident #51 dropped the cigarette onto the apron. The resident sitting next to Resident #51 picked the cigarette up from the apron and disposed of it. The resident then picked up Resident #51's second cigarette from his/her lap and put it in his/her mouth. Nurse #3 then opened the door and entered the patio to light the cigarette for Resident #51. Resident #51 proceeded to smoke the second cigarette with it hanging out of his/her mouth only held in place by his/her lips. Resident #51 was attempting to talk while balancing the cigarette in place. Neither Nurse #3 nor the other nurse that came to the patio looking for a resident to administer medications provided intervention to ensure the cigarette was secure while he/she was smoking. During an interview on 8/29/24 at 1:05 P.M., Resident #51 said they keep their cigarettes in their room because they are afraid someone will steal them. Additionally, he/she said they don't use that stupid tube smoke thing; they like to hang the cigarette from their mouth. He/she said, If I drop it, one of the other residents that sits near me usually pick it up for me. During an interview on 8/29/24 at 1:12 P.M., CNA #6 said Resident #51 keeps his/her cigarettes in the top drawer of the dresser with the lock. She said Resident #51 thinks people will steal them, so we keep them there and put two on his/her lap before he/she goes out to smoke. During an interview on 8/29/24 at 2:00 P.M, the Director of Nurses (DON) said she just found out Resident #51 likes to keep cigarettes in their room which is against policy. The DON said the care plan indicates an adaptive ashtray is in use. However, we tried it a while ago and he/she did not like it, so he/she does not use it. The DON said Resident #51 likes to smoke with the cigarette hanging from their mouth which really is not safe. Additionally, she said Resident #51 used to shake their head to get the ashes to fall off into the taller ashtray outside but having them just fall onto the apron is not safe. (The taller ashtray the DON was referring to was not in reach of Resident #51 during either smoking observation.) The DON said other residents should not be picking up cigarettes to help Resident #51 and he/she needs to be reevaluated. At 3:00 P.M, the DON said although staff can observe smoking from inside for most people, someone should be sitting with Resident #51 (1:1) as he/she cannot safety hold the cigarette or ensure ashes and the cigarette do not fall on him/her. During an interview on 8/29/24 at 2:45 P.M., the Staff Development Coordinator said Resident #51 holds his/her cigarette in their mouth; he/she does not use an adaptive ashtray; he/she usually bends their neck and shakes their head to flick ashes off. She said staff can stand inside to supervise in general but with Resident #51 there should be a staff member sitting next to the Resident (1:1), because he/she cannot hold the cigarette in their mouth or pick it up if it falls. Additionally, she said other residents should not be picking up the cigarette if it falls from someone else's mouth.

Based on observations, interviews, and record review, the facility failed to ensure one Resident (#53), out of a total sample of 18 residents, received care and treatment to promote healing of a pressure ulcer. Specifically, the facility failed for Resident #53, to implement treatments as ordered for an unstageable pressure ulcer (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough (necrotic (dead) tissue that is green, yellow, tan, or brown and may be moist, loose, or stringy) or eschar (dry, thick, leathery tissue)) on the sacrum (lower spine area). Findings include: Review of the facility's policy titled Pressure Ulcers/Skin Breakdown- Clinical Protocol, dated as revised in December 2023, indicated the following: -the physician will order pertinent wound treatments including dressings and application of topical agents -the nurses shall describe and document current treatments Resident #53 was admitted to the facility in July 2022 with a diagnosis of dementia and was on hospice services. Review of the care plans indicated Resident #53 had actual skin impairment on the sacrum with interventions to complete the treatments as ordered by the physician. Review of the medical record indicated Resident #53 developed a Deep Tissue Injury (DTI) (intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue) on the sacrum on 4/9/24. Review of the Wound Evaluation and Management Summary from the wound consultant physician, dated 8/8/24, indicated Resident #53 had a stage 3 (full-thickness loss of skin in which fat is visible in the ulcer and granulation tissue and rolled wound edges are often present) pressure ulcer on the sacrum measuring 3.0 centimeters (cm) in length by 1 cm in width by 0.1 cm in depth with DTI within the wound bed. The treatment indicated to utilize Alginate Calcium with silver and Mupirocin topical ointment with a superabsorbent gelling fiber with silicone border dressing. Review of the medical record included a recommendation, dated 8/2/24, from hospice for wound care: cleanse with normal saline, pat dry, apply barrier cream to periwound, apply Calcium Alginate to wound bed, cover with non-adhesive foam followed by transparent dressing, three times weekly and as needed for soilage or dislodgement. Review of the Treatment Administration Record (TAR) for August 2024 indicated a new treatment started on 8/9/24: Sacrum- cleanse with normal saline, pat dry, apply barrier cream to periwound, apply Calcium Alginate to wound bed, cover with superabsorbent silicone dressing every evening shift every Monday, Wednesday, Friday for wound care. During an interview on 8/28/24 at 2:00 P.M., the Staff Development Coordinator (SDC) said she had contacted the primary physician with the hospice recommendation to change the treatment, including decreasing the frequency to three times per week and left a message. During an interview on 8/29/24 at 11:00 A.M., the primary physician said he could not recall specifically speaking with staff about changing the treatment on 8/9/24 but he does verify all orders or treatments that are presented. Review of the Wound Evaluation and Management Summary from the wound consultant physician, dated 8/15/24, indicated Resident #53 had an unstable (due to necrosis) pressure ulcer of the lower sacrum measuring 3.5 cm in length by 1.5 cm in width by 0.1 cm in depth with 40% necrotic tissue. The treatment indicated to add Santyl and continue to utilize Alginate Calcium with silver and Mupirocin topical ointment with a superabsorbent gelling fiber with silicone border dressing. Review of the August 2024 TAR indicated the treatment order for changing the dressing three times per week remained in place until Monday 8/19/24 and the last treatment was completed on Friday 8/16/24. The TAR indicated the order was discontinued on 8/19/24 before the treatment was completed. The TAR indicated the treatment recommended on 8/15/24 by the wound consultant physician began on 8/20/24. Review of the TAR indicated no treatment was completed on 8/20/24. The sacrum pressure ulcer dressing was not changed for five days. During an interview on 8/28/24 at 3:33 P.M., the SDC said she had spoken with hospice and the hospice staff did not provide a dressing change for Resident #53 on 8/19/24 or 8/20/24. During an interview on 8/29/24 at 12:46 P.M., the Director of Nurses (DON) said the nursing supervisor, who completed rounds with the wound consultant physician on 8/15/24, had not updated the treatment orders. The DON said she noticed on 8/19/24 that the order was not up to date and initiated the new treatment. She said the treatment order had changed in the electronic medical record prior to the treatment being completed on 8/19/24 and therefore the treatment was missed. The DON said the nurse should have completed the treatment on 8/20/24. During an interview on 8/30/24 at 6:00 P.M., the wound consultant physician said he had not known that on 8/9/24 the wound treatment had changed to be completed three times per week. He said a dressing cannot be left on that long on a necrotic wound. He said the treatment was now twice per day due to the incontinence (including feces) and to keep the dressing and the wound clean. Review of the active Physician's Orders indicated the following: -Sacrum: Cleanse with 1/4 strength Dakins (topical antiseptic used to prevent infections in wounds) pat dry apply Santyl (ointment used for debriding necrotic tissue from the wound) to slough (collection of dead tissue usually yellow or tan in color) and mupricin (sic) (Mupirocin-ointment used to treat skin infections) to remaining areas, then cover with calcium alginate with silver (antimicrobial dressing to prevent infection in wounds). Skin Prep (wipe used to create a barrier between skin and dressing) wound edges and cover with a super absorbent silicone bordered dressing daily and as needed for displacement. (8/23/24) On 8/29/24 at 10:00 A.M., the surveyor observed Nurse #1 perform Resident #35's wound care which included but was not limited to the following: -Nurse #1 gathered supplies at the doorway to the Resident's room, entered the room, and prepared the worktable with the following supplies: 1/2 strength Dakins solution, 4x4 gauze pads, a super absorbent dressing, calcium alginate, skin prep wipes, and a zip lock bag with two ointments. The nurse failed to obtain the correct Dakins solution, the correct calcium alginate, and the correct ointments. -Dakins 1/4 strength was ordered and 1/2 was placed in the work field. -Calcium Alginate with silver was ordered and calcium alginate was placed in the work field. -Santyl and Mupirocin ointments were ordered, and the zip lock bag placed on the work field contained ointments belonging to another resident. -Nurse #1 and Unit Manager #2 (UM) performed hand hygiene (HH), put on a gown and gloves before turning Resident #53 to provide wound care. -Nurse #1 removed the soiled dressing, removed gloves, and put on clean gloves without performing HH. -Nurse #1 cleansed the wound with the Dakins 1/2 strength solution and 4x4 gauze pads, removed gloves, performed HH, and put on clean gloves. -Nurse #1 opened the zip lock bag, after inspecting the tubes, he realized they did not belong to Resident #53. He then walked to the treatment cart (at the doorway), opened the drawer to get the correct supplies, returned to the work field and placed the ointments on the table. -Nurse #1 failed to change gloves or perform HH after handling the wrong tubes of ointment and touching the treatment cart. -Nurse #1 proceeded to open the tube of Santyl and squeezed the ointment directly from the tube onto to deep open wound, touching the wound bed and covering the entire wound bed (not just the area with slough). -Nurse #1 picked up the Mupirocin ointment and proceeded to squeeze the ointment directly from the tube onto the superficial open areas surrounding the deep wound. -Nurse #1 removed his gloves and put on new gloves without performing HH. -Nurse #1 cut the Calcium Alginate to fit in the wound bed and packed the dressing into the wound bed. -Nurse #1 removed his gloves and put on new gloves without performing HH. -Nurse #1 applied skin prep to the peri wound (skin surrounding the wound). -Nurse #1 removed his gloves, performed HH, and put on new gloves. -Nurse #1 folded a 4x4 piece of gauze, placed it over the calcium alginate, and covered the wound with the super absorbent dressing. -Nurse #1 removed gloves to get a marker from UM #2, put on new gloves without performing HH, proceeded to write the date on the dressing that was on Resident #53's body and then put the incontinent brief back on. -Nurse #1 removed his gloves and put on new gloves without performing HH. -Nurse #1 opened skin prep pads and applied skin prep to Resident #53's bilateral heels. -Nurse #1 removed his gloves and did not perform HH, then proceeded to clean up the supplies on the table. During an interview on 8/29/24 at 10:33 A.M., Nurse #1 said he did not have the correct supplies (he used 1/2 strength Dakins and regular Calcium Alginate) because that was all they had. Additionally, he said the order says for the Santyl to be applied to the slough, but it goes in the entire wound bed and the Mupirocin goes around it on the smaller areas. He said he squeezed the ointment directly from the tubes onto the wound and he should not have. He said sometimes he puts the ointment directly onto the Calcium Alginate but not always and he said the extra 4x4 piece of gauze he put on was not part of the order, but he always puts it there for reinforcement. Nurse #1 said he does not perform HH every time he changes his gloves and usually only does it every 2-3 times he changes them. During an interview on 8/29/24 at 2:00 P.M., the Director of Nurse (DON) and Infection Preventionist/Staff Development (IP/SDC) said HH should be done with every glove change. Additionally, they said the ointments should never be applied directly to the wound for infection control purposes, the ointments should be squeezed to a clean surface and then applied. The DON said the 4x4 is not part of the order and should not have been added to the dressing. Additionally, she said the 1/4 strength Dakins and Calcium Alginate with Silver are in the building and he should have used the correct wound supplies and followed the treatment order.

Based on observation, record review, and interviews, the facility failed to ensure for one Resident (#53), out of a total sample of 18 residents, infection prevention and control measures were implemented to prevent the potential transmission of infections. Specifically, the facility failed to ensure staff followed basic infection control practices, including hand hygiene, resulting in potential cross contamination (transfer of pathogens from one surface to another). Findings include: Review of the facility's policy titled Handwashing/Hand Hygiene, dated as last revised August 2019, indicated but was not limited to the following: -This facility considers hand hygiene the primary means to prevent the spread of infections. -Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap and water for the following situations: a. Before and after direct contact with a resident. b. Before performing any non-surgical invasive procedures. c. Before handling clean or soiled dressings, gauze pads, etc. d. Before moving from a contaminated body site to a clean body site during resident care. e. After handling used dressings, contaminated equipment, etc. f. After contact with objects in the immediate vicinity of the resident. g. After removing gloves. -Applying and Removing Gloves: Perform hand hygiene before applying non-sterile gloves and after removing gloves. Review of Centers for Disease Control and Prevention (CDC) guidance titled Infection Control in Healthcare: An Overview, dated 2/7/24, indicated but not limited to the following: Common reservoirs in and on the human body: Skin -Many germs live and grow on healthy skin and normally do not cause harm. -Your skin interacts with the environment daily, especially when you touch things with your hands. -Pathways for germs to spread from skin include: -Touch, especially with your hands. Review of Centers for Disease Control and Prevention titled Infection Control Basics, dated 4/3/24, indicated but not limited to the following: Transmission can happen through activities such as: -Physical contact, like when a healthcare provider touches medical equipment that has germs on it and then touches a patient before cleaning their hands. Resident #53 was admitted to the facility in July 2022 with diagnoses including dementia, scoliosis, and protein calorie malnutrition. Review of the Minimum Data Set (MDS) assessment, dated 6/4/24, indicated Resident #53 was rarely/never understood, had severe cognitive impairment, and had an unhealed pressure ulcer. Review of the Wound Evaluation and Management Summary, dated 8/22/24, indicated but was not limited to the following: -Focused Exam (Site 2): Unstageable (due to necrosis) (full thickness tissue loss that is covered by a layer of dead tissue, or eschar, that prevents the physician from seeing the wound bed to determine the stage) of the lower sacrum (area located at the base of the lumbar vertebrae connected the pelvis) -Wound Size: 4.5 centimeters (cm) x 3.5 cm x 0.2 cm Review of the active Physician's Orders indicated the following: -Sacrum: Cleanse with 1/4 strength Dakins (topical antiseptic used to prevent infections in wounds) pat dry apply Santyl (ointment used for debriding necrotic tissue from the wound) to slough (collection of dead tissue usually yellow or tan in color) and mupricin (sic) (Mupirocin-ointment used to treat skin infections) to remaining areas, then cover with calcium alginate with silver (antimicrobial dressing to prevent infection in wounds). Skin Prep (wipe used to create a barrier between skin and dressing) wound edges and cover with a super absorbent silicone bordered dressing daily and as needed for displacement. (8/23/24) On 8/29/24 at 10:00 A.M., the surveyor, with Unit Manager #2 present, observed Nurse #1 perform wound care on Resident #53 which included but was not limited the following: -Nurse #1 removed the soiled dressing, removed gloves, and put on clean gloves without performing HH. -Nurse #1 opened a zip lock bag, after inspecting the tubes, he realized they did not belong to Resident #53. He then walked to the treatment cart (at the doorway), opened the drawer to get the correct supplies, returned to the work field and placed the ointments on the table. -Nurse #1 failed to change gloves or perform HH after handling the wrong tubes of ointment and touching the treatment cart. -Nurse #1 proceeded to open the tube of Santyl and squeezed the ointment directly from the tube onto the deep open wound, touching the wound bed. -Nurse #1 picked up the Mupirocin ointment and proceeded to squeeze the ointment directly from the tube onto the superficial open areas surrounding the deep wound. -Nurse #1 removed his gloves and put on new gloves without performing HH. -Nurse #1 cut the Calcium Alginate to fit in the wound bed and packed the dressing into the wound bed. -Nurse #1 removed his gloves and put on new gloves without performing HH. -Nurse #1 applied skin prep to the periwound (skin surrounding the wound). -Nurse #1 removed his gloves, performed HH, and put on new gloves. -Nurse #1 folded a 4x4 piece of gauze, placed it over the calcium alginate, and covered the wound with the super absorbent dressing. -Nurse #1 removed gloves to get a marker from UM #2, put on new gloves without performing HH, proceeded to write the date on the dressing that was on Resident #53's body and then put the incontinent brief back on. -Nurse #1 removed his gloves and put on new gloves without performing HH. -Nurse #1 opened skin prep pads and applied skin prep to Resident #53's bilateral heels. -Nurse #1 removed his gloves and did not perform HH, then proceeded to clean up the supplies on the table. During an interview on 8/29/24 at 10:33 A.M., Nurse #1 said he did squeeze the ointment directly from the tubes onto the wound and he should not have. He said sometimes he puts the ointment directly onto the Calcium Alginate but not always. Nurse #1 said he does not perform HH every time he changes his gloves and usually only does it every 2-3 times he changes them. During an interview on 8/29/24 at 2:00 P.M., the Director of Nurse (DON) and Infection Preventionist/Staff Development (IP/SDC) said HH should be done with every glove change. Additionally, they said the ointments should never be applied directly to the wound for infection control purposes, the ointments should be squeezed to a clean surface and then applied.

Based on record review and staff interviews, the facility failed to ensure for one Resident (#42), out of a total sample of 18 residents, that the Resident's drug regimen was free from unnecessary drugs. Specifically, the facility failed to ensure Azithromycin (antibiotic) was not administered without an adequate indication for use for an excessive duration of time (one year). Findings include: Resident #42 was admitted to the facility in December 2022 with diagnoses which included chronic respiratory failure, chronic obstructive pulmonary disease (COPD), and pneumonia. Review of the Minimum Data Set (MDS) assessment, dated 6/26/24, indicated Resident #42 scored 12 out of 15 on the Brief Interview for Mental Status (BIMS), was cognitively intact, and was taking an antibiotic. Review of the medical record indicated Resident #42 had been admitted to the hospital in August 2023. Review of the hospital Discharge Summary, dated 8/8/23, indicated the Resident was discharged back to the facility on a 5-day course of antibiotics for pneumonia. The Discharge Summary failed to indicate the need or recommendation for long-term prophylactic treatment with antibiotics. Review of the Medication Administration Record (MAR) for August 2023 indicated he/she completed the 5-day course of antibiotics as recommended in the discharge orders. Review of the primary care physician (PCP) progress note, dated 8/22/23, indicated Resident #42 was being seen for follow up from pneumonia, had no shortness of breath or overnight issues. Additionally, his/her lungs were clear and oxygen saturation levels were over 90% and to continue current management. Review of the respiratory progress note, dated 8/22/23, indicated Resident #42 was seen by the respiratory therapist and pulmonary doctor, and indicated that the pulmonary doctor recommended Azithromycin and Prednisone (steroid) taper. Review of the nursing progress note, dated 8/22/23, indicated new orders per pulmonologist: Prednisone Taper 40-10 milligram (mg) (two days each dose) and Azithromycin 250 mg three times a week. MD in agreement. Review of the active Physician's Orders indicated but were not limited to the following: -Azithromycin Oral tablet 250 mg give one tablet by mouth one time a day every Monday, Wednesday, Friday related to COPD. (8/23/23) Review of the comprehensive care plan failed to indicate a care plan had been developed for the prophylactic use of antibiotics with an indication for use or for the diagnosis of COPD. Review of the medical records (paper and electronic) failed to indicate a progress note from the pulmonologist indicating his evaluation, recommendation for prophylactic antibiotic, and the indication for use. Review of the medical records (paper and electronic) failed to indicate the primary care physician had evaluated the need for prophylactic antibiotics and the indication for use. During an interview on 8/29/24 at 1:19 P.M., Nurse #4 said she thinks the recommendation came from respiratory therapist and/or pulmonologist. Nurse #4 was unable to provide the surveyor with any documentation regarding the indication for prophylactic antibiotic use. Additionally, Nurse #4 said she did not know why he/she has been on the antibiotic for a year now. During an interview on 8/29/24 at 2:00 P.M., the Director of Nurses (DON) said she was unable to find any documentation in the medical record except the one respiratory note, dated 8/22/23, indicating the recommendation came from the pulmonologist. She said he usually would write notes in the chart and was not sure why there was not a note in the paper or electronic medical record. The DON said she placed a call to the respiratory therapist to try and contact the pulmonologist. She said the pulmonologist no longer comes to the facility, however the respiratory therapist was still in contact with him, so she reached out to see if there was a progress note that was not uploaded. She said there should be a note from the Pulmonologist and the PCP in the medical record regarding the indication for use and there is not. The facility failed to provide any additional documentation regarding the prophylactic antibiotic use by the conclusion of the survey.

Based on record review and interview, the facility failed to provide indwelling catheter (a flexible tube inserted into the bladder to drain urine outside of the body) care and management consistent with professional standards for one Resident (#2), out of a total sample of 18 residents. Specifically, the facility failed to ensure the Foley catheter was assessed for removal as soon as possible after returning from the hospital and failed to ensure he/she followed up with Urology as recommended. Findings include: Resident #2 was admitted to the facility in April 2024 with diagnoses including overactive bladder and epilepsy (seizure disorder). Review of the Minimum Data Set (MDS) assessment, dated 7/31/24, indicated Resident #2 scored 9 out of 15 on the Brief Interview for Mental Status (BIMS) indicating he/she had moderate cognitive impairment, had epilepsy, had been hospitalized recently, and had a Foley catheter. Review of the active Physician's Orders indicated but were not limited to the following: -Foley Catheter Care every shift for urinary elimination. (7/25/24) -Foley Catheter 16 French/10 milliliter (16F/10cc) balloon every shift for monitoring. (7/25/24) Review of the Comprehensive Care plan indicated Resident #2 had a Foley catheter for neurogenic bladder (bladder dysfunction caused by the nervous system). Review of the medical record failed to indicate a diagnosis of neurogenic bladder. Further review of the medical record indicated Resident #2 had been hospitalized from 7/19/24 through 7/24/24 for seizures and did not have a Foley catheter prior to this hospitalization . Review of the discharge summary, dated 7/24/24, indicated Resident #2 had acute urinary retention (inability to empty the bladder) resulting in repeated straight catheterizations (small tube inserted to drain urine but not left in place) and urethral trauma, requiring Foley catheter placement. Discharge recommendation included Urology follow up in 3-4 weeks and a voiding trial (attempt to remove Foley to evaluate if able to void without it). Review of the medical record including physician and nursing notes, orders, and treatment sheets failed to indicate a voiding trial had been attempted or discussed. Review of the Physician's progress note, dated 7/26/24, indicated Resident was noted with urinary retention, Foley inserted while inpatient with recommendation to follow up with urology in 3-4 weeks. Review of the Appointment book on the unit failed to indicate a urology appointment had been made. Review of the nursing progress notes indicated the following: -8/22/24, Resident #2 had a seizure, was restless and repeatedly asked staff to check the catheter. The catheter was draining, but not closed all the way, and was leaking into the privacy bag. -8/24/24, Resident #2 pulled the Foley catheter out and was transferred to the hospital at his/her request. -8/25/24, Resident #2 returned from the emergency room with a new catheter in place. -8/27/24, Resident #2 stated the catheter was leaking, the bag had a hole in it and was replaced. -8/28/24, Resident #2 said the room smelled like urine and he/she was not sleeping in there. Resident was out of bed in the wheelchair and at 6:30 A.M., was observed sideways in bed, and stated they were trying to get into bed. Further review of the progress notes failed to indicate staff had reached out to the physician to discuss a voiding trial or to inquire if a Urology follow-up was scheduled. During an interview on 8/28/24 at 9:51 A.M., Nurse #4 said every appointment is logged into the binder and that it is used to book transport as well. She was unsure if he/she had a Urology appointment scheduled. During an interview on 8/29/24 at 1:15 P.M., Nurse #4 said she did not know why the Urology appointment was never made but she was going to call the office. She said she thought the Unit Manager had booked it but there was nothing in the book. During an interview on 8/29/24 at 2:00 P.M., the Director of Nurses (DON) said she was not sure how the appointment was missed but the ball was dropped, and the process needs improvement. The DON said the Foley catheter is new and the appointment should have been made. The DON said we want him/her to have a voiding trial and not have a Foley catheter that is not needed. During an interview on 8/29/24 at 3:11 P.M., Nurse #4 said she called the Urologist's Office and unfortunately Resident #2 had an appointment yesterday and missed it because it was never put into the appointment book and transportation was never booked. She said the next available appointment now is not until October. She said she was going to call the physician to see what he wanted to do about the voiding trial. No additional information was provided to the surveyor prior to exit.

Based on observations, interviews, and record reviews, the facility failed to ensure one Resident (#16) with a pressure ulcer received treatment and services to promote wound healing, in a sample of five residents with pressure ulcers. Specifically, the facility failed to ensure for Resident #16, a. wound treatment recommendations were implemented, and b. the pressure-relieving air mattress was utilized following professional standards. Findings include: Resident #16 was admitted to the facility in August 2022 and had diagnoses including re-occurring c-diff (clostridium difficile- a bacteria that causes diarrhea) and diabetes; hospice services were initiated in March 2023. Review of the Minimum Data Set (MDS) assessment, dated 5/17/23, indicated Resident #16 scored a 7 out of 15 on the Brief Interview for Mental Status, indicating severe cognitive impairment. Review of the Care Plans indicated Resident #16 had a skin impairment related to incontinence and a mobility deficit, initiated February 2023. The goal was to reduce the size of the pressure ulcer through interventions of utilizing a wound consultant and the use of a low air loss mattress. Review of the medical record indicated Resident #16 had a Stage 3 pressure ulcer (full-thickness loss of skin in which subcutaneous fat may be visible in the ulcer) to the sacrum (lower back near the pelvis) and the facility wound consultant had re-initiated services on 4/29/23. a. Review of the Wound Evaluation and Management Summary from the wound consultant indicated Resident #16 was seen by the wound consultant on 4/29/23. The wound consultant had indicated a change in dressing treatment for the stage 3 pressure ulcer on the sacrum. The dressing treatment plan now indicated to discontinue Alginate Calcium, Santyl, and Gentamycin Ointment and the following treatment was recommended: Alginate Calcium with silver, once daily and as needed followed by a superabsorbent silicone border. Review of the April 2023 Treatment Administration Records (TAR) indicated the following order for the Sacrum, dated 4/30/23: cleanse with normal saline, apply Calcium Alginate with Silver to wound bed, fill wound cavity with Maxorb (a dressing used to absorb drainage), cover with superabsorbent silicone border dressing, daily. Review of the medical record did not include documentation to indicate the use of Maxorb as part of the treatment. Review of the Wound Evaluation and Management Summary, dated 5/5/23, indicated to discontinue the Alginate Calcium with Silver and add Alginate Calcium and Santyl and to continue the superabsorbent silicone border dressing. Review of the May 2023 TAR indicated there had been no changes to the Sacrum pressure ulcer treatment and the treatment continued as Alginate Calcium with Silver and had not been changed to Alginate Calcium and Santyl. Review of the Wound Evaluation and Management Summary, dated 5/12/23, indicated to continue Alginate Calcium and Santyl and to add Mupirocin (an antibiotic ointment). Review of the May 2023 TAR indicated there had been no changes to the Sacrum pressure ulcer treatment and the treatment continued as Alginate Calcium with Silver and had not been changed to the previously recommended Alginate Calcium and Santyl and the current recommended Mupirocin. Review of all Wound Evaluation and Management Summaries, from 5/12/23 through 6/30/23, indicated the wound consultant continued to recommend the treatment to apply Alginate Calcium, apply Santyl, and apply Mupirocin ointment. During an interview on 7/7/23 at 3:33 P.M., the Director of Nurses said the process for the wound consultant was that when the wound consultant rounded on residents the nursing supervisor was present, the wound doctor would make verbal recommendations and the nursing supervisor would contact the primary physician for an order. She said the physicians would defer to the wound consultant for wound recommendations and agreed with the treatments. During an interview on 7/11/23 at 12:33 P.M., the Director of Nurses said she would have to review the medical record to determine if hospice had consulted on the treatment recommendations to determine why the wound consultant's recommendations were not followed. Review of the hospice recommendations for Resident #16 indicated the last hospice note regarding treatments to the Sacrum pressure ulcer was on 3/16/23. During an interview on 7/12/23 at 9:23 A.M., the Staff Development Coordinator said she had reviewed the documentation and was unable to determine why the recommendations from the wound consultant were not followed including continuing the use of Maxorb, not changing the treatment from Alginate Calcium with Silver to Alginate Calcium and Santyl and not including Mupirocin. During an interview on 7/12/23 at 9:59 A.M., the Physician of Resident #16 said the wound consultant recommendations (Wound Evaluation and Management Summary) are put directly into the electronic medical record and he is able to access them. He said the nurses notify him of any changes with the wound treatments and he will defer to the wound consultant for the treatment recommendations. He said the would treatments to the Sacrum pressure ulcer should reflect those recommended by the wound consultant. b. Review of the facility's policy titled Support Surface Guidelines, dated as revised in September 2013, indicated the following: -Review the resident's care plan to assess for any special needs of the resident. -Redistributing support surfaces are to promote comfort for all in bed, prevent skin breakdown, promote circulation and provide pressure relief or reduction. -Support surfaces are modifiable. Individual needs differ. -Elements of support surfaces that are critical to pressure ulcer prevention and general safety include pressure redistribution, moisture control, shear reduction, heat dissipation/temperature control, friction control and life expectancy. During an interview with observation on 7/6/23 at 11:27 A.M., the surveyor observed Resident #16 lying in bed, on an air mattress set to the correct weight setting. Resident #16 said the staff continue to put those tissues (disposable pads) under my butt. The surveyor observed a fitted sheet, a folded blanket\, and a folded sheet (both folded in half twice, creating multiple layers) between the Resident and the air mattress. On 7/7/23 at 8:41 A.M., the surveyor observed Resident #16 lying in bed with a fitted sheet and a folded sheet between the Resident and the air mattress. During an interview on 7/11/23 at 9:01 A. M., Resident #16 said he/she had just the usual underneath his/her buttocks. He/she said they tell staff not to let the items bunch up because it hurts the pressure ulcer. During an interview with observation on 7/11/23 at 10:48 A.M., Nurse #3 observed a fitted sheet, a folded sheet and a folded blanket between the resident and the air mattress. Nurse #3 said maybe the items were there for comfort and Resident #16 replied, No, I don't want all these. Nurse #3 said the items placed between the air mattress and the Resident would not assist with making the air mattress pressure relieving. During an interview on 7/11/23 at 11:07 A.M., the Director of Nurses said the air mattress was implemented for Resident #16 to promote wound healing. She said there should not be multiple layers between the air mattress and the Resident as this can change the effect of the air mattress.

Based on observations, interviews, policy review, and record review, the facility failed to ensure an individualized plan of care was developed and implemented for three Residents (#66, #28, and #77), in a total sample of 19 residents. Specifically, the facility failed: 1. For Resident #66, a. to develop a care plan for an indwelling urinary catheter, an intravenous (IV) catheter, and an active infection, and b. to ensure the air mattress settings were implemented per the plan of care; 2. For Resident #28, to develop a care plan for edema; and 3. For Resident #77, to ensure the air mattress settings were implemented per the plan of care. Findings include: Review of the facility's policy titled Comprehensive Person-Centered Care Plans, dated March 2022, indicated but was not limited to: -A comprehensive, person-centered care plan that includes measurable objective and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. - The comprehensive, person-centered care plan describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psycho-social well-being -Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change -The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition; b. when the desired outcome is not met; c. when the resident has been readmitted to the facility from the hospital stay; and d. at least quarterly, in conjunction with the required quarterly MDS assessment. 1. Resident #66 was admitted to the facility in February 2023 with diagnoses which included dementia, cerebrovascular accident (stroke), and multiple pressure ulcers. a. Review of Resident #66's current Physician's Orders indicated: -Foley Catheter Order, dated 5/25/23 -Foley Catheter Care, dated 5/25/23 -Cefepime HCL (antibiotic) 2 grams intravenously every 8 hours for infection, dated 6/27/23 -Daptomycin (antibiotic) 500 milligrams intravenously every 24 hours for infection, dated 6/27/23 Review of Resident #66's Nursing Note, dated 6/27/23, indicted Resident #66 was readmitted to the facility with an indwelling urinary catheter, was on antibiotics for an infection, and had an intravenous catheter. Review of Resident #66's Nursing Note, dated 7/10/23, indicted Resident #66 continued to have an indwelling urinary catheter, continued on antibiotics to treat a coccyx wound infection, and had an intravenous catheter in his/her right upper extremity. Review of Resident #66's care plans indicated no documented evidence that a care plan for an indwelling urinary catheter, an active infection, and an intravenous catheter had been developed. During an interview on 7/11/23 at 4:40 P.M., the Staff Development Coordinator said the indwelling catheter care plan was not in place before today but has since been developed. During an interview on 7/11/23 at 4:41 P.M., the Director of Nurses (DON) reviewed Resident #66's current care plans and said there was not a care plan for the active infection or intravenous catheter. The DON said the expectation was for care plans to be updated and inclusive of any changes or acute issues. b. Review of the manufacturer's guidelines for Protekt Aire pump and mattress system included but was not limited to: -The mattress is indicated for the prevention and treatment of any and all stage pressure ulcers when used in conjunction with a comprehensive pressure ulcer management program. -Operating instructions include: determine the patient's weight and set the control knob to that weight setting on the control unit. Review of Resident #66's current Physician's Orders indicated: -Low Air Loss Mattress set at 125 pounds +/- 10 pounds, check every shift, dated 3/1/23 Review of Resident #66's care plan included but was not limited to: -Focus: The resident has (multiple) pressure ulcer sizes may vary due to debridement, initiated on 2/24/23 and revised on 5/17/23 -Intervention: Air mattress for pressure relief-check function every shift, initiated 2/24/23 Review of Resident #66's weight summary indicated the most recent documented weight of 125.2 pounds on 3/1/23. Throughout survey, the surveyor observed Resident #66 and his/her air mattress control unit (located at the foot of the bed) as follows: -On 7/6/23 at 11:30 A.M., Resident #66 lying in bed with air mattress set at 170 pounds -On 7/10/23 at 8:20 A.M., Resident #66 lying in bed with air mattress set at 170 pounds -On 7/10/23 at 11:23 A.M., Resident #66 lying in bed with air mattress set at 170 pounds -On 7/10/23 at 2:50 P.M., Resident #66 lying in bed with air mattress set at 170 pounds -On 7/11/23 at 7:59 A.M., Resident #66 lying in bed with air mattress set at 170 pounds During an interview on 7/11/23 at 3:00 P.M., Nurse #2 said when a resident has an air mattress it should be set based on his/her weight. Nurse #2 said the computer system tells the staff to check the setting every shift. During an interview on 7/11/23 at 4:32 P.M., the Director of Nurses (DON) said the expectation was for an air mattress to be set per orders and nurses are prompted every shift to verify settings. 27189 2. Resident #28 was admitted to the facility in August 2017 with diagnoses including diabetes mellitus and hemiplegia of the right side due to cerebrovascular disease. Review of an Occupational Therapy Screen, dated 5/9/23, indicated but was not limited to the following: Reason for the Screen: Quarterly Screen Change in other areas: Positioning, Range of Motion, Edema Occupational Therapy Evaluation Indicated: Yes Review of the July 2023 Physician's Orders indicated the following: -Isotoner glove (used to provide compression) Right hand wearing schedule, to don (put on) daily during A.M. routine for 6 hours as tolerated every day shift, (order date 6/29/23) Please keep right arm elevated on pillow all of the time for increased edema +2 every shift, monitor skin integrity. SPLINT: Right Upper Extremity (RUE) trough to wheelchair for comfort, positioning, and decrease risk of injury, every shift. Review of an Occupational Therapy Treatment note, dated 7/12/23, indicated but was not limited to the following: The elevated arm trough was provided due to a concern for edema of the RUE to allow passive control. Pt (patient) continues to present with minimal to moderate edema. Caregivers should continue to utilize appropriate positioning technique to assist with edema control. Review of the comprehensive care plans failed to indicate that a care plan had been developed related to the Resident's edema and interventions that addressed potential problems/focus, goals, and interventions. During an interview on 7/12/23 at 10:34 A.M., Clinical Nurse #1 and Clinical Nurse #2 reviewed Resident #28's medical record and said the comprehensive care plan related to the Resident's edema had not been developed and should have been. 15214 3. Resident #77 was admitted in December 2022 with a diagnosis of a right hip fracture following a fall. Review of the medical record indicated the Resident was admitted to Hospice in April 2023 for end-stage care, to include treatment for a pressure injury to the sacrum that developed in April 2023. Review of the Resident's care plan indicated that adaptive equipment included the use of an air mattress set to a weight of 125 pounds (lbs.), plus or minus 10 lbs., check every shift for functioning. On 7/6/23 at 8:42 A.M., the surveyor observed Resident #77 lying in bed. The Resident's air mattress control unit was attached to the bottom of the bed, set on static, and on a pressure for a Resident's weight of 160 lbs. On 7/11/23 at 8:39 A.M., the surveyor observed the Resident lying in bed. The mattress control unit was attached to the bottom of the bed and observed to be set for a weight of 170 lbs., instead of the weight of 125 lbs. listed on the care plan. On 7/11/23 at 11:28 A.M., the surveyor and Nurse #4 observed the Resident's air mattress control unit set at 170 lbs. During an interview on 7/11/23 at 11:28 A.M., Nurse #4 said, that after reviewing the physician's order, and visualizing the air mattress control unit, the air mattress was not set at the proper pressure level for the Resident. She said that the physician's order indicated that the mattress should be set at 125 lbs., plus or minus 10 lbs. Nurse #4 confirmed with the surveyor that the last recorded weight for the Resident was 127.8 lbs. on 3/24/23.

Based on observation and interview, the facility failed to ensure the resident environment was clean, comfortable, and homelike for the residents residing on two of three units. Specifically, 1. For the Astoria Unit (2nd floor), multiple areas in the environment were found to be dirty and/or in disrepair; and 2. For the [NAME] Unit (4th floor), multiple concerns were identified with regard to the cleanliness of resident rooms and equipment. Findings include: 1. The surveyor observed the Astoria Unit and made the following observations of the residents' environment: On 7/6/23 from 10:51 A.M. to 11:15 A.M., the surveyor observed the following: -An air conditioner in room [ROOM NUMBER] had a black mold-like substance material at the louvered side panels that meet the sides of the windows. -An air conditioner in room [ROOM NUMBER] had a black mold-like substance at the louvered side panels that meet the sides of the window and in the air conditioner vents. A soiled glove was observed on the floor between the beds. The floor was observed to have brown stains on it. -The bathroom between room [ROOM NUMBER] and 203 had trash on the floor and on top of the trash can. -The floor in the dining room was observed to be lifting at the edges in multiple areas creating a potential safety hazard for residents. On 7/11/23 at 8:03 A.M., the surveyor observed that the wall in room [ROOM NUMBER]-C had a long piece of chair rail molding behind the resident's bed, nearly detached from the wall, exposing white plaster underneath. On 7/12/23 from 8:35 A.M. to 12:05 P.M., the surveyor observed the following: -An end table in the sitting area opposite the nurses' station had a piece of laminate detached from the edge of the table. -A wooden nightstand in room [ROOM NUMBER] had the right hand front corner and front with scraped finish exposing the bare wood. -An air conditioner in room [ROOM NUMBER]-C had a black mold-like substance around the side panels. -An air conditioner in room [ROOM NUMBER] had a black mold-like substance around the air conditioner at the left and right air blowers. -A resident's personal fan in room [ROOM NUMBER]-C had a large accumulation of gray dust in the back of the fan. -The left, lower bathroom door frame in room [ROOM NUMBER] had the white paint scraped in multiple areas from the metal door frame, exposing gray and black paint underneath. -The Cool zone/ activity room window shades were dirty; the ceiling (above the middle picture window) had paint/plaster peeling with yellowish brown stains on it. -In room [ROOM NUMBER]-A (unoccupied), to the left, back of the bed, two large areas of paint were scraped from the wall, exposing the plaster beneath. The electric bed controller had a broken plastic tab that fastens it to the bed rail. -The dresser in room [ROOM NUMBER]-B had a significant amount of dried water/liquid stains on the wooden surfaces in the top, middle, and bottom drawers. -The top drawer of the dresser in room [ROOM NUMBER]-A had a large amount of hard, black, shiny substance and black stains scattered throughout the wooden surface of the drawer. The privacy curtain between A and B beds had a large, brownish-red stain at the level of the A bed. -room [ROOM NUMBER]-B (unoccupied) had a dresser with large water/liquid stains in the top, middle, and bottom drawers. -room [ROOM NUMBER] (unoccupied) had an air conditioner with a black mold-like substance at the front of the air conditioner. -room [ROOM NUMBER]-B had a metal, bi-fold door, with a sharp edge observed at the left edge of the right door -A chair across from the elevator had a push pin stuck in the fabric in the back of the chair. During an interview on 7/12/23 at 11:50 A.M., the Administrator said that he understood that there were environmental concerns that needed to be addressed at the facility, which included those identified by the surveyors during the survey. 27189 2. The surveyor observed the [NAME] Unit (4th floor) and made the following observations of the residents' environment: On 7/6/23 from 8:15 A.M. through 9:15 A.M. the surveyor observed: -room [ROOM NUMBER]-strong urine odor with the odor present at different times of day (the smell of urine remained in the room throughout the survey). ~The windowsill in the room was being used as a storage area by the Resident for movie/music tapes. The view was impeded by the storage of the tapes/movies. The tapes extended the entire length of the windowsill and was over 10 inches in height. -room [ROOM NUMBER] - debris (old cups, dried out/old food particles, used soda bottles) on the floor and under both beds the floors were laden with dust and debris. The floor in the room was dirty and sticky in certain areas. ~Bed A-Two overbed tables (#1 and #2) were badly stained with spills of liquids that had dried, were sticky to the touch and the laminate was lifting. The table could not be cleaned/disinfected properly because the integrity of the laminate was compromised and not intact. The overbed tables were in disrepair. ~Overbed table #1- There were numerous personal care items -lotion, spray deodorant, roll on deodorant, 2 bottles of mouthwash, a tube of hydrocortisone cream and a tube of a prescription cream. ~Overbed table #2- A urinal filled with urine, numerous Styrofoam cups that had been used, Styrofoam cups that were overflowing with condiments that the resident was hoarding, and four over ripened bananas. ~25 Styrofoam cups that had been stacked and stored behind the television on the dresser. There were 6 bowls of dry cereal loosely covered with a plastic lid and the surface of the dresser was dusty and stained from spills. ~The oxygen concentrator (as needed use only) was laden with dust and a walker and wheelchair piled up on top of the concentrator. ~The wheelchair and walker were dusty and needed cleaning. -room [ROOM NUMBER]- A large crack in the window near the air conditioner was observed. There was debris scattered throughout the room on the floor, including under the bed. The overbed tables had multiple dirty cups stored on them. During an interview on 7/6/23 at 8:55 A.M., Resident #18 said there are lots of mice and that he/she saw a mouse last night. In the far corner of the room, under the window was a bait station for mice. -room [ROOM NUMBER] had scattered debris on the floor. During an interview on 7/6/23 at 9:00 A.M., Resident # 5 said that there are always mice, but that he/she saw a rat recently that was as big as a cat. -room [ROOM NUMBER]-The fall mat placed next to B bed was dirty, dusty and had old stains. -room [ROOM NUMBER] (A bed)- an arm trough (used to elevate an extremity while seated in a wheelchair) was dirty, the blue foam was stained in multiple areas as was the plastic portion and the entire trough was in disrepair. -A tan Isotoner glove (used for edema) was on the dresser that had dried food on the glove and was stained. - (B bed)-Three urinals present on overbed table that were dirty and stained (old). -The shared bathroom for rooms #406 and #408 had a foul smell present when entering the bathroom and the grout around the toilet was brown and stained. -The flooring in the unit dining room was observed to be lifting at the edges in multiple areas creating a potential safety hazard for residents. The shades and windows were dirty. -All the rooms observed (#401 through room [ROOM NUMBER]) had floors with debris present, that consisted of old food items, paper, cups, etc. The above rooms remained cluttered and dirty throughout the day on 7/6/23 and at 4:27 P.M., the environment remained unchanged. On 7/10/23 from 8:00 A.M. through 1:00 P.M. the following was observed: -room [ROOM NUMBER] The urine odor was present and had not improved since initial observation on 7/6/23 -room [ROOM NUMBER] A bed-the same personal care items and the hydrocortisone cream remained on the overbed table #1; Observed on top of the dresser was a tube of prescription cream, four containers of dry cereal and multiple stacks of Styrofoam cups. Overbed side table#2 had multiple cups filled with condiments, used Styrofoam cups and open banana sitting on top of the dirty overbed table. Both overbed tables (#1 and #2) that remained in unsanitary condition -room [ROOM NUMBER] B bed (window) A urinal filled with urine on the overbed table. -room [ROOM NUMBER] pieces of paper on the floor. -room [ROOM NUMBER] A bed- the arm trough remained in the same position/place on the dresser and was in the same condition noted on 7/6/23. An empty chocolate ice cream cup and cover was observed under the bed. -room [ROOM NUMBER] B bed (window) two dirty urinals placed on the overbed table. -The shared bathroom for room [ROOM NUMBER] and room [ROOM NUMBER] continued to have brown spots on the floor and on the toilet. The foul smell was present when entering the bathroom and the grout around the toilet was brown. The bathroom remained dirty. -The shared bathroom for room [ROOM NUMBER] and #404 had brown grout around the toilet area and had a stale smell. The facility failed to maintain an environment that was sanitary and homelike.

Based on a resident group meeting, interview, policy review, and document review, the facility failed to ensure grievances and concerns brought forward by the Resident Council were addressed and/or responded to. Findings include: Review of the facility's policy titled Resident Council, dated as revised February 2021, indicated but was not limited to the following: - The purpose of the Resident Council is to provide a forum for discussion for concerns, communication between residents and staff, and to gather feedback. - a resident council response form will be utilized to track issues and their resolutions. Review of the facility's policy titled Resident and family concerns and grievance policy, dated 2020, indicated but was not limited to the following: - residents may voice a grievance to the facility staff in person, by phone, or written communication - a formal investigation of the grievance will occur as soon as is practicable - the facility will document all steps of the grievance resolution, including whether or not the residents were satisfied with the resolution Review of the Resident Council Minutes, dated 5/23/23, indicated but were not limited to the following: - Nursing department: staff not speaking English - ongoing (discussed at morning meeting) Review of the Resident Council Minutes, dated 6/21/23, indicated but were not limited to the following: - Nursing department: no issues There was no documentation in the 6/21/23 Resident Council Minutes to indicate the facility responded to the residents' concerns from the previous meeting on 5/23/23. On 7/7/23 from 10:30 A.M. - 11:00 A.M., the surveyors held a group meeting with 14 residents in attendance. Collectively, the residents said issues were brought up monthly at Resident Council meetings, but they did not feel the facility provided follow up or resolution to the issue of staff speaking foreign languages in resident areas on all three floors of the facility. In addition, individual residents, who were alert and oriented, commented as follows: - Resident #60 said he/she felt that if you have a disagreement with a staff member they discuss you in their primary language with a friend (another staff member) very loudly while looking at you and it can be intimidating because you cannot understand what is being said. Resident #60 said the issue is brought up in Resident Council all the time and the residents are told education will be provided to the staff, but the issue has not improved. - Resident #57 said sometimes a group of staff will stand around together on the nursing units and speak their primary language, which is foreign to the facility, and it feels like they could be targeting someone who may have just asked a question. - Resident #1 said staff frequently gather outside of his/her room speak loudly in their dominant language, which he/she cannot understand. The Resident said he/she has told them to move along because they were being loud and disruptive. Resident #1 said he/she has been told by the staff to mind his/her business and then they continue speaking near his/her doorway in a language he/she cannot understand. - Resident #74 said the staff get together in common areas in the facility, like dining rooms or sitting rooms, while residents are in there and speak to each other in their own foreign language and it is annoying, since he/she cannot understand what is being said. - Resident #78 said when staff speak in a foreign language in the resident common areas, and you ask them to stop, they either ignore you or speak louder and look at you and laugh as they continue to do it. - Resident #24 said he/she does not know why things have not improved with staff speaking foreign languages on the nursing units because it is brought up in Resident Council every month. During an interview on 7/7/23 at 1:37 P.M., the Activity Director said she documents any concerns that come up in Resident Council. She said she discusses the concerns at morning meeting the following day with all the department heads and grievance forms are completed for issues that have been brought forward. She said the facility grievance process is the method used for Resident Council concerns and then she will document improvement or resolution of issues in the meeting minutes (not the resident council response forms, per the resident council policy). She said the concern about staff speaking a foreign language in the facility is brought up monthly by the residents. She said the residents have told her the issue is ongoing and there has been no change or improvement in the concern. She said she was told not to document the issue of staff speaking a foreign language in the monthly minutes any longer and that staff would be in-serviced. She said she does not recall completing a grievance form for the voiced resident council concern of staff speaking a foreign language in the facility. Review of the completed grievance forms for 2023 (January 1 to July 7) failed to indicate a Resident Council grievance was completed for the concern of staff speaking a foreign language. During an interview on 7/7/23 at 2:49 P.M., the Director of Nurses said she was aware that occasionally residents have voiced that staff speak a foreign language in resident areas but she was unaware that it was an ongoing issue. She said if she is informed she addresses it with those involved at the time the concern is voiced to her. She said the process for Resident Council concerns is that the Activity Director facilitates Resident Council, maintains the minutes, fills out grievances for concerns and brings them to morning meeting the following day for the department heads to address. She said she was not aware the Resident Council had voiced the group concern of foreign language in their May 2023 meeting. She was made aware of the concerns brought forth in the group meeting and said she was unaware of the issue being ongoing and surprised the residents had such strong comments to make. She said the process for resolving Resident Council concerns does not appear to have been followed in this instance. During an interview on 7/7/23 at 3:06 P.M., the Administrator was made aware of the concerns brought forth during the group meeting and said he was unaware that this was an ongoing concern of the residents. He said although the concern is documented in the May Resident Council minutes he does not recall seeing a grievance form to coincide with that concern. He reviewed the facility grievance log and said the grievance was not documented. He said the process is for concerns to be brought to morning meeting the next day and grievance forms initiated to start the full grievance process and the process for resolving this resident concern was not followed as it should have been.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who required the assistance of two staff members with Activities of Daily Living (ADL) including bed mobility, the Facility failed to ensure that he/she was provided adequate assistance and remained free from an accidents with injury, when on 6/25/20, Certified Nurse Aide (CNA #1) provided care to Resident #1 and repositioned him/her in bed unassisted by another staff member, Resident #1 rolled off the bed, fell on to the floor, sustained a laceration to his/her forehead and was transferred to the Hospital Emergency Department for evaluation. Findings include: The Facility's Policy titled Positioning of the Resident, dated 8/2016, indicated that the Facility will ensure that residents' care plan interventions are implemented correctly and consistently. Resident #1 was admitted to the Facility in July 2015, [DIAGNOSES REDACTED]. Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], indicated he/she required extensive assistance of two staff persons with bed mobility and transfers. Review of Resident #1's Plan of Care, dated as revised on 05/05/20, indicated he/she was at increased risk for falls due to decreased mobility and [MEDICAL CONDITION]. The Plan of Care indicated Fall interventions included Resident #1 to be assisted by two staff members during transfers and bed mobility. The Facility's Incident Report, dated 06/25/20, indicated that Certified Nurse Aide (CNA) #1 provided morning care to Resident #1 which included bed mobility assistance, and the CNA #1 provided care by herself. The Investigation indicated that Resident #1 rolled out of bed and fell on to the floor. The Investigation indicated that Resident #1 required treatment at the hospital, because as a result of the fall, he/she sustained a one centimeter (cm) laceration above his/her eye. Review of Certified Nurse Aide (CNA) #1's Written Witness Statement, dated 06/25/20, indicated that CNA #1 provided incontinent care to Resident #1 by herself. The Statement indicated that Resident #1 fell on to the floor when she (CNA #1) rolled Resident #1 over onto his/her side. The Statement indicated that this was not the first time that CNA #1 provided care to Resident #1 by herself and that CNA #1 said she did not wait for help, because it took to long for another staff member to come. During an interview on 7/8/20, at 12:00 P.M., CNA #1 said she attempted to provide incontinent care to Resident #1 by herself, and said that is what she usually did. CNA #1 said that when she rolled Resident #1 over in bed, he/she fell on to the floor. CNA #1 said that her gloves were wet and slippery. Review of the Staff Development Coordinator (SDC)'s Written Statement, dated 6/25/20, indicated that she was on Resident #1's unit when two staff members approached her to ask for help because Resident #1 was on the floor. The SDC said that she saw Resident #1 on the floor in a prone (lying on stomach/face down) position. The SDC said that she rolled Resident #1 over and saw blood on the floor, which appeared to be coming from his/her nose. The SDC said that when she asked CNA #1 what happened, CNA #1 said words to the effect of, I turned Resident #1 over to his/her side to provide incontinent care, my hands were slippery, and he/she fell on the floor. During an interview on 7/2/20, at 11:30 A.M., the Staff Development Coordinator (SDC) said that CNA#1, who worked for an agency at the time of the incident, used to work for the Facility as a staff employee and said CNA #1 was familiar the Resident Kardex (care cards use by CNAs) that provided level of assistance required by staff when assisting residents. During an interview on 7/2/20, at 0:00 A.M., the Director of Nurses (DON) said that CNA #1 did not follow Resident #1's Plan of Care when she provided care to Resident #1 on 6/25/20 by herself. The DON said that CNA #1 provided care to Resident #1 alone, and that Resident #1 required two staff members to assist with ADL care.

Based on record review and interviews, for one of three sampled residents, (Resident #1) the Facility failed to implement individualized interventions for Resident #1, who was at risk for dehydration related to severe dysphagia (inability to swallow or difficulty in swallowing), pocketing of food and fluids, and unplanned weight loss. On 12/28/12, Resident #1's sodium blood level (used to evaluate and monitor fluid and electrolyte balance and therapy) was high at 151 with therapeutic levels of 133-145, the Physician was notified, and the Physician said to encourage fluids even though CNA #1 and CNA #2 said it was difficult to feed Resident #1 because he/she took sips of fluids and food, held the food in his/her mouth, and in the end had little food and fluid intake. On 1/18/13 at 6:00 P.M., Resident #1 was transferred to the Hospital for evaluation, his/her sodium was critically high at 175, and the Physician said Resident #1 was very dehydrated. Findings include: Resident #1 was admitted to the Facility May of 2012 and [DIAGNOSES REDACTED]. The initial nutrition assessment, dated 5/10/12, indicated that Resident #1's fluid needs were approximately 1790-2150 cc (cubic centimeters) of fluids daily. The nutrition assessment indicated that Resident #1's diet was ground with nectar thick liquids and an enteral tube feeding included [MEDICATION NAME] 1.5 calories, 240 cc if meal intake less than 50%, and 240 cc daily at midnight. The care plan, dated 5/11/12, indicated that Resident #1 was a high risk for dehydration due to his/her cognitive state, and care plan interventions included increase fluids during hot months and check every hour for signs and symptoms of dehydration. The physician's orders [REDACTED]. The Surveyor interviewed the Dietician on 3/12/13 at 11:15 A.M. The Dietician said when Resident #1 was first admitted to the Facility, he/she ate well, and with the supplemental gastrostomy tube feeding, he/she was over weight for a while. The Dietician said Resident #1 had removed the gastrostomy tube on occasion so the gastrostomy tube was removed due to his/her adequate meal intake. The Dietician said Resident #1's meal intake decreased toward December of 2012, when his/her meal intake averaged only 50% and a dysphagia consultation was conducted because of Resident #1's pocketing of food and fluids. The physician's progress note, dated 12/27/12, indicated that Resident #1 had decreased meal intake, his/her antipsychotic medication, [MEDICATION NAME] was put on hold, and laboratory tests were ordered. The laboratory report, dated 12/28/12, indicated that Resident #1's sodium, an indicator of fluid and electrolyte balance, was high at 151 with therapeutic levels of 133-145. The nurse's note, dated 12/28/12, indicated that the Physician was notified of Resident #1's high sodium level and the Physician said to encourage fluids. The Surveyor interviewed CNA #1 and CNA #2 on 3/12/12, CNA #1 at 2:00 P.M. and CNA #2 at 3:25 P.M. CNA #1 and CNA #2 said it was difficult to feed Resident #1 because he/she took sips of fluids and food, held the food in his/her mouth, and in the end had little oral intake. The Facility hydration policy indicated that if inadequate fluid intake and or signs of dehydration were observed, fluid intake and output monitoring may be observed and incorporated into the care plan. The Surveyor interviewed the Dietician on 3/12/13 at 11:15 A.M. The Dietician said Resident #1 had a gastrostomy tube prior for meal supplements, and the gastrostomy tube was removed because Resident #1 pulled the tube out and he/she had good nutritional intake at the time. The dysphagia consultation, dated 1/3/13, indicated that Resident #1 had increased coughing, choking and poor oral intake; the evaluation indicated that Resident #1 had moderate to severe oral dysphagia, oral residuals, oral holding and delayed airway clearing. The meal and fluid intake record indicated that from 1/3/13 to 1/18/13, Resident #1's fluid intake varied and were as follows: 1/3/13- a total fluid intake of 1320 cc 1/4/13- a total fluid intake of 1020 cc 1/5/13- a total fluid intake of 840 cc 1/6/13- a total fluid intake of 780 cc 1/7/13- a total fluid intake of 1080 cc 1/8/13- a total fluid intake of 960 cc 1/9/13- a total fluid intake of 840 cc 1/10/13-a total fluid intake of 1080 cc 1/11/13-a total fluid intake of 1080 cc 1/12/13-a total fluid intake of 840 cc 1/13/13- incomplete 1/14/13-a total fluid intake of 1200 cc 1/15/13-a total fluid intake of 1240 cc 1/16/13-a total fluid intake of 1200 cc 1/17/13- a total fluid intake of 480 cc 1/18/12-a total fluid intake of 360 cc The dietary progress note, dated 1/17/13, indicated that Resident #1 had a significant weight loss, and there was no indication Resident #1's fluid status was addressed. The nurse's note, dated 1/18/12, indicatedthat blood work on 1/18/13 showed a critically high sodium level of 175, the Physician was notified, and the Physician ordered Resident #1 transferred to the Hospital for evaluation. The Surveyor interviewed the Director of Nurses (DON) on 3/12/13 at 9:00 A.M. The DON said she thought Resident #1's Guardian did not want the gastrostomy tube replaced. The Surveyor interviewed the Guardian on 3/12/13 at 10:30 A.M., and on 3/27/13 at 9:00 A.M. The Guardian said at first Resident #1 was eating and drinking sufficient amounts, but Resident #1 became very frail and debilitated. The Guardian said she was not aware that Resident #1 was so frail and neither staff nor the Physician notified him/her about the option to replace the gastrostomy tube. The Surveyor interviewed the Physician on 3/12/13 at 2:15 P.M. The Physician said he was aware of Resident #1's decreased intake, an appointment was scheduled for Resident #1 to have his/her gastrostomy tube replaced (no date provided by the Physician or Facility staff), but Resident #1 became dehydrated and on 1/18/13, he/she was transferred to the Hospital. The Surveyor interviewed the Complainant on 3/13/12 at 11:10 A.M. The Complainant said, and the Hospital discharge summary, dated 1/25/13, indicated that by the time Resident #1 was transferred to the hospital on [DATE], he/she had a water deficit of 5.7 liters, he/she had a large weight loss, and Resident #1 was severely hypovolemic. The Complainant said, and the discharge summary indicated that Resident #1's gastrostomy tube was replaced, and his/her sodium levels returned to a normal level of 145 by 1/25/13. Please refer to F 325.

Based on record review and interviews, for one of three sampled residents, (Resident #1), the Facility failed to ensure that nursing staff and the Dietician monitored Resident #1's weight loss, notified the Physician and Resident #1's family regarding the weight loss, and addressed Resident #1's weight loss in a timely manner, per the dietary care plan. Consequently, Resident #1, who was at risk for suboptimal nutrition due to dysphagia (inability to swallow or difficulty in swallowing), and had a decline in functional status with increased dysphagia, experienced a 47.8 lbs. unplanned weight loss from 11/7/12, with a weight of 172.6 lbs., to 1/9/13, with a weight of 147 lbs,. Findings include: Resident #1 was admitted to the Facility May of 2012, and [DIAGNOSES REDACTED]. The initial nutrition assessment, dated 5/10/12, indicated that Resident #1 was above ideal body weight of 140 to 141 pounds (lbs.) at 194.8 lbs., and Resident #1's diet order was ground with nectar thick liquids. Resident #1 had an enteral tube feeding of [MEDICATION NAME] 1.5 calories, 240 cc (cubic centimeters) if his/her meal intake was less than 50%, and a scheduled feeding of 240 cc of the [MEDICATION NAME] at midnight. The nutrition assessment indicated that Resident #1 had a habit of holding food in his/her mouth, and he/she was dependent for meals. The care plan, dated 5/10/12, indicated that Resident #1 was at risk for poor nutrition due to dysphasia, poor cognition, and gastrostomy tube support. Care plan interventions included house puree nectar thick liquids, feed Resident #1 at meals, monitor diet texture tolerance, and refer to speech therapy as needed. The staff development inservice record, dated 7/19/12, indicated that the Speech Therapist educated staff on techniques to feed Resident #1 safely, and the techniques included utilizing a volume controlled drinking cup to improve safety during meals. The dietary progress note, dated 7/31/12, indicated that Resident #1's weight was 187.8 lbs on 7/18/12, a decrease of 3.6 % since admission, his/her protein levels were within normal limits, his/her weight was still above the ideal body weight, and intake was 84% at meals with supplements ordered by the Physician. The physician's orders [REDACTED]. The Surveyor interviewed the Dietician on 3/12/13 at 11:15 A.M. and on 4/3/13 at 10:00 A.M. The Dietician said Resident #1 ate well when he/she was admitted to the Facility, but had a slow weight loss when his/her meal intakes went from 93% on October of 2012 to 54% in January of 2013. The Dietician said Resident #1 had a gastrostomy tube on admission for meal supplements, and the gastrostomy tube was removed because Resident #1 pulled the tube out and he/she had good meal intakes at the time. The dietary progress note, dated 9/13/12, indicated that Resident #1's weight was 181.2 lbs. on (9/6/12), his/her meal intakes were 85% and recommendations included 4 ounces of healthshake with lunch and dinner. The dietary progress note, dated 10/23/12, indicated that Resident #1 had a slow weight loss at 177.8 lbs, he/she was still above ideal body weight, he/she ate 93% of meals and meal intakes remained good. The dietary progress note indicated that Resident #1 had no skin breakdown, took house supplements at lunch and dinner, and was dependent with meals. The dietary care plan, updated on 10/23/12, indicated that Resident #1 was at risk for suboptimal nutrition due to dysphagia, brain injuries, and a history of gastrostomy tube. Care plan interventions included obtain and monitor weight and notify Physician, Nurse Practitioner, Dietician, and Family of any significant weight loss. The weekly weight record, dated 11/7/12, indicated that Resident #1's weight was 172.6 lbs, a weight loss of 22.2 lbs since admission, and a weight loss of greater than 10%. The Facility weight policy and procedures indicated that weekly weights were obtained upon admission for four weeks, variances would be addressed by the Dietician, and possible interventions for weight loss included a 3 day calorie count, or review by the Dietician. The Dietician said Resident #1 had a significant weight loss of 11% on 11/7/12, when his/her weight went from 194.8 lbs to 172.6 lbs. The Dietician said she saw the significant weight loss on 11/7/12, but did not write a progress note and did not update the plan of care. The Dietician said she was not familiar with the Facility policy which indicated that a calorie count may be used to identity poor nutrition. The Physician was interviewed on 3/12/13 at 2:15 P.M. and on 4/3/13 at 2:30 P.M. The Physician said he was not sure if he was aware of Resident #1's significant weight loss on 11/7/12, and he would have ordered a calorie count if the weight loss continued. The weekly weight record indicated that Resident #1 continued to lose weight, the weights were as follows- 11/14/12-172.0 lbs 11/21/12-167.6 lbs 11/28/12-168.0 lbs 12/12/12-164.0 lbs 12/26/12-157.6 lbs 1/2/13-145.2 lbs The Surveyor interviewed the Director of Nurses (DON) on 3/12/13 at 9:00 A.M. and on 4/3/13 at 8:30 A.M. The DON said there was no set policy for staff regarding discrepancies in weights, and at what stage to notify the Physician or Dietician when there was a weight loss. The DON said the Certified Nurse Aides (CNAs) should tell the nursing staff if there was a weight change of 5 lbs, and the Dietician assessed the weights weekly. The Dietician said she was not aware of Resident #1's continued weight loss, she did not review weights weekly, there was a monthly weight meeting that was discontinued, she never observed the nursing staff feed Resident #1, and usually the nursing staff would notify her when there was a weight loss. The meal intake record was reviewed from 12/26/12 to 1/1/13. Resident #1's intake varied, and on several dates Resident #1 ate 50% or less of his/her meals as evidenced by the following examples: 12/26/12- intake for dinner was charted as none to very little 12/29/12- intake for lunch was charted as 50 % 12/29/12- intake for dinner was charted as 25 % 12/31/12-intake for lunch was charted as 50 % 12/31/12- intake for dinner was charted as 25 % 1/1/13- intake for breakfast was charted as 25 % 1/1/13- intake for dinner was charted as 50 % The physician's progress note, dated 12/27/12, indicated that Resident #1 had decreased oral intake; his/her antipsychotic medication, [MEDICATION NAME] was put on hold, and laboratory tests were ordered. The physician's orders [REDACTED]. The laboratory report, dated 12/28/12, indicated that Resident #1's total protein (measured the amount of protein in the diet) was low at 6.1 (reference range 6.4 to 8.3) The dysphagia consultation, dated 1/3/13, indicated that Resident #1 had increased coughing, choking, and poor oral intake, the evaluation indicated that Resident #1 had moderate to severe oral dysphagia, oral residuals, oral holding, and delayed airway clearing. The treatment recommendations included Resident #1 to be upright 90 degrees during meal intake and 30 minutes after meals. Also small bites and sips were recommended. The Surveyor interviewed the Rehabilitation Manager on 4/3/13 at 11:00 A.M. The Rehabilitation Manager said during trials of food with the Speech Therapist on 12/13/12 and 12/19/12, Resident #1 was only able to eat 20 % to 30 % of pureed foods so that was why the dysphagia consultation was done. The Rehabilitation Manager said the previous Speech Therapist, who treated Resident #1 three times a week after the speech evaluation, had concerns about Resident #1's increased confusion, and lethargy. The physician's orders [REDACTED]. The meal intake record was reviewed after the 1/3/13 dysphagia consultation, Resident #1's intake varied, and on several dates Resident #1 ate 50% or less of his/her meals as evidenced by the following- 1/4/13- intake for lunch was charted as none to very little 1/5/13- intake for lunch was charted as none to very little 1/5/13- intake for dinner was charted as 50 % 1/6/13- intake for lunch was charted as 50 % 1/7/13- intake at lunch was charted as 50 % 1/7/13- intake at dinner was charted as none to very little 1/8/13- intake at lunch was charted as 50 % 1/9/13- intake at breakfast was charted as 25% 1/9/13- intake at lunch was charted as 25 % 1/9/13- intake at dinner was charted as 25% The Surveyor interviewed the Unit Manager on 3/12/12 at 12:00 P.M. The Unit Manager said after the dysphagia consultation showed Resident #1 had increased dysphagia, Resident #1 was fed all three meals in the dining room for better supervision. The Surveyor interviewed CNA #1 and CNA #2 on 3/12/12, CNA #1 at 2:00 P.M. and CNA #2 at 3:25 P.M. CNA #1 and CNA #2 said it was difficult to feed Resident #1 because he/she took sips of fluids and food, held the food in his/her mouth, and in the end had little oral intake. The physician's progress note, dated 1/14/13, indicated that Resident #1 was not eating and the Physician recommended a nutritional consultation. The DON said the Physician wanted the Dietician to assess Resident #1. The nurse's note, dated 1/16/13, indicated that Resident #1 continued with his/her poor appetite, and he/she pocketed foods and fluids. There was no dietary progress notes in the clinical record from 10/23/12 to 1/17/13. The Dietician said she did not write any progress notes from 10/23/12 to 1/17/13. The Dietician said she missed the fact that Resident #1 had a significant weight loss on 11/7/12, and did not update the plan of care. The dietary progress note, dated 1/17/13, indicated the Dietician noted a significant weight loss for Resident #1 in the last 180 day and 30 days due to a decreased daily intake of 54%, during the review period. The dietary progress note indicated that Resident #1 had a new pressure sore, and recommendations included: add 4 ounces of health shake to breakfast, even though Resident #1 pocketed food and fluids. The Physician said he was aware of Resident #1's decreased meal intake, an appointment was scheduled for Resident #1 to have his/her gastrostomy tube replaced (no date provided for the appointment by the Physicia or nursing staff), but he/she became dehydrated and on 1/18/13, he/she was transferred to the Hospital. The Physician said if a family member had requested that the gastrostomy tube be replaced, he would have replaced the tube. There was no indication through record review or interviews with the Physician, the DON, and the Dietician that any discussions were held with Resident #1's family regarding replacement of the gastrostomy tube. The Dietician said she never met or spoke with any of Resident #1's family members. The Surveyor interviewed the Guardian on 3/12/13 at 10:30 A.M., and on 3/27/13 at 9:00 A.M. The Guardian said at first Resident #1 was eating and drinking sufficient amounts, but Resident #1 became very frail and debilitated. The Guardian said she was not aware that Resident #1 was so frail and neither staff nor the Physician notified him/her about the option to replace the gastrostomy tube, for better nutrition for Resident #1. Please refer to F 327.

Based on record review and staff interviews, the facility failed to adequately assess and monitor, for one sampled resident #16, the change in clinical condition and had administered [MEDICATION NAME] (a [MEDICATION NAME] medication used for chest pain) and aspirin without a physician order. Findings included: For Resident #16, who complained of radiating left arm pain, the facility administered three doses of [MEDICATION NAME] and a higher dose of aspirin without a physician's orders. The facility failed to communicate to the hospital where the resident was transferred that these medications were administered. Resident #16 was a long term care resident with multiple [DIAGNOSES REDACTED]. A review of the medical record indicated the resident had a recent hospitalized from [DATE] - 8/12/11 with pneumonia [MEDICAL CONDITION]. Review of the most recent quarterly Minimum Data Set (MDS) assessment, signed 7/26/11, indicated the resident had some recall and orientation with cueing. The assessment indicated the resident required total assistance from staff for mobility, transfers, dressing and hygiene, and had a functional limitation in range of motion for both sides in the upper and lower extremities. Additionally, the assessment noted the resident received a scheduled pain medication. A review of the physician's orders for the month of August 2011, indicated the resident had received [MEDICATION NAME] 800 mg three times daily. A review of the nurses' notes dated 7/25/11, indicated that, during the 11 PM - 7 AM shift, the resident had complained of "eating fish, I'm not suppose to" and the nurse noted that the resident's allergies [REDACTED]. The nurse wrote the resident was not showing any signs of an allergic reaction. At 5:30 AM, the nurse wrote the resident complained of left arm pain and medicated the resident with [MEDICATION NAME] 650 mg with effect. The nurse recorded the resident's blood pressure as 110/70 and heart rate as 92. The next nurses' note for the same day, 7/25/11 with no specific time, noted the resident complained of pain and described the pain as "searing and radiating to my shoulder." The nurse wrote the resident had a blood pressure of 140/90 and a heart rate of 104. The nurse noted that the resident appeared to have some anxiety and was given Aspirin 325 mg followed by [MEDICATION NAME] 0.4 mg three times with no effect. The resident had no physician orders for the Aspirin or the [MEDICATION NAME]. The record had no evidence of the physician being contacted for these orders nor was the physician notified of the resident's medical change in status. The nurse had no documentation of the time the resident complained of pain, no detailed assessment of the resident's physical presentation and no documentation of when each dose of the [MEDICATION NAME] was administered. The nurse wrote that after the three [MEDICATION NAME] tablets, the resident's blood pressure was 110/80 with a heart rate of 115. The nurse noted the resident appeared to be in more distress and called 911. The resident was placed on Oxygen at 15 liters without relief and became pale and diaphoretic. When the paramedics arrived, the resident was transferred to the hospital. Per review of the hospital's documentation, the resident arrived at the hospital at 2:04 PM, and the Hospitalist admission note, dated 7/25/11, indicated the resident had presented with complaints of chest pain. The Hospitalist noted the resident had left sided chest pain radiating to the left shoulder and had no shortness of breath, cough, nausea or diaphoresis. The Hospitalist noted the duration of the problem for the chest pain had been over three weeks and described as constant.(The facility's nurses' notes had no documentation of the resident complaining of chest pain prior to the 7/25/11; there were no nurses notes between 6/16/11 and 7/25/11.) The resident remained in the hospital from 7/25/11 to 8/12/11. The hospital discharge summary dated 8/11/11, noted the resident was diagnosed with [REDACTED]. There was no evidence that the hospital had been informed of the resident receiving three [MEDICATION NAME] tablets at the facility. The resident was treated at the hospital with extensive IV antibiotics that included three different antibiotics. The medical record was reviewed by the Assistant Director of Nurses and the nurse consultant 8/25/11. When interviewed, they had confirmed the resident had no standing orders for the [MEDICATION NAME] and Aspirin. The facility failed to ensure the resident's acute change in medical condition with complaints of chest pain and left arm pain was accurately assessed, monitored and treated appropriately. The nurse administered [MEDICATION NAME] medication to the resident with no cardiac history without a physician's order. Nursing staff did not accurately monitor the resident's condition after administering the medication. The resident had also received Aspirin at a higher dose than was ordered by the physician.

Based on the resident group interview, review of documentation and interviews with residents and staff, the facility failed to fully investigate an injury of unknown origin, failed to recognize resident allegations of misappropriation of resident belongings, failed to fully investigate all such allegations and failed to report these allegations to the Department of Public Health as required by federal and state regulation, for 2 sampled residents (#11 and #13) in a sample of 23 residents and 1 nonsampled resident (Resident C). Findings are as follows: The facility failed to investigate three allegations of misappropriated resident property and failed to report these allegations to the Department of Public Health as required by Federal and State regulation. During the group meeting with the residents on 6/27/11 at 1:30 PM, three of the sixteen residents (#11, #13 and nonsampled Resident C) in attendance reported that personal belongings, including jewelry and money, was missing from their rooms. The residents stated they had each reported the missing items to staff. a) At the group meeting, Resident #11 reported missing $12.00. The resident stated he/she had placed the $12.00 in his/her nightstand drawer, but had not locked the drawer. The next morning the money was missing. The resident stated nothing had been done about it even though the resident had filled out a grievance form.. During interview on 6/27/11 at 2 PM, the resident again stated that grievances had been filed for missing clothing and money. The resident reported the facility disregarded his/her complaints. Follow up on the resident's claims revealed that no grievance form was on file, and therefore no investigation into the missing clothing and money had never been initiated. No report to the Department of Public Health had been made of the allegation of misappropriated items. b) At the group meeting, Resident #13 reported he/she was missing jewelry, which included a pair of diamond earrings. The resident reported the missing jewelry to the Administrator, who informed him/her that his/her adult child was contacted and confirmed the resident owned the jewelry, but did not know if the resident had the jewelry in the facility. The resident stated the Administrator disallowed the loss. The resident was interviewed on 6/30/11 at about 12:00 pm and repeated the claim of the missing earrings and jewelry. Follow up on the resident's claim revealed no grievance was on file related to the missing earrings and jewelry. However, record review revealed the resident frequently discussed the loss during his/her one to one psychotherapy. There was no evidence that any thorough investigation into the disappearance of the resident's jewelry had been done. No report to the Department of Public Health had been made of the allegation of the misappropriated diamond earrings and jewelry. c) At the group meeting, Resident C reported he/she had reported missing money ($50.00) approximately one month previously. The resident stated the loss was reported to the facility staff. However, when they were told, facility staff informed the resident that they "doubted it had been stolen." The resident had not gotten any money returned. Follow up on the resident's claim revealed no grievance was on file related to the missing $50.00 and there was no documentation that the resident had made the complaint or that any investigation into the missing money had been undertaken. No report to the Department of Public Health had been made of the allegation of misappropriated money. On 6/30/11 at 4:15 PM, during an interview with the Administrator, Director of Nurses and Corporate Regional Nurse, they were advised of the residents' reports and agreed that they should have been investigated and submitted to the state Department of Public Health as required by state and federal mandate.

Based on observations, staff interviews and record review, the facility failed to provide the necessary care and services, for one sampled resident (#6) from a total sample of 23. Findings included: For Resident #6, the facility failed to (A) the facility staff transferred the resident to [MEDICAL TREATMENT], rather than to follow the physician's plan of care to transfer the resident to the hospital for care and treatment; and (B) failed to provide the necessary care and services in order to control the resident's break through pain and treat the perineal pain; and (C) failed to ensure the resident received proper care and treatment for [REDACTED]. Resident #6 was admitted to the facility at the end of May 2011 and had [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment, dated 5/31/11, revealed the resident's short and long term memory was intact and there were no mood or behavioral indicators. The resident was Spanish speaking, but understood English and was able to clearly communicate his/her needs. The resident required extensive assistance of two staff for bed mobility, transfers, dressing, toilet use, personal hygiene and bathing. The resident was unable to ambulate, was incontinent of bowel and bladder and was at risk of developing pressure ulcers. The resident participated in the pain assessment and was receiving a scheduled pain medication regimen and also received pain medication as needed (PRN). The MDS indicated that during the past five days, the resident had frequent pain. The resident rated his/her pain as a 7 on a numeric rating scale of 0 to 10. The resident received [MEDICAL TREATMENT] treatment, three times per week. The medical record was reviewed on 6/29/11 at 7:30 AM, and revealed that although the resident and family wanted him/her to return home, his/her complex medical condition was fragile. The resident had both end stage liver and [MEDICAL CONDITIONS] and co-morbidities (including infections and intolerance to the placement of a feeding tube). The resident had been ruled out for a liver transplant. (A) For Resident #6, the facility staff transferred the resident to [MEDICAL TREATMENT], rather than to follow the physician's plan of care to transfer the resident to the hospital for care and treatment. Record review revealed that the resident had [DIAGNOSES REDACTED]. A review of the medical record revealed, that due to preadmission abnormal laboratory results, the primary physician was monitoring the resident's laboratory tests. The physician had ordered laboratory tests on 6/2/11, 6/6/11, 6/10/11 and 6/14/11. The laboratory results remained abnormal. On 6/15/11, the laboratory results contained critical findings and the resident was noted with low blood pressures, was experiencing increased confusion, had increased pain and his/her intake was poor. The physician reviewed the laboratory results and made arrangements for the resident to have his/her [MEDICAL TREATMENT] treatment and a blood transfusion done at the hospital. The resident agreed to the physician's plan. However, prior to the transfer to the hospital, the 3:00 PM to 11:00 PM staff had sent the resident to his/her scheduled [MEDICAL TREATMENT] treatment. No information was provided by facility staff to the [MEDICAL TREATMENT] center regarding the resident's critical laboratory results or the physician's plan to have [MEDICAL TREATMENT] and transfusion done at the hospital. At 8 PM on 6/15/11, the [MEDICAL TREATMENT] center notified the facility the resident had been transferred from the [MEDICAL TREATMENT] center and admitted to the hospital with [REDACTED]. The hospital discharge summary dated 6/18/11, reported the resident arrived at the hospital after [MEDICAL TREATMENT] with increasing lethargy and suspected altered mental status. The resident was noted to have low blood pressure, a urinary tract infection and mild dehydration. During the acute hospital stay, per the physician's readmission note dated 6/20/11, the resident had received a blood transfusion. During discussion on 6/29/11 at 11:45 AM, Unit Manager #2 acknowledged that no information had been shared with the [MEDICAL TREATMENT] center. (B) For Resident #6 the facility failed to implement an effective pain management program to address the resident's on-going break through pain and failed for 24 days to address the resident's perineal pain. Review of the hospital discharge record dated 5/31/11, indicated at the time of discharge, the resident's pain regimen consisted of [MEDICATION NAME] (a narcotic pain reliever) 2 mg. (milligrams) every 4 hours as needed. The hospital record stated the resident had significant peri-anal irritation secondary to diarrhea ([MEDICAL CONDITION]) and low back pain. The resident's pain treatment at the hospital, had been the [MEDICATION NAME] medication, sitz baths and [MEDICATION NAME] jelly applied to the inner buttock for relief. The [MEDICATION NAME] jelly and sitz baths were not ordered at the time of the resident's admission. The treatment plan was to administer the [MEDICATION NAME], based on a numeric scale (0 - 10) every shift. The admission assessment dated [DATE], identified that the resident had pain caused by abdominal pain associated with ascites and an excoriated buttocks. The assessment reported the frequency of pain in the resident's buttock as occasional and failed to assess the pain intensity of the perineal pain and the abdominal pain. There was no mention of the resident's back pain. The assessment reported that the pain was relieved by medication ([MEDICATION NAME] 2 mg every 4 hours as needed) and perineal care (application of a protective lotion). Review of the record revealed the resident's pain medications were changed on 6/1/11. The physician ordered [MEDICATION NAME] (a narcotic pain reliever) 50 mg every 6 hours for general pain and changed the [MEDICATION NAME] to 2 mg every 6 hours for severe pain, rather than every 4 hours. On 6/2/11, the physician assessed the resident and discontinued the PRN [MEDICATION NAME] and ordered [MEDICATION NAME] 2 mg to be given every 8 hours, until supply was gone, and then decrease the [MEDICATION NAME] to 1 mg every 8 hours. The nurses' notes from 6/2/11 through 6/9/11 indicated the current pain regimen was effective, but also documented that the resident continued with frequent episodes of loose stools. The June 2011 treatment sheets confirmed that the perineal area remained inflamed and excoriated. The perineal treatment remained unaltered and staff documented that a house lotion was applied as needed. On 6/10/11, the resident complained of pain and an assessment was completed using the pain scale. The nursing staff recorded his/her as a 4 out of 10. There was no indication that the resident was administered a PRN pain medication or that any alternate intervention was implemented. On 6/11/11 at 2:30 PM, the resident's family complained to the nurse that the resident complained of increased pain during care and repositioning. The nurse administered the PRN pain medication and educated the staff on how to handle the resident during care to prevent pain. A care plan for pain was developed on 6/11/11. The care plan indicated the resident's pain was chronic and related to end-stage renal and liver disease. The goals were to relieve pain within 30 minutes after receiving the intervention, and to not experience a decline in overall function related to the pain. The interventions were standardized and included the following: monitor for signs and symptoms of pain and for worsening pain, report any changes in pain location or type, frequency or intensity to physician, provide comfort measures (relaxation techniques, repositioning, diversion activities, administer scheduled and PRN pain medication, pain assessments to be completed on admission, quarterly and with significant change and make referral to physician to consider pre-medicating for pain prior to treatments. Review of the nurses' notes dated 6/12/11 through 6/15/11 indicated the resident had no pain, however the MAR indicated [REDACTED]. On four of the shifts the resident rated his/her pain as a 4, on two occasions a rating of 5, on one occasion a 6 and on two occasions a rating of 8 out of the numeric scale of 0 to 10. There was no evidence the staff administered the PRN pain medication or implemented an alternative intervention to relieve the resident's suffering. The resident was hospitalized from [DATE] through 6/18/11 and had [DIAGNOSES REDACTED]. The hospital reported they had stopped the scheduled [MEDICATION NAME] therapy because it was thought it might have contributed to the resident's decreased alertness and change in condition. The hospital, after titrating the resident off the [MEDICATION NAME], recommended the [MEDICATION NAME] be administered at 1 mg every 4 hours as needed. However, when the resident returned to the facility, the staff resumed the prehospitalization scheduled dose of [MEDICATION NAME] 2 mg every 8 hours, rather than the suggested change made by hospital. A readmission pain assessment was completed on 6/18/11. The assessment determined that the resident's back, leg and arm pain was chronic. The assessment documented the resident was on scheduled [MEDICATION NAME] and [MEDICATION NAME] as needed. The assessment stated both medications were effective and referred to the care plan for interventions. Review of the care plan revealed it had not been updated. Review of the readmission physician orders [REDACTED]. On 6/20/11, the physician had assessed the resident and ordered a decrease of the [MEDICATION NAME] from 2 mg three times per day to two times per day for ten days, then to decrease the [MEDICATION NAME] to 2 mg every morning and 1 mg at night. In addition, the physician ordered [MEDICATION NAME] 50 mg every 6 hours for break through pain and a [MEDICATION NAME] (a topical pain reliever) to the resident's back daily. The MAR from 6/20/11 through 6/24/11 revealed the resident complained of break through pain one to two times per shift, during this four day period, a total of 9 times. In addition, the nurses' notes confirmed the resident's complaints of back pain and perineal pain. The resident was administered the PRN [MEDICATION NAME] only 2 times for the 9 times he/she complained of pain. The perineal pain was not addressed until Hospice assessed the resident on 6/24/11. The Hospice staff made recommendations for pain management after determining the resident was in "a lot of pain." The recommendations were reviewed by the physician and he/she agreed to add a scheduled [MEDICATION NAME] 50 mg three times per day and [MEDICATION NAME] jelly to be applied to the inner perineal area. This last recommendation for the [MEDICATION NAME] jelly, made by the hospice, had been a recommendation from the hospital on the resident's original admission on 5/31/11, but had not been acted upon. For 24 days, other than applying a standard house lotion, the facility had failed to relieve the pain caused by the resident's excoriated and reddened perineal pain. On 6/27/11 at 8:15 AM, during the tour of the unit, Unit Manager #2 introduced the resident. The resident was lying in bed, eyes open and fidgeting and restless. The resident verbalized several times to the surveyor, during this short observation, that he/she was in pain and needed medication. On 6/29/11 at 11:45 AM, Unit Manager #2 was interviewed. The Unit Manager could not provide evidence that the facility had implemented an effective pain management program to address the resident's on-going break through pain, nor could he/she provide evidence that the staff addressed the resident's perineal pain during the past 24 days. (C) For Resident #6, the facility failed to ensure that this resident receive proper care and treatment as ordered to fingers. The resident was hospitalized from [DATE] through 6/18/11. Upon readmission, the nurse completed a skin assessment. The readmission skin assessment dated as completed on 6/18/11, identified that the tip of the second finger of the right hand was necrotic. Review of the hospital discharge record, also dated 6/18/11, made no mention of the condition of the resident's finger. On 6/20/11, two days after the resident was readmitted to the facility, the physician examined the resident's fingers. The physician identified that three, not one, of the fingers on the right hand were necrotic. The physician ordered a consult with a vascular surgeon. Further review of the medical record failed to find evidence that prior to the physician's visit on 6/20/11, the nursing staff had not monitored the resident's fingers for changes or notified the physician of the condition of the fingers. At 4 PM on 6/20/11, the nurse documented that he/she had contacted the vascular surgeon and he/she was unavailable. The plan was to call the surgeon on 6/21/11, the following day. From 6/20/11 through 6/22/11, the record revealed no evidence the nursing staff were monitoring the condition of the resident's fingers, or what the status of the vascular surgeon's appointment was. On 6/23/11, the nurse's note revealed the resident was sent to the emergency room where a vascular surgeon evaluated the resident's fingers. The surgeon stated the resident had informed him/her that the he/she had mistakenly put his fingers on an electrical cord and gotten burnt. The nurse documented that the surgeon ordered a topical antibiotic to the affected necrotic areas until the fingers were healed. According to the emergency room transfer record dated 6/23/11, the surgeon diagnosed the necrotic fingers as burned. The treatment record from 6/23/11 through 6/29/11, indicated the nursing staff had treated the finger tips twice, once on 6/23/11 and on 6/27/11. There was no evidence of an assessment or description of the fingers on either the treatment sheets or in the medical record. The only documentation addressing the status of the resident's fingers was documented in the Hospice's certified nursing attendants notebook, dated 6/27/11. He/she reported the finger tips were open. On 6/29/11 at 9:30 AM, Unit Manager #2 was interviewed. The manager reported that he/she was unaware that the resident's fingers were burned and the tissue was necrotic. He/she stated the Assistant Director of Nurses (ADON) was responsible for the weekly skin assessments and that he/she would be contacted to clarify the status of the resident's finger tips. An interview with the ADON on 6/29/11 at 11 AM, confirmed that he/she was responsible for the weekly skin rounds and assessments. This nurse reported that he/she was unaware of the resident's fingers and added that he/she would not have documented on them anyway because they were not "pressure ulcers." Subsequent interviews with Unit Manager #2, the ADON and the Director of Nurses during the morning hours of 7/1/11, revealed that none of the staff had made any effort to look at the resident's fingers. In addition, the facility staff could not provide any explanation why, after identifying the skin issue on 6/23/11, the facility had not monitored or implemented treatment to heal the wounds.

Based on record review, interview with staff and observation, the facility failed to appropriately treat and prevent pressure sores for two residents (#1 and #6) in a total sample of 23. Findings included the following: 1. For Resident # 6, the facility failed, on admission, to assess a pressure wound (buttocks), obtain treatment orders in a timely manner and failed to implement treatments and services to prevent a decline of the wound. The facility staff also failed to identify, assess and treat an additional pressure ulcer (left hip) which subsequently developed in the facility. Resident #6 was admitted to the facility at the end of May 2011 and had [DIAGNOSES REDACTED]. On 6/18/11, the resident returned from a three day medical leave of absence. The hospital discharge record dated 6/15/11 through 6/18/11, identified a 1 cm by 1 cm necrotic area on the resident's left hip. The Hospital record described the area as not open, dry, and the area around the wound was slightly reddened. The recommended treatment was to do a normal saline wash, apply a wound dressing of carasyn aquacil and cover with a [MEDICATION NAME] sterile dressing every three days. Review of the medical record had no evidence the left hip pressure ulcer was treated. The facility's readmission skin assessment dated [DATE] noted a 2 cm by 2 cm non-stageable area to the left buttock. The nurse described the left buttock as purplish tissue, surrounded by superficial open, reddened skin with a yellow center. Review of the admission orders [REDACTED]. Interview on 6/29/11 at 11:45 AM, the Assistant Director of Nursing (ADON)/Wound Nurse could not provide an explanation why a treatment had not been implemented on readmission for the resident's pressure areas. He/she stated that he/she assessed the resident's skin four days after the resident was readmitted because weekly wound and skin assessments were only done once a week on Wednesdays. Review of the weekly wound flow sheet revealed the buttock area was assessed on 6/22/11 and described the pressure ulcer as a Stage II, 2 cm by 2 cm in size. The center of the wound was open and described as yellow with a scant amount of drainage. The outer area of the ulcer was noted to be reddened. Review of the corresponding nurses notes and treatment sheets, since readmission, documented the following: On 6/18/11 and 6/19/11 there was no documentation of the wound. On 6/20/11, the left buttock wound was described as a 2 cm by 2 cm area with yellow center. On 6/22/11, the wound was open and had extended by 1 cm in size. On 6/23/11, the nurse documented the center of the wound was dark yellow and had not improved. Hospice care was implemented on 6/24/11 and recommended a low air mattress to prevent further skin breakdown. The nurse documented on 6/25/11 that the mattress would be applied to the resident's bed "when delivered." Record review revealed that as of 6/29/11, the mattress had not been delivered or applied to the resident's bed. Observation of the resident on 6/28/11 and 6/29/11 throughout the day confirmed that the mattress had not been applied. On 6/27/11, 4 days after it was noticed that the left buttock wound had showed a change, the nurse documented the area continued to have a dark center with drainage and the surrounding skin was red. There were no subsequent documentation. On 6/29/11, the ADON completed his/her weekly skin assessment which revealed the buttock wound had increased from 2 cm by 2 cm to 5 cm by 4 cm. No change was made to the treatment and there was no evidence the physician was informed of the change. During discussion on 6/29/11 at 11:45 AM, the ADON stated after completing the assessment and discovering a decline on 6/29/11, a pressure ulcer investigation was completed. According to the ADON, the investigation determined that the decline in the resident's pressure ulcer had been unavoidable because the facility had provided routine preventative care. However, the ADON was unable to identify routine care in the medical record documentation, including implementation of the pressure relieving mattress. The surveyor observed the pressure wound dressing change on 6/30/11 at 10:30 AM, with the ADON performing the treatment. Prior to the observation the physician's treatment was reviewed and indicated there was one pressure area on the left buttock. The treatment was to wash the wound with normal saline followed by Santyl ointment and a dry clean dressing to the open area. The treatment was done daily on the day shift. The treatment orders also noted the resident had a low air mattress on the bed. The ADON was observed to don a yellow paper gown and a pair of disposable gloves outside the resident's room. When the ADON opened the resident's door and entered the room, the resident had been positioned onto the his/her right side and held over by a staff person. The resident was observed to have two wounds. One had a dressing cover on the left buttocks area and there was another wound, not covered, on the left hip area. The ADON informed the surveyor that the left hip wound was just found that morning. However, this was the area the hospital discharge record had identified on 6/18/11. The resident had no low air mattress on the bed. The surveyor observed the left hip area to be a large open wound with yellow slough in the crater of the wound. The ADON measured the open pressure wound to be 9.5 x 4 cm. Immediately following the treatment observation, an interview was completed with ADON. The surveyor inquired about the wound on the left hip which was not on the physician orders [REDACTED]." 2. For Resident #1, who was admitted with three Stage IV (sacrum, right ischial and left ischial), and three Stage II (fifth toe of the right foot, left heel and right heel) pressure ulcers, the facility failed to ensure the resident received necessary treatment and services to promote healing. Resident #1 was admitted at the end of May 2011 with [DIAGNOSES REDACTED]. There was no MDS completed for review. See F272. Review of the medical record indicated the resident was dependent on staff for all activities of daily living. The resident had a [MEDICAL CONDITION], gastrostomy and a supra pubic catheter. According to the hospital discharge record dated 5/26/11, the resident had six pressure sores and a recommended treatment for [REDACTED]. a) Stage IV sacral pressure ulcer which was 8 cm by 3 cm in width and length, with 100 % granulation tissue. b) Stage IV left ischial pressure ulcer which was 7 cm by 4 cm by 1.6 cm in depth, with 90 % granulation tissue and tan slough. c) Stage IV right ischial pressure ulcer which was 7 cm by 3.8 cm by 0.8 cm with 90 granulation tissue, deep tan slough with slight maceration. d) Stage II left heel which was 2 cm by 2 cm with eschar. e) Stage II right heel which was 2 cm by 2 cm with eschar. f) Stage II 5th toe of the right foot which was 0.5 cm by 1 cm with redness. Review of the nursing admission assessment dated [DATE] identified five of the six pressure ulcers. The nursing staff had not identified the area on the resident's 5th toe of the right foot. Review of the admission physician's orders [REDACTED]. On 6/1/11, the Assisted Director of Nurses (ADON) completed a skin and wound assessment. The ADON identified five of the six pressure ulcers which excluded the toe. However, he/she did include the left heel, indicating the area was 3 cm by 2 cm, a change from the admission assessment that reported the ulcer was 2 cm by 2 cm. In addition, the wound was noted to have some redness, moderate amount of serosanguinous drainage and a treatment. The alleged treatment was to off-load the heel with a pillow for pressure relief, Clinitron specialized bed, and wash area with a normal saline wash, pat dry, skin preparation to outer edges, followed by Allevyn heel cup, Kling dressing to keep the cup in place daily. Review of the treatment record confirmed that no treatment was documented for the toe and left heel from 5/26/11 through 6/8/11. On 6/6/11, the resident was evaluated at the wound clinic. Review of the recommendations Included a treatment for [REDACTED]. There was no mention of the toe. Review of these physician orders, initiated on 6/8/11, included: *Treatment to the left heel was to wash area with a normal saline wash, pat dry, skin preparation to outer edges, followed by Allevyn heel cup, Kling dressing to keep the cup in place daily. *Treatment to the right and left ischial were altered, as recommended by the wound clinic. *Although, the wound clinic had recommended the treatment to the sacrum be changed from daily to every three days, the treatment remained unchanged. There was no documentation clarifying why this recommendation was not followed. The written care plan, dated 6/10/11, included a problem for "resident has pressure ulcer(s) to sacrum and right and left buttock (ischial)." There was no care plan identifying the resident's bilateral heels or toe. Further review of the medical record failed to locate any comprehensive progress assessment for any of the pressure ulcers, other than a brief weekly skin assessment. On 6/15/11, the weekly skin and wound assessments, which were not considered by the facility as part of the medical record and were kept separately, were completed by the ADON. The left heel had changed from 3 cm by 2 cm to 2 cm by 2 cm, after initiation of a treatment on 6/8/11. The sacrum also appeared to have improved, as the ADON documented the pressure ulcer as 7 cm by 2.4 cm with no depth, a change from 6/8/11 when it was 10 cm by 4 cm with 2 cm of depth. However, the resident was evaluated by the wound clinic on 6/16/11 who recommended a [DEVICE] to the left ischium and continuing the previous wound treatments. The 6/22/11 skin and wound assessment documented that the sacrum had increased in size to 9.6 cm by 7 cm. There was no assessment of the 5th toe on the right foot. No wound care was observed because the resident declined the surveyor's request. During interview on 6/30/11 at 10 AM, Unit Manager #1 stated he/she was unaware of an area on the resident's 5th toe of the right foot, confirmed that there was no treatment. The Unit Manager confirmed no treatment to the left heel for fourteen days (5/26/11 through 6/8/11 as noted above). In addition, he/she could not explain the 6/8/11 wound clinic's recommendation for the treatment schedule for the sacrum had not been ordered and implemented. A subsequent discussion on 6/30/11 at 11 AM, was held with the ADON and DON (Director of Nurses). They stated they were unaware of current history and treatment of [REDACTED].