Every finding on record at Continental Care and Rehabilitation

Based on interview and record review, the facility failed to ensure residents with indwelling urinary catheters received care to prevent urinary tract infections; failed to identify a root cause of repeated urinary tract infections for 2 (#s 6 & 9); and failed to follow up timely with urology referrals and appointments for 1 (# 9) of 19 sampled residents. Findings include1. Review of resident #9's medical record showed three hospitalizations occurring in 2026. Review of resident #9's hospital Discharge summary, dated [DATE] - 1/22/26 showed:- Diagnoses: Sepsis due to catheter associated Morganella morganii UTI with bilateral hydronephrosis .- Follow up Recommendations for PCP: Close follow-up with urology .Review of resident #9's hospital Discharge summary, dated [DATE] - 4/17/26 showed:-Diagnoses: Sepsis due to catheter associated Pseudomonas UTI with bilateral hydronephrosis-Follow up Recommendations for PCP: Once daily acetic acid irrigation ordered but can increase to 3 times daily if needed. This is an attempt to reduce the frequency of urinary tract infections with his chronic Foley.Review of resident #9's hospital Discharge summary, dated [DATE] - 5/8/26 showed:-Diagnoses: Sepsis secondary to UTI urine cultures positive for MRSA and Enterococcus faecalisA. Review of resident #9's care plan, initiation date 1/10/26, showed, [Resident #9] has a foley catheter in place he is at risk for trauma, infection and alterations in comfort. Interventions included, Urology as per referral dated 4/29/26.A request was made on 6/3/26 for urology notes for resident #9. None were provided by the facility. During an interview on 6/3/26 at 4:24 p.m., staff member A stated they were having difficulty getting resident #9 in to see a urologist due to his hospitalizations and dialysis schedule, which was limiting his availability. Staff member A stated there was no longer a urologist locally, so they were looking at referrals to outside cities.During an interview on 6/4/26 at 12:31 p.m., staff member A stated they did not have an answer as to why resident #9 could not see the local urologist that resident #6 saw.During an interview on 6/4/26 at 1:28 p.m., staff member L stated the referral to get resident #9 into a urologist had come back in April, but between his hospitalization in May and the three-times-weekly dialysis schedule, it had been difficult to schedule. Staff member L stated that if needed, the dialysis clinic could be contacted to arrange for dialysis on a different day. Staff member L stated an appointment was now made to see [traveling urology provider] in August, in addition to a referral to [NAME] if they had earlier availability. Staff member L stated they did not realize there was a local urologist as an option.B. During an interview on 6/4/26 at 8:03 a.m., staff member F stated that nursing did catheter care.During an interview on 6/4/26 at 8:07 a.m., staff member A stated that catheter care had always been a CNA task and was included in their training.During an interview on 6/4/26 at 12:31 p.m., staff member A stated that catheter care was considered a basic standard of care and there wasn't necessarily a check-off spot in the record for CNAs to document each time it was completed. Staff member A stated there was an order for nursing to monitor the catheter every shift. During an interview on 6/4/26 at 1:47 p.m., resident #9 stated, They haven't done anything with my catheter today. It gets done maybe once a week. I know you were hoping for a different answer.During an interview on 6/4/26 at 1:50 p.m., staff member E stated nursing did catheter care for resident #9 when there were flushes ordered, but not since those flushes had been discontinued. Staff member E stated there might be miscommunication about catheter care in the hallway. Review of the facility assessment, dated 3/26/26, showed, Competencies (as appropriate for staff per their respective responsibilities): - CNAS: . perineal care (female and male), .- Licensed Nurses: . Indwelling insertion/removal/care .Review of the facility policy, Catheter Care, not dated, showed, . Catheter care will be performed every shift and as needed .document care and report any concerns noted to the nurse on duty.Review of resident #9's medication administration record, dated 4/18/26 - 5/4/26, showed acetic acid irrigations once daily with one missed administration in April. The acetic acid irrigations were discontinued upon the resident's return from his May hospitalization.2. Review of resident #6's medical record showed three hospitalizations occurring in 2026. Review of resident #6's hospital Discharge summary, dated [DATE] - 2/9/26 showed:- Diagnoses: Severe sepsis due to UTI and pyelonephritis- Follow up Recommendations for PCP: follow up on susceptibility testing for candida glabrata in urine.Review of resident #6's hospital Discharge summary, dated [DATE] - 3/9/26, showed:- Diagnoses: sepsis . likely source is complicated UTI candida glabrata . chronic foley.Review of resident #6's hospital Discharge summary, dated [DATE] - 4/21/26, showed:- Diagnoses: Sepsis secondary to MRSA bacteremia . and catheter associated urinary tract infection .-Follow up Recommendations for PCP: monthly Foley exchange with [local urology provider name].A. During an interview on 6/4/26 at 8:22 a.m., staff member J stated that indwelling Foley catheters would be changed, dependent on the patient and what was recommended in the hospital discharge summary. Staff member J stated they would have to talk with the medical director for more guidance on when a long-term Foley catheter should be evaluated by urology.During an interview on 6/4/26 at 10:42 a.m., staff member K stated urology consults were variable, dependent on the patient and their ability to attend an outpatient appointment, and the travel time to get there. Staff member K stated that to address the high number of repeated urinary tract infections, the facility had done staff education on peri and catheter care. Staff member K stated resident #6 had a UTI that was Candida, which was a lot harder to treat.A request for monthly Foley exchange appointment documentation was made on 6/4/26. A calendar detail of an appointment for 4/27/26 was provided. During an interview on 6/4/26 at 1:30 p.m., staff member A stated they were trying to figure out if resident #6 had gone to a urology appointment in May.During an interview on 6/4/26 at 2:03 p.m., staff member A stated they had just gotten off of the phone with the urology office. Staff member A stated they were told the urology office did not want to see resident #6 monthly.B. Review of resident #6's treatment administration record, dated April 2026 - May 2026, showed the following orders: - Indwelling urinary catheter size FR#16/10ml balloon. Monitor placement every shift. Start date 4/21/26.Three out of 19 opportunities in April were not documented. 13 out of 62 opportunities in May were not documented.- Per [local urology provider name] irrigate bladder with 60ml acetic acid every shift BID allow to drain into foley catheter bag by gravity. Start date 4/28/26. [sic]Two out of six opportunities in April were not documented. 15 out of 62 opportunities in May were not documented.Review of resident #6's comprehensive care plan, with an initiation date of 5/1/26, showed a focus area:[Resident #6] has an indwelling catheter. The focus area was several months past the resident's Foley catheter initiation, and there were no interventions related to repeated infections.

Based on interview and record review, the facility failed to provide a resident or resident representative with notice of bed hold or transfer/discharge, which could lead to the resident not knowing their rights for 1 (#10) of 21 sampled and supplemental residents. Findings include:Review of nursing progress notes dated 5/17/26, showed resident #10's family requested resident #10 be sent to the hospital and an ambulance was called for transport.Review of resident #10's electronic medical record failed to show the facility provided resident #10 or their representative with a notice of bed hold or transfer/discharge before the ambulance picked resident #10 up for transport to the hospital.During an interview on 6/3/26 at 4:30 p.m., staff member M stated staff would usually go up to the hospital and have the resident sign the bed hold and transfer notices, and that did not get done with resident #10 since she was sent to a hospital out of town. During an interview on 6/4/26 at 10:15 a.m., staff member A stated the admitting staff will review the bed hold notice policy with the residents when they are admitted to the facility, and then the discharging nurse is supposed to go over it again with the resident before they discharge. Staff member A stated it was a routine struggle to get them filled out when it was an emergency transfer. Review of a facility document titled Bed Hold Policy, undated, showed: It is the policy of this facility to provide written information to the resident and/or the resident representative regarding bed hold practices, both well in advance and at the time of a transfer for hospitalization or therapeutic leave.2. In the event of an emergency transfer of a resident, the facility will provide written notice of the facility's bed-hold policies to the resident and/or the resident representative within 24 hours. Resident #10 was admitted to the facility on [DATE]. The bed-hold policy was signed by resident #10 on 5/13/26. Resident #10 was sent to the hospital on 5/17/26. The facility provided an unsigned notice of resident transfer or discharge, and a bed-hold notice with the resident's discharge date of 5/17/26 and the resident's name. Showing it was never given to resident #10 before she was discharged to the hospital.

Based on interview and record review, the facility failed to identify a resident had left the facility AMA and failed to inform the resident of the risks of leaving the facility AMA and their rights for 1 (#17) of 21 sampled and supplemental residents. This deficient practice put the resident at risk for a negative medical outcome. Findings include:Review of resident #17's Comprehensive MDS dated [DATE], showed: section C, Cognitive Patterns: BIMS Summary Score (C0500), 12 (Moderate Impairment). During an interview on 6/1/26 at 4:49 p.m., NF4 stated resident #17 never wanted to be at the facility and wanted to leave. NF4 stated that resident #17 had threatened to leave the facility AMA (Against Medical Advice) at one point and eventually did. NF4 stated, I am unsure of the facility's policy on AMA discharge, but there was no documentation filled out when she left.During an interview on 6/2/26 at 3:03 p.m., staff member O stated the facility's process for when a resident leaves is to have the resident sign out at the front desk and tell the nurse. Then the resident will sign back in when they come back. Staff member O stated that if the resident does not return, the nurse would call the on-call nurse and let management know. During an interview on 6/3/26 at 8:14 a.m., NF2 stated resident #17 never wanted to be in the facility and wanted to be discharged closer to home. NF2 stated, I was able to just walk in and take [Resident Name] out of the facility with no questions from staff or paperwork to fill out. During an interview on 6/3/26 at 8:55 a.m., staff member B stated the normal process when a resident leaves the facility for an outing or appointment would be for them to sign out at the front desk with the date and time. The resident would then communicate with the nurse and staff, and then sign back in to the facility when they return. Staff member B stated in resident #17's case, her friend was supposed to pick her up for her appointment out of town that was scheduled for 5/19/26. Staff member B stated she had worked out the transportation details with NF2 before the appointment. Staff member B stated NF2 arrived at the facility, and a former Ombudsman was with her. Staff member B stated NF2, and the former Ombudsman left the facility with resident #17 and all her belongings. Staff member B stated she called the Ombudsman's office, left a message for the local Ombudsman, and waited until around 6:00 p.m. for resident #17 to return to the facility. Staff member B stated the facility's normal process for a resident who leaves due to an AMA discharge is to educate the resident on the risks of leaving against medical advice and have them sign an AMA form. Staff member B stated the process was not followed for resident #17 because the facility staff thought she was going to an appointment out of town. During an interview on 6/3/26 at 9:33 a.m., NF3 stated she was asked to be a witness to interactions between the facility and NF2 when she picked [Resident Name] up for an appointment. NF3 stated she met NF2 in the lobby of the facility and asked the nurse where the residents' room was. The nurse on duty walked them to the resident's room, where resident #17 had been sitting with all of her belongings packed up. The nurse asked resident #17 if she had everything she needed for her appointment and left the room. NF3 stated resident #17, NF2, and herself left the room with all of the resident's belongings, then they all left the facility. NF3 stated, It was a three-minute ordeal. No one stopped us or asked us what we were doing.During an interview on 6/4/26 at 7:35 a.m., staff member M stated they had put together a timeline of events for resident #17, and they (staff) were aware resident #17 had left the facility with her belongings, her friend, and the ombudsman. Review of resident #17's electronic medical record showed an incomplete discharge evaluation was started on 5/21/26. Review of a timeline of events provided by the facility, undated, showed: 5/19/26, SSD was informed by staff that ombudsman was present in facility when [Non Facility Staff Name] coming to pick up [Resident Name] for a scheduled medical appointment in [Town Name] on 5/19/16 at approx 11:30 am. Staff then reported that [NF Name], [Resident Name], and ombudsman were moving all of [Resident Name] personal items from her room. SSD called ombudsman and left a message requesting call back. [sic]Review of resident #17's social service progress Note dated 5/19/26, showed: Attempted to call [NF2] regarding [Resident Name] return to facility. Left a message requesting call back. [sic]Review of resident #17's nursing progress notes failed to show the resident left for an appointment on 5/19/26, and failed to show resident #17 left with all her belongings. The facility failed to identify resident #17 had left the facility AMA.Review of a facility document titled Transfer and Discharge (including AMA), undated, showed: Policy: It is the policy of this facility to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility, except in limited circumstances.11. Discharge Against Medical Advice (AMA)a. AMA only applies when a resident expresses their wishes to be discharged earlier than outlined in the care plan. These situations do not apply if the facility offers to discharge a resident to a location which does not meet their health and/or safety needs, and the resident agrees.b. The resident and family/legal representative should be informed of the risks involved, the benefits of staying at the facility, and the alternatives to both.c. The physician should be notified of the intended AMA discharge and be encouraged to speak with the resident to encourage them to stay at the facility.d. Documentation of this notification should be entered in the nurses' notes by the nursing department. The social service designee should document any discussions held with the resident/family in the social service progress notes, if present.e. Notify Adult Protection Services, or other entity as appropriate.

Based on observation, interview, and record review, the facility failed to ensure that a resident (#32) was free from physical abuse from another resident (#62) of the 19 sampled residents. The facility identified the failure and corrected it on 5/11/26, which was before the start of the survey period. This deficient practice is cited as past noncompliance. This failure had the potential to cause resident #32 physicial and or psychosocial harm. Findings include:During an observation on 6/1/26 at 3:54 p.m., resident #62 was sitting in her room with the light off and there was no noise. Resident #62 was unable to verbalize or answer questions.Review of a facility-reported incident dated 3/15/26, showed: [Resident #32's initials] reported that [Resident #62] hit him on the arm. No injuries noted and resident appears to be at baseline. Incident reported to family and provider. Order received to send accused party to the acute (hospital) for evaluation. Investigation initiated. [sic]During an interview with staff members N and M on 6/4/26 at 7:35 a.m., staff member N stated, We could have put more detail in the bounds report when referencing the event between #32 and #62. Staff member M stated resident #62 was flailing around and had an increase in behavior when she hit resident #32, so they sent her to the emergency department for assessment. Staff member M stated the hospital ended up keeping resident #62 due to a UTI and sepsis. During an observation and interview on 6/4/26 at 9:51 a.m., resident #32 was sitting in his room and appeared happy. Resident #32 stated he does not remember the incident with resident #62 and he was not worried about an incident happening again.Review of resident #62's Comprehensive MDS with a date of 4/5/26, showed resident #62 had a BIMS of 3 (severely cognitively impaired).Review of resident #62's care plan with a revision date of 5/11/26, showed: Focus: [Resident Name] at times, can demonstrate physically aggressive behaviors towards staff and peers. She has, at times, demonstrated behaviors of hitting, slapping, kicking, pushing.Goal: [Resident Name] will not harm self or others through the review date. Interventions: Analiyze of key times, places, circumstances, triggers, and what de-escalates behavior and document. Monitor/document/report to MD of danger to self and others. Redirect [Resident Name] from peers when agitated, as she will allow. [sic]Review of a facility document titled Internal Medicine History and Physical dated 3/15/26, showed: .presents to the ED from [Facility Name] due to altered mental status and aggressive behavior.patient was becoming combative and was sent to the ED for further evaluation. She is restless and agitated and was given multiple sedatives in the ED. [sic]Review of resident #62's nursing progress notes dated 3/15/26, showed: Pt sent to ER for dx. Fall x2 today behaviors all day hitting staff and throwing things and food. Pt refusing meds. Tachycardia when allowed to check pulse. Orders for labs and a ua. Threw meds across room. [sic] Review of a facility document titled IDT - Interdisciplinary Post Event Note dated 3/18/26, showed: Patient (resident #32) reported he was hit on the arm by peer [Resident initials], unprovoked, as they were crossing paths in the hallway. On 3/15/26 at 5:20 p.m. [sic]During an interview on 6/4/26 at 10:15 a.m., staff member A stated the process for resident-to-resident incidents would be for the facility staff to intervene immediately, remove the resident to a safe place, IDT would review the incident, the care plan would be updated, and appropriate notifications would be made. Corrective Measures:Review of the facility's Final Report for abuse allegation, dated 3/21/26, showed resident #32 was assessed for injury with none noted. Social service interviewed resident #32, and he reported that there were no other incidents related to resident #62, and he feels safe in the facility. Resident #62 was sent to the ER for evaluation and was admitted . Five other residents were interviewed with no issues noted. All required notifications were made to the physician and representatives, and care plans were updated. The facility identified this as a resident-to-resident incident and reported it to the State Certification Bureau. Review of the facility's investigation documents showed other residents were interviewed on whether they had similar experiences or if they felt safe in the facility on 3/17/26, and no other concerns with resident #62 were identified. As a corrective measure the facility interviewed other residents to identify the potential of other residents effected. Social services followed up with resident #32 on three occasions (3/16/26, 3/17/26, and 3/21/26) following the incident for psychosocial monitoring. No negative effects from the incident were identified for resident #32. The facility followed up with the affected resident to ensure no negative outcome from the incident occurred. Resident #62's care plan was updated on 5/11/26 to include behavioral interventions. Education was provided to all nursing staff on abuse prevention and dementia on 3/18/26. This is cited at past noncompliance since the facility identified the resident-to-resident abuse occurred, immediately separated the residents and assessed them, interviewed other residents to identify others possibly effected, implemented interventions to prevent further incidents from happening, and educated staff on abuse and dementia. These steps were taken prior to the start of the survey period beginning on 6/1/26.

Based on observation, interview, and record review, the facility failed to have a consistent process for finding or replacing missing clothing, and the resident had missing clothing, for 1 (#3) of 19 sampled residents. Findings include: During an interview on 6/2/26 at 10:30 a.m., NF1 stated, There was a time when the laundry machine was down and so the facility was taking clothing to the laundromat. NF1 stated all of resident #3's stuff disappeared. NF1 stated she came to visit and resident #3 was wearing a bra, a shirt and had a blanket on her lap. There were no pants in her entire room. NF1 stated all of resident #3's clothing was clearly labeled with her name, including each individual sock. NF1 stated the facility did not replace any of the missing clothing.During an interview on 6/3/26 at 9:09 a.m., staff member B stated if a resident reported something was missing facility staff would check against the resident's inventory sheet and start investigating. If the item was unable to be located the facility would replace it to the best of their ability.A request was made on 6/3/26 for the log of missing items and facility replacements. There was no mention of clothing replacement for resident #3.During an observation and interview on 6/4/26 at 8:52 a.m., there was a large laundry bin overflowing with clothing identified as being unlabeled. Staff member G stated it was the CNAs responsibility to label all new clothes. If clothing did not have a resident's name, it was difficult to return to the owner. Staff member G stated the facility did not have a process to investigate or return unlabeled clothing. Staff member G stated NF1 had looked through the bin of unlabeled clothing and did not find resident #3's missing socks or pants.Review of resident #3's Inventory of Person Items sheet, dated 3/23/26, showed an intake of three black, one grey, one dark grey, one brown, one black and white marble, and one green pair of leggings. During an observation on 6/4/26 at 11:29 a.m., resident #3's closet contained three total pairs of leggings, one green, one brown, and one grey.

Based on observation, interview, and record review, the facility failed to maintain a sanitary kitchen by covering a hole in the floor where plumbing was being fixed with plywood, which was an uncleanable surface, and the wood could not be maintained for cleanliness. This failure could affect any resident receiving food from the kitchen. Findings include:During an observation and interview on 3/3/26 at 11:08 a.m., the [NAME] end of the kitchen had two, four by eight-foot sheets of bare plywood laying on the floor over areas where the tile was missing. The sheets of plywood had areas of various shades of black staining on them and the tile floor around the plywood had scattered debris and white/gray stains on it. Staff member E stated maintenance had to dig holes under the flooring to fix the drainpipes. Staff member E further stated the construction had been going on for approximately two weeks, and it was occurring at night when the kitchen was not in use. Staff member E stated they had draped plastic sheeting for barriers, to keep the dust out of the rest of the kitchen.During an interview with staff members F and G, on 3/3/26 at 11:16 a.m., staff member G stated they had hung permanent tenting around the areas of digging during construction, because there was a lot of sand and concrete that had to be dug through. Staff member F sated he didn't know what else to cover the missing tile with because he did not want to create a tripping hazard for staff. Staff member G further stated that the floor would be fixed in about a week, they were just waiting for the new tile. A review of a facility document titled, 2022 Food Code, U.S. Food and Drug Administration, showed:. Cleaning of Equipment and Utensils4-601 Objective4-601.11 Equipment, Food-Contact Surfaces, Nonfood- Contact Surfaces, and Utensils.(C) NONFOOD -CONTACT SURFACES of EQUIPMENT shall be kept free of accumulation of dust, dirt, FOOD residue, and other debris.4-602.13 Nonfood-Contact Surfaces.NONFOOD-CONTACT SURFACES of EQUIPMENT shall be cleaned at a frequency necessary to preclude accumulation of soil residues. [sic]A review of a facility policy titled, Sanitation Inspection, with a copyright date of 2025, showed: Policy:It is the policy of this facility, as part of the department's sanitation program, to conduct inspections to ensure food service areas are clean, sanitary and in compliance with applicable state and federal regulations.Policy Explanation and Compliance Guidelines:All food service areas shall be kept clean, sanitary, free from litter, rubbish.

Based on observation, interview, and record review, the facility failed to provide meals at the regular scheduled times for 5 (#s 23, 24, 36, 49 and 76) of 25 sampled residents. This deficient practice had the potential to affect all residents of the facility. Findings include: 1. During an observation and interview, on 5/17/25 at 1:01 p.m., resident #49 was lying in bed with no lunch tray. Resident #49 stated food was always late, especially the breakfast and lunch meals. Resident #49 stated he had not received his lunch yet. He stated lunch would often be delivered between 1:30 p.m. and 2:30 p.m. Resident #49 stated he would order food from local restaurants to be delivered if he was really hungry or did not like the food when he finally got it. During an observation on 5/17/25 at 1:10 p.m., eight residents were seated at tables in the C dining room, with drinks in front of them, but no food. Room trays had not been delivered on the unit yet to the residents in their rooms. During an observation on 5/17/25 at 1:12 p.m., in the A/B dining room, some residents had their food, others were waiting. Room trays had not been delivered for the unit. During an observation on 5/17/25 at 1:16 p.m., the posted mealtimes, for residents and staff to see, showed: -Breakfast for A/B wing at 8:00 a.m., Solana at 8:15 a.m., and C wing at 8:45 a.m. -Lunch for A/B wing at 12:00 p.m., Solana at 12:15 p.m., and C wing at 12:45 p.m. -Dinner for A/B wing 5:00 p.m., Solana at 5:15 p.m., and C wing at 5:45 p.m. During an observation and interview on 5/17/25 at 2:32 p.m., staff member P was passing lunch trays and stated, [Staff member O] is cooking today so trays will come out late, food is cold when its late, and residents complain a lot. During an interview on 5/17/25 at 4:11 p.m., staff member N stated dietary staffing had fluctuated a lot for several months. Staff member N stated she had a new process she was about to implement in the next week, so that all the facility dining rooms would be served at the same time. During an observation on 5/18/25 at 8:25 a.m., the A/B dining room had 13 residents seated at tables with drinks. No residents had any food, and no room trays were delivered. During an observation and interview, on 5/18/25 at 8:37 a.m., resident #76 was lying in bed and had no breakfast delivered. Resident #76 stated he never knew when his meals would be delivered, it was not consistent. Resident #76 stated the food seemed late, but he would eat whenever the food tray was delivered. During an observation on 5/18/25 at 9:02 a.m., in the C dining room at least nine residents were seated at tables with drinks, but no food. The dining cart was being set up. No room trays had been delivered on the unit. During an observation and interview, on 5/18/25 at 9:07 a.m., resident #49 was lying in bed waiting for his breakfast tray. He stated he would probably get his tray at 10:00 a.m. Resident #49 stated he received his lunch around 2:00 p.m., and his dinner between 6:00 p.m. and 6:30 p.m. the day prior. During an interview on 5/18/25 at 9:55 a.m., staff member G stated most residents were receiving their medications late as it was, due to the [NAME] meal services. During an interview on 5/18/25 at 11:00 a.m., staff members N and O stated breakfast was late because a staff member was sent home for respiratory symptoms. Staff member N stated the mealtimes were what was on the newest form provided with breakfast starting at 8:00 a.m., lunch at 12:00 p.m., and dinner at 5:00 p.m. During an observation and interview on 5/18/25 at 2:39 p.m., resident #36 was sitting in a dining chair in his room by the sink. Resident #36 stated he was hungry but did not eat. Resident #36's room tray was observed on his nightstand, untouched. 2. During an interview on 5/17/25 at 3:00 p.m., resident #23 stated all the meals are late, I got lunch at 2:30 today and it was cold. During an observation and interview on 5/17/25 at 3:02 p.m., resident #24 was sitting in a chair with the overbed table in front of her with a meal tray on it. She stated she was served her lunch about 40 minutes prior. During an observation on 5/18/25 at 12:53 p.m., the meal cart was in the C wing dining room and a staff member was beginning to serve the residents in the dining room. During an observation and interview on 5/18/25 at 12:54 p.m., resident #24 was sitting in her room and stated she had not been served lunch yet. Resident #24 further stated she was hungry. During an observation and interview on 5/18/25 at 1:30 p.m., staff member P was outside of resident #24's room on C hall, getting a tray out of the meal cart. Staff member P stated that A and B halls, and Solana were served meals before C hall residents. Staff member P further stated that it was normal for C hall residents to receive their meals late. During an observation on 5/18/25 at 1:35 p.m., staff member P brought resident #24's lunch tray to her room. Review of the facility provided mealtime form, gathered from the survey entrance request, showed mealtimes were at: -Breakfast for A/B wing and Solana at 7:30 a.m. to 8:00 a.m., and C wing 8:00 a.m. to 8:30 a.m. -Lunch for A/B wing and Solana at 11:30 a.m. to 12:00 p.m. and C wing at 12:00 p.m. to 12:30 p.m. -Dinner A/B wing and Solana 4:30 p.m. to 5:00 p.m. and C wing 5:00 p.m. to 5:30 p.m. The mealtime policy was requested, which showed mealtimes were documented to be held at: -Breakfast for the A/B wing at 8:00 a.m., Solana at 8:15 a.m., and C wing at 8:45 a.m. -Lunch for the A/B wing at 12:00 p.m., Solana at 12:15 p.m., and C wing at 12:45 p.m. -Dinner for the A/B wing at 5:00 p.m., Solana at 5:15 p.m., and C wing at 5:45 p.m. 44769

Based on observations, interviews, and record reviews, the facility failed to ensure residents were assessed and found safe to self-administer their own medications, prior to doing so; and the facility failed to document the assessments or a physician order in the EHRs, for 4 (#s 23, 45, 49, and 53) of 25 sampled residents. This deficient practice increased the risk of a negative outcome for the residents, in the event the medication and self/staff monitoring were not handled properly. Findings include: 1. During an observation and interview on 5/18/25 at 7:50 a.m., staff member G entered resident #45's room and placed a cup of pills on his bedside table. Staff member G then left the room without the resident taking the medications. The cup of pills contained loratadine (antihistamine), nifedipine Extended-Release (calcium channel blocker), and a Velphoro chew (treats hypocalcemia). Resident #45 stated he did not like to take his pills without food, and meals were often late, so the nurses routinely left the medications with him to take on his own. Review of resident #45's Nursing care plan, revised on 4/11/25, reflected a focus area of: - [Resident #45] has impaired cognitive function r/t Disease Process (ESRD), Impaired decision making, with an intervention reflecting: - Administer medications as ordered. Monitor/document for side effects and effectiveness. The Nursing Care Plan did not contain a reference to resident #45's ability to self-administer medications, to include if it was safe for the resident to administer the medications or how this would be monitored. Review of resident #45's EHR did not reflect an assessment for safety of self-administration of medications, or a physician's order for the resident to self-administer medications. 2. During an observation and interview on 5/18/25 at 9:42 a.m., staff member G entered the room of resident #53, and then placed a cup of pills on her meal tray, which was on her bedside table. Staff member G asked resident #53 if she needed anything, and then left the room, without the resident taking the medication. The cup of pills contained aspirin, levothyroxine (thyroid hormone), vitamin D3, amiodarone HCI (antiarrhythmic), and Eliquis (anticoagulant). Resident #53 set the pills aside and began to eat her breakfast. Resident #53 stated the nurses routinely leave the medications with her to take on her own. Resident #53 stated she was not sure what the pills were in the cup or what conditions the pills were treating. Review of resident #53's Nursing Care Plan, revised on 4/15/25 reflected a focus area of: - [Resident #53] has a dx of MDD and delusional disorders. She is at risk for alterations in mood status, with an intervention of: - Administer medications as ordered. Monitor/document for side effects and effectiveness . The Nursing Care Plan did not contain a reference to resident #53's ability to self-administer medications. Review of resident #53's EHR did not reflect an assessment for safety of self-administration of medication or a physician order for the resident to self administer the medications. 3. During an observation and interview on 5/15/25 at 9:45 a.m., resident #49 was sitting in bed. A bedside table was over his lap, and a cup of pills had been placed on the bedside table. Resident #49 stated the nurses left the medications with him, and he decided whether he would take them after eating. Resident #49 stated, when discussing him taking the medications, Sometimes I do, and sometimes I don't, you just never know. Resident #49 stated he knew the medications upset his stomach if they were not taken with food, and he often received meals much later than scheduled. He was not sure why all the medications were being taken, the side effects, or what monitoring he should be doing after taking, or not taking, the medications. The pill cup contained Famotidine (treats and prevents ulcers), lisinopril (lowers blood pressure), multivitamin, potassium, zinc, and furosemide (a diuretic). 4. During an interview on 5/18/25 at 9:38 a.m., resident #23 stated They leave my pills on my tray, and I take them. During an interview on 5/18/25 at 9:55 a.m., staff member G stated meal services were often late, and most residents could take their own medications without her standing there. Staff member G stated some residents were very slow to take their medications, and she would not be able to complete the medication pass if she had to wait on each resident to take their medications. Staff member G stated most residents were receiving their medications late, due to the [NAME] meal services. Staff member G stated the self-administration of medications did not require a physician's order, a resident assessment, or additional documentation as far as she was aware. During an interview on 5/18/25 at 10:07 a.m., staff member F stated the procedure for self-administration of medication required a physician's order, an assessment for safety, and a risk/benefit conversation with the resident. During an interview on 5/18/25 at 1:02 p.m., staff member C stated all resident assessments for the self-administration of medications would be under the evaluations tab, in a resident's EHR. Staff member C stated if a self-administration assessment was not showing up in the evaluations tab, then it was not done. Review of the facility's policy, Resident Self Administration of Medication, dated 2025, reflected: - .A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely. - . The results of the interdisciplinary team assessment are recorded on the Medication Self-Administration Form, which is placed in the resident's medical record. - . The care plan must reflect resident self-administration and storage arrangements for such medications and CGM devices.

Based on observations, interviews, and record reviews, the facility failed to follow smoking assessment safety recommendations for residents who were smoking; failed to monitor the location were residents were smoking; failed to ensure the residents signed out of the facility when smoking (as needed); and failed to follow and adhere to the facility policy related to resident smoking. These failures occurred throughout the survey period, for multiple shifts and days, and multiple staff failed to adhere to the policy, for 3 (#s 40, 75, and 238) of 5 sampled residents who smoke. This deficient practice placed all residents entering the activities room at risk of exposure to second-hand smoke and risk for fire. This deficient practice placed residents at risk of injury while smoking, increased risk of fires, and accidents related to smoking. Findings include: 1. During an observation and interview on 5/18/25 at 2:15 p.m., resident #75 was sitting immediately outside the activity door smoking. Resident #75 stated staff member B stated he could smoke outside the door. Resident #75 stated he was blind and could not get out to the gate when there was bad weather. Resident #75 stated he felt the ground with his feet, and he could get out to the smoking area at the gate, and he would know when his foot kicked the cigarette butt can, he had reached the smoking area. Resident #75 stated he kept his lighter, vape pen, and cigarettes on him, or in his room, on his bedside table. Resident #75 stated he did not usually sign anything (such as a facility sign out sheet) to go outside and smoke, he just went when he wanted. Dozens of cigarette butts littered the ground around outside the activity room windows, door, tables, and the grassy area. Resident #75 stated he, resident #40, and #238, regularly smoked outside the activity door under the awning. Staff member A approached resident #75 and asked that he go to the gate to smoke and resident #75 reiterated his statement that staff member B told him he could smoke in this spot, and he refused to move. Staff member B arrived and told resident #75 he could not smoke near the door, and she would assist him to the gate to smoke. Staff member B pushed resident #75's wheelchair out to the smoking area while resident #75 yelled at her about his rights to smoke where he wants. During an interview on 5/18/25 at 3:00 p.m., staff member F stated residents #40, 75, and 238 smoke independently and they are not supervised. Staff member F stated smoking residents keep their own smoking paraphernalia and do not check in with nursing. Staff member F stated the floor staff knew who the smokers were and knew when they would be outside. Staff member F stated she was aware of the cigarette butts and smoking occurring outside the activity's door. Staff member F stated the residents refused to follow the rules and often became belligerent if approached to move out to the gate. During an interview on 5/18/25 at 3:14 p.m., staff member H stated the smoking residents were not supervised and she was aware they were smoking outside the activity's door. Staff member H stated, I leave those issues for the nurse to handle and stay out of it. During an observation on 5/18/25 at 3:15 p.m., resident #75 was smoking on the sidewalk halfway between the smoking area and the door, on the property. During an interview on 5/18/25 at 3:16 p.m., staff member I stated she saw residents smoking outside the activity's door regularly, but was not aware it was not allowed because smoking had been happening there for as long as she could remember. Staff member I stated it seemed they would go out to the gate sometimes and other times, like when it was raining or there was too much snow, they would all huddle by the door. During an interview on 5/18/25 at 3:58 p.m., NF1 stated the facility was aware of the smoking problems when they accepted resident #75 to the facility. NF1 stated resident #75 nearly burnt down his apartment with ash everywhere and had caused so much smoke damage at another apartment that he was evicted. NF1 stated she did not know resident #75 was leaving the facility to smoke at all and did not believe he would be safe to smoke off property without supervision because he was blind and reckless with his smoking. Review of resident #75's, Clinical Admission Evaluation Smoking Safety Evaluation, dated 3/31/25, reflected resident #75 was not able to smoke safely and was a high fall risk. Review of resident #75's Nursing Care Plan, revision date 5/6/25 reflected: - [Resident #75] desires to use tobacco products but has been deemed unsafe to smoke d/t blindness, balance problems, medications, use of oxygen and refusal to remove prior to leaving facility property, unable to safely smoke independently and risk for falls/injury. - .[Resident #75] has gone against medical advice regarding smoking and is given 4 cigarettes when off campus per his preference/wishes. Review of resident #75's Brief Interview for Mental Status, dated 4/1/25, reflected resident #75 had a BIMS of 8.0 (Moderate impairment). 2. During an interview on 5/18/25 at 2:49 p.m., resident #238 stated he usually smoked outside the gate when the weather was good, but he and others would stay under the awning by the door sometimes to smoke. Resident #238 stated the staff had not talked to him about the rules until one day when the staff saw him going to smoke and he had oxygen on him. Resident #238 stated, The cna came and got me and told me the smoking rules then so now I try to remember to not bring my oxygen tank out with me anymore. Resident #238 stated he kept his smoking paraphernalia with him or in his room. Resident #238 stated he was not aware of a smoking apron he was to wear while smoking. Review of resident #238's, Clinical Admission Evaluation Smoking Safety Evaluation, dated 5/15/25, reflected resident #238 needed to wear a smoking apron to safely smoke. Review of resident #238's Nursing Care Plan did not reflect resident #238 was a smoker and required an apron to smoke. 3. During an observation and interview on 5/18/25 at 2:56 p.m., resident #40 stated he had never been assessed or asked by staff to watch him safely smoke. Resident #40 had a pack of cigarettes and a lighter sitting on his bedside table. Resident #40 stated he usually would go out to smoke by the activity door or the gate, if the weather was good, about four times a day. During an observation on 5/19/25 at 8:08 a.m., residents #75 and 238 were out smoking on the property. Resident #238 did not have an apron on and neither had signed out to smoke as they left the facility through the activity room door. During an interview on 5/19/25 at 8:11 a.m., staff member E stated resident #40 was a repeat offender with smoking on the property. Staff member E stated resident #40 was also social and would pull others into a group around the door to smoke socially. Staff member E stated resident #75 was a bully to staff and would not follow rules around smoking. Staff member E stated resident #75's POA had voiced concerns with history of damage to his apartments and burns from ash everywhere. Staff member E stated the only thing she could do would be repeat education and then hand the smoking noncompliance off to leadership to handle. During an interview on 5/19/25 at 8:31 a.m., staff member M stated she was concerned about resident #75's safety smoking while blind, had to feel his way down the hallway using the rail, and history of recent hyperkalemic/hypervolemic episodes requiring he be airlifted to the hospital and intubated. Staff member E stated resident #75 became belligerent if the staff took smoking away from him in the past so the facility was in a bit of a spot on how to handle resident #75. Review of the facility's policy, Tobacco-Free Facility and Campus Policy, no date, reflected: - . No accommodations for smoking and/or tobacco products will be made. Tobacco and other, smokeless, tobacco products are not permitted on the premises.

Based on interviews and record reviews, the facility failed to ensure gradual dose reductions were attempted, unless the prescriber documented a rationale for the contraindication of the change, for 3 (#s 10, 19, and 54) of 25 sampled residents. Findings include: A review of the State Operations Manual, Appendix PP, under F605, showed: Adequate Indications for use refers to the identified, documented clinical rationale for administering a medication that is based upon an assessment of the resident's condition and therapeutic goals, and after any other treatments have been deemed clinically contraindicated. For psychotropic medications, without documentation in the record explaining that the practitioner has determined that other treatments have been deemed clinically contraindicated, the indication for use is inadequate. Also, adequate indication for use means that the medication administered is consistent with manufacturer's recommendations and/or clinical practice guidelines, clinical standards of practice, medication references, clinical studies or evidence-based review articles that are published in medical and/or pharmacy journals. 1. Review of resident #10's EHR diagnosis list reflected a diagnosis of dementia. Review of resident #10's Note To Attending Physician/Prescriber, dated 2/19/25, reflected a recommendation from the pharmacist for a gradual dose reduction on resident #10's Seroquel, 50 mg, which was given for depression. The response from the prescriber reflected a declination to complete a gradual dose reduction, but she documented the following rationale: - . At this time patient is stable from a mood standpoint. Continued dosing is appropriate. [sic] No other Gradual Dose Reducations were located in the medical chart for resident #10. 2. Review of resident #19's Note To Attending Physician/Prescriber, dated [DATE]-March 30 [sic], reflected a recommendation from the pharmacist for a gradual dose reduction on resident #19's Sertraline, 100 mg. The document showed the prescriber documented the following, which failed to show the rationale for the continued use of the medication, at the continued dose: - . Things look good . [sic] 3. Review of resident #54's Note To Attending Physician/Prescriber, dated May 23- June 21 [sic], reflected a recommendation from the pharmacist to complete a psychotropic medication review on resident #54's Duloxetine - 30 mg, Trazodone- 50 mg, and Provigil - 100 mg, and all three were all recommendations for gradual dose reductions. The response from the prescriber reflected declinations of the pharmacist's recommendation, but the prescriber failed to document the patient-specific rationale for why the gradual dose reduction was not attempted, or a reasoning for this decision. During an interview on 5/19/25 at 11:15 a.m., staff member M stated she was unaware of the requirements for documentation related to supporting or declining the support a gradual dose reduction. Staff member M stated she was trying to catch up on gradual dose reduction recommendations from the pharmacy, specifically for March and April 2025, due to personal issues. Review of the facility's policy, Gradual Dose Reduction of Psychotropic Drugs, not dated, reflected: - Residents who use psychotropic drugs receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. - . 5. For an individual who is receiving a psychotropic medication to treat expressions or indications of distress related to dementia, the GDR may be considered clinically contraindicated for reasons that include, but are not limited to: - a. A resident's target symptoms returned or worsened after the most recent attempt at a GDR within the facility; and - b. The physician has documented the clinical rationale for why any additional attempted dose reduction at that time would be likely to impair the resident's function or increase distressed behavior. - . 7. Rationale for clinical contraindications may be documented on the Clinically Contraindicated Dose Reduction Form. [sic] Further review of the State Operations Manual, Appendix PP, under F605, showed: Comprehensive Assessment and Behavioral (Nonpharmacological) Interventions The indications for initiating, maintaining, or discontinuing medication(s), as well as the use of non-pharmacological approaches, in accordance with S483.45(e)(2), are determined by evaluating the resident ' s physical, behavioral, mental, and psychosocial signs and symptoms in order to identify and rule out any underlying medical conditions, including the assessment of relative benefits and risks, and the preferences and goals for treatment. The use of nonpharmacological approaches must be attempted, unless clinically contraindicated, to minimize the need for psychotropic medications, use the lowest possible dose, or discontinue the medications. The resident ' s medical record should include documentation of this evaluation and the rationale for chosen treatment options. 52362

Based on interview and record review, the facility failed to failed to correctly reflect the code status of a resident in the EHR for 1 (#68) of 25 sampled residents, and this failure increased the risk of the resident being resuscitated in a health crisis, when that was not the resident's preference or what was documented on the resident's POLST form. Findings include: During an interview on 5/19/25 at 7:59 a.m., staff member E stated social services assures the POLST is reviewed and accurately completed for the resident upon admission. Staff member E further stated the code status on the POLST form should be the same as the code status in the EHR. A review of resident #68's POLST form showed Section A, under the heading Treatment options the box for Do Not Attempt Resuscitation was checked. A review of resident #68's EHR showed his code status as Full Code/Full Treatment A review of a facility policy titled Residents' Rights Regarding Treatment and Advance Directives, with a copyright date of 2025, showed: Policy: It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate advance directives . 9. Any decision making regarding the resident's choices will be documented in the resident's medical record and communicated to the interdisciplinary team and staff responsible for the resident's care .

Based on interview and record review, the facility failed to accurately complete a POLST form with the resident's first name, for 1 (#241), and failed to have the resident/POA sign the POLST form placed in the EHR, for 1 (#24) of 25 sampled residents. These deficient practices had the potential to create complications, or hinder emergency treatment necessary, related to a resident's DNR wishes. Findings include: During an interview on 5/19/25 at 7:59 a.m., staff member E stated social services assures the POLST is reviewed and accurately completed for the resident upon admission. Staff member E stated the code status is in the residents EHR within seven days after admission. Staff member E further stated the code status on the POLST form should be the same as the code status in the EHR, the POLST form should accurately reflect the residents first name, and it was very important the POLST form was signed by the resident or the residents POA. 1. A review of resident #241's POLST form showed the first name was not the resident's first name, middle name, or a name the resident used. 2. A review of resident #24's POLST form showed the box labeled Signature of Patient or Decision-Maker (required) [sic], was blank.

Based on observation, interview, and record review, the facility failed to assist with making appointments and arranging timely transportation for a resident with impaired vision needs, and this failure caused an eye surgery to be canceled, and appointments were not able to be scheduled due to missed appointments, for 1 (#58) of 25 sampled residents. The resident had difficulty doing things she loved, as well as fear of leaving her room, because she may run into someone due to her poor eyesight. Findings include: During an observation and interview on 5/17/25 at 1:05 p.m., resident #58 stated her biggest concern living at the facility was getting vision appointments, and then getting transportation to the appointments on time. Resident #58 stated the facility had made and canceled several appointments for her since November of 2024, without telling her, or the doctor's offices. Resident #58 stated some of the provider offices will not see her now as a patient because, I have been late or missed so many appointments, and once you're late they won't see you, and after so many times they won't let you come back. Resident #58 stated her vision started to deteriorate in October of 2024, and the one appointment she was able to get in January of 2025, she was told she needed cataract surgery. Resident #58 stated because she was late to the surgeon's appointment in February of 2025, she could not come back, and now they will not perform the surgery. Resident #58 stated when she called the scheduler at the surgeon's office herself, she was told, I know it's out of your hands, I'm sorry. Resident #58 showed this surveyor she could not read the book her roommate had given her. Resident #58 stated, I can't see you, my food, anything now. Resident #58 stated the facility had a new scheduler, but she had not heard anything for two weeks regarding when the next appointment was able to be made. During an interview on 5/18/25 at 4:17 p.m., staff member J stated she was the scheduler for all outside facility appointments. Staff member J stated there were no vision appointments scheduled for resident #58, and followed that comment with stating, None that I know of, I just took over three weeks ago. Staff member J looked at the list of all appointments that had been made for resident #58, and stated the last vision appointment for resident #58 was in January of 2025 at [local clinic name]. During an interview on 5/18/25 at 4:23 p.m., staff member K stated staff member E would know about appointments. During an interview on 5/19/25 at 8:18 a.m., resident #58 stated she met another resident in physical therapy recently, and They got their eye appointment and surgery so fast, it made me so mad, why won't they help me like that. During an interview on 5/19/25 at 9:57 a.m., staff member L stated she cares for resident #58 on a regular basis, and she was unaware of any vision concerns. During an interview on 5/19/25 at 10:06 a.m., staff member E stated she was not the right person to ask about helping residents with appointments. Review of the Care Plan Report for resident #58, with an admitted [DATE], showed no goals or interventions to assist or accommodate vision appointments. Review of facility progress note entries for resident #58 from 11/18/24 to 5/12/25 showed: - Entry on 1/28/25 at 11:00 p.m., (resident) stated, . She is on her way to an eye appt . - Entry on 2/4/25 at 3:30 p.m., (resident) stated, . Resident has been upset about a pre-op appointment for her eye surgery . an appointment has been made. Resident reports that she called there [local clinic], and they do not have an appt. [sic] - No other eye appointment entries were noted in the six month time frame in the resident's record. Review of a Social Service progress note entry for #58's Care Conference Summary, dated 3/13/25, showed, Getting eye surgery/cataract procedure done in [City Name], based on surgeon availability. No questions or concerns at this time. [sic]

Based on interview and record review, the facility failed to implement a comprehensive care plan to include bowel and bladder incontinence for 1 (#241) of 25 sampled residents. Findings include: Review of resident #241's Admission MDS, with an ARD of 5/12/25, showed the resident was always incontinent of bowel and bladder. Section V, Care Area Assessment Summary, showed the bladder incontinence care area had triggered and should be care planned. A review of resident #241's Baseline Care Plan, dated 4/30/25, showed the resident was frequently incontinent of bowel and bladder. A review of resident #241's comprehensive care plan failed to show the resident was incontinent of bowel and bladder. During an interview on 5/18/25 at 4:22 p.m., staff member B stated the nurse managers and MDS Coordinators developed the residents care plans, and she assumed that bowel and bladder incontinence should be on the care plan. Staff member B further stated that resident #241 was relatively new to the facility, and his care plan may not be completed yet. A review of a facility policy titled, Care Plan Revisions Upon Status Change, undated, showed: Policy: The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan . b. The MDS Coordinator and the Interdisciplinary Team will discuss the resident condition and collaborate on intervention options.

Based on observation, interview and record review the facility failed to accurately assess the vision needs of a resident on the comprehensive assessment, for 1 (#23) of 25 sampled residents, and the resident was unable to read or see her food when eating. Findings include: During an observation and interview on 5/17/25 at 1:05 PM, resident #23 stated her vision started to deteriorate in October of 2024, due to cataracts. Resident #23 showed this surveyor she could not read the book her roommate had given her. Resident #23 stated, I can't see you, my food, anything now. During an interview on 5/18/25 at 4:23 p.m., staff member K stated there was no vision concerns or appointments needed that she could think of for resident #23. Staff member K stated she would bring up vision needs for residents during care conferences, and if there were any, it would get reported on the MDS, and staff member K stated questions were asked, like, do you need glasses? Staff member K also looked into making appointments if there was a need. Staff member K stated during the last care conference resident #23 was being treated for an ear infection; no vision needs were addressed. Review of resident #23's MDS, with an ARD of . showed for Section B1000 and B1200: - B1000 - sees fine detail, such as regular print in newspapers/books . - B1200 - corrective lenses used in completing B1000, and the response was marked as, No Review of a facility policy titled, Resident Assessment - RAI, copyright 2024, reflected: . This facility makes a comprehensive assessment of each resident's needs, strengths, goals . . The assessment will include at least the following: . e. Vision . . The assessment process will include direct observation and communication with the resident .

Based on observations, interviews, and record review, the facility failed to provide therapeutic meals that followed physician orders for 2 (#13 and 14) of 2 sampled dialysis residents. Findings include: During an interview on 10/22/24 at 11:51 a.m., NF1 stated the facility did not properly provide appropriate meals for dialysis patients. NF1 stated, They just can't properly care for . dialysis patients. NF1 stated residents often told them their meals were commonly high in salt, and the meal would consist of something like a ham sandwich and chips. NF1 stated this extra salt would lead the residents to drink more water which had a negative impact on their kidneys, and required more dialysis. During an observation and interview on 10/22/24 at 1:39 p.m., the surveyor had walked into resident #13's room and he stated, That soup was really really salty. When asked, resident #13 stated he can control his dialysis better with water, but his water limit was one liter per day. Resident #13 stated he commonly had diarrhea. Resident #13 had a roast beef sandwich (no cheese), plain green beans and kidney beans mixed together, a bowl of soup, a cup of mandarin oranges, two glasses of juice, and a glass of a protein drink. The sandwich and green bean/kidney bean mix was untouched by the resident as he stated he did not like them. Review of resident #13's EHR showed the physician order: Renal diet . Deli meats (such as roast beef, turkey, or ham), most cheeses, and chips, are high in sodium. Concerning dialysis patients, the CDC (Centers for Disease, Control and Prevention) showed, Foods to limit: Eat less salt/sodium. Over time, your kidneys lose the ability to control your sodium-water balance. Less sodium in your diet will help lower blood pressure (CDC, 2024). The FDA (Food and Drug Administration) showed: .about 40% of the sodium consumed by Americans comes from the following foods: Deli meat sandwiches .soups . (FDA, 2024). According to Dr. [NAME], a researcher for the Mayo Clinic School of Medicine in the Nephrology and Hypertension Division showed diarrhea was a common side effect of electrolyte imbalances particularly sodium ([NAME], 2019). High sodium levels (or hypernatremia) could cause the symptom of loose and watery bowel movements due to hypotonic fluid loss (also referred to as osmotic diarrhea) ([NAME], 2019). [NAME] showed, Sustained hypernatremia can cause irreversible cell/organ damage and high mortality ([NAME], 2019). During an interview on 10/22/24 at 1:41 p.m., staff member H stated the food was often served late and each tray had very similar food which did not follow the physician therapeutic orders. Staff member H stated therapeutic orders were not followed for many types of diet orders, not just the dialysis residents. Review of the posted meal Serve Times showed lunch was scheduled to be served for resident #13 at 11:30 a.m. to 12:00 p.m. During an interview and observation on 10/22/24 at 1:50 p.m., resident #14 stated she received dialysis regularly (Monday, Wednesday, and Fridays). Resident #14 stated the food was kind of salty. Resident #14's tray consisted of a turkey sandwich (with cheese), a bowl of soup, a cup of mandarin oranges, two glasses of juice, and two packets of saltine crackers. Review of resident #14's EHR showed the physician order: Renal diet . During an observation on 10/21/24 at 1:57 p.m. resident #19's plate consisted of turkey sandwich (with cheese), a cup of mandarin oranges, green bean/kidney bean mix, a glass of juice, and a bowl of tomato soup. Review of resident #19's EHR showed the physician order: Regular diet . References: Centers for Disease Control and Prevention. (2024, May 15). Diabetes and Kidney Disease: What to Eat? Centers for Disease Control and Prevention. https://www.cdc.gov/diabetes/healthy-eating/diabetes-and-kidney-disease-food.html Food and Drug Administration. (2024, March 5). Sodium in Your Diet. Food and Drug Administration. https://www.fda.gov/food/nutrition-education-resources-materials/sodium-your-diet [NAME], Qi. Hypernatremia. Clinical Journal of the American Society of Nephrology 14(3):p 432-434, March 2019. | DOI: 10.2215/CJN.12141018

Based on interviews and record reviews, the facility failed to identify the root cause, address, and obtain necessary services for the behavioral health care needs for 1 (#2) of 20 sampled residents which could result in harm to staff or other residents, and it did affect 1 (#15), due to resident #1's aggressive behaviors. Findings include: Review of a Facility Reported Incident, with an initial report date of 10/5/24, showed both resident #2 and resident #15 resided in the dementia care unit. Resident #2 punched resident #15 in the jaw which resulted in resident #15 hitting resident #2 back. During an interview on 10/21/24 at 12:02 p.m., staff member C stated resident #2 had moments of being verbally aggressive and would yell at staff or residents. Staff member C stated they worked the night prior to resident #2 hitting resident #15. Staff member C explained a situation where resident #2 had been confused and was wearing resident #15's belt. Staff member C stated resident #2 would often go through resident #15's clothing or try to wear his clothing. When staff member C asked resident #2 to take the belt off, resident #2 lunged at staff member C. Staff member C was able to get out of the way, but staff member C stated, He gets these bursts of energy, and he's strong. Staff member C stated resident #2 and resident #15 had been arguing, and resident #2 jumped off the bed very quickly, to go over to resident #15. Staff member C stated she intervened in this situation and was able to prevent anything from happening. Staff member C stated, I did notify [upper management]. During an interview on 10/21/24 at 1:55 p.m., staff member E stated resident #2 had aggression, and there was an instance in the past, where they were told resident #2 had his hands around a staff member's neck. Staff member E stated this incident was reported to upper management. During an interview with staff member A and B on 10/21/24 at 4:37 p.m., staff member B stated after an incident the nurses will do a pain and/or fall assessment if applicable. Staff member B stated IDT would talk about the situation and would complete a root cause analysis of the situation. The surveyor asked for more in-depth information regarding the root cause analysis and reports of resident #2's behavior assessments, other applicable assessments (ie: falls, pain), number of incidences, interventions after the incidences, and a re-evaluation of resident #2's activities. Staff member A stated there were no other reports of resident #2 being aggressive than the incident on 10/5/24. When asked about the situation with resident #2's hands around a staff member's neck, staff member B stated there was only the initial nursing note about the incident where resident #2 had placed his hands near another staff member's neck. Staff member B stated it was their understanding that resident #2 had placed his hands on the staff member's upper chest, near their neck, and this was why they felt no report or investigation was needed. When asked if it was acceptable or appropriate for a reasonable person or any resident to touch a staff member anywhere near their neck, staff member B stated, No. When asked if either staff member would feel uncomfortable if a resident would touch them anywhere near their neck, staff member B stated, Yes. Staff member B stated they felt resident #2's aggression seemed to stem from a person in his past. When asked if staff member B or A had asked resident #2 who [Name] was or why [Name] made him upset, staff member B stated they did not get a chance to ask resident #2. During an interview on 10/22/24 at 7:48 a.m., staff member K stated [Name] seemed like a friend to resident #2. Review of a nurse's note, dated 10/15/24, showed, About 1720 today this resident got upset with staff . he (#2) started to swing his walker at the staff member . Then at about 1900 resident put his hands around a staff members throat. Staff member thought that he was just playing around because he didn't put any pressure on him when he did it . 911 was called for assistance. 911 sent a cop over first to assess the situation. He then called the ambulance to come pick him (#2) up . During an interview with staff member A and B on 10/22/24 at 8:10 a.m., staff member B stated resident #2 did have behaviors but did not show signs of aggression prior to hitting resident #15 on 10/5/24. Staff member A stated, We talked about it, the facility had tried telehealth options for resident #2. Staff member A stated behavioral health options were difficult to find in the state. Staff member A stated staff member M was supposed to be working on behavioral health appointments. Review of resident #2's EHR showed a prior physician's note, dated 8/4/24, which showed for #2, His mood seems to be very agitated, and he gets very frustrated easily. Review of resident #2's EHR showed a prior nurse's note, dated 9/30/24, which showed, Resident is noncompliant with staying in his room and is refusing to wear his mask (isolation) when not in his room. He was in his neighbors room when his neighbor started to yell at him telling him to get out of his room. [Resident #2] refused to leave this room. Staff tried to redirect him out of that room, but he was refusing to leave. When staff was able to get him out of the neighbors room he tried to hit staff with his walker. Staff then asked him to put on his mask if he was going to be out with the rest of the residents and he refused. He then started to walk into a female's room and when staff stepped in front of him, he started swearing at staff and throwing his walker around at the staff member in his way. Another staff member came and was able to redirect him back to his room. Resident has been going into his neighbors' room and telling everyone that it's his room and his stuff. In the past he was usually easy to redirect. He has been getting aggressive at random times usually between 5pm and 9 pm. [sic] Review of resident #2's EHR nurse's notes showed dates where aggressive behavior continued: 10/8/24, 10/15/24, 10/20/24. Review of a physician's note showed, .S [NAME] he is so agressive with violent outbursts I did not feel safe to continue the appointment once he became more aggressive toward me. [sic] Review of resident #2's EHR showed no pain assessments, fall assessments, behavioral health assessments, re-evaluations or updates to the individualized care plan regarding activities (last revised 6/25/24) after the incident on 10/5/24. Resident #2's Care Plan showed generic activities and did not show person-oriented activities specific to resident #2. During an interview with staff member A, B, and M, on 10/22/24 at 10:37 a.m., staff member A stated, Yes, we could button up on that more, related to using root cause analyses after incidents. Staff member M stated resident #2 had seen psychiatry in the past, but was not currently seeing anyone. Staff member M stated a referral was not completed, but the facility had received signatures from resident #2's POA (on 10/7/24) concerning permission to schedule the appointment. Review of the Authorization for the Use and Disclosure of Health Information for [Provider Name], Licensed Clinical Social Worker, dated 10/7/24, showed a blank line and no signatures where the authorized representative and/or client would sign. During an interview on 10/22/24 at 12:13 p.m., staff member M stated they followed up with all nursing staff daily about the resident's behaviors; however, staff member M stated they did not document anything regarding these follow ups or the noted behaviors. Staff member M stated, . I have not been as good as I should be.

Based on observation, interview, and record review, the facility failed to schedule a sufficient number of CNAs as identified in the facility assessment recommendations, resulting in 2 (#s 18 and 19) of 20 sampled residents waiting over 20 minutes for the call light to be answered timely; 6 (#s 8, 9, 16, 18, 19, and 20) of 20 sampled residents expressing concern and complaints regarding long call light times and short staffing; and for 2 (#s 1 and 8) of 20 sampled residents not receiving enough showers; and 5 nursing staff expressed concerns with staffing ratios and not recieving breaks. Findings include: During an interview on 10/21/24 at 12:22 p.m., resident #9 stated he had waited up to 40 minutes for his call light to be answered. During an interview on 10/21/24 at 4:37 p.m., staff member B stated the facility did call light audits, kind of indirectly, but never kept a record of this. Staff member B stated they would test the call light times once a month by pushing the button in a resident's room and testing the staff's reponse time. Staff member B stated they would test this more often if there was an issue. During an interview on 10/21/24 at 1:55 p.m., staff member E stated sufficient staff was important for meeting toileting and feeding needs for each individual resident, and sufficient staff was needed to provide the necessary safety for each resident. During an interview on 10/21/24 at 2:38 p.m., staff member F stated they often got done with their shift at 6:40 p.m. Staff member F stated her shift ran from 6:00 a.m. to 6:00 p.m. Staff member F stated the showers were getting done on their shift, but they never recieved any breaks throughout the shift due to high acuity residents, low staffing, frequent call lights, and scheduled showers. During an observation on 10/21/24 at 5:11 p.m., three call lights were on (for resident #16, resident #18, and resident #19). During an interview on 10/21/24 at 5:15 p.m., resident #16 stated she consistently waited 15 minutes for staff to answer her call light. During an observation and interview on 10/21/24 at 5:27 p.m., the three prior call lights were still on (for resident #16, resident #18, and resident #19), in addition to one more call light. When speaking with resident #19, who had previously been yelling out of his room for attention and help, he stated he really needed to use the restroom. Resident #19 was squirming in his bed and sat up very quickly when the surveyor walked in, hoping someone would take him to the restroom. Resident #19 stated he often waited 15 minutes or more for his call light to be answered which he felt was frustrating and as if he was disregarded by staff because his needs were not being met. During an interview on 10/21/24 at 5:29 p.m., resident #20 stated he commonly waited 15 minutes for his call light to be answered. During an observation and interview on 10/21/24 at 5:34 p.m., resident #18 was sitting on the edge of her bed and stated she needed to urgently use the restroom. Resident #18 stated, They need more help, definitely. Resident #18 stated, One night I almost peed, I waited so long. During an observation and interview on 10/21/24 at 5:35 p.m., staff member H stated there was one nurse on the B wing and one nurse on the A wing. One CNA was assigned to deliver trays between the two halls and one CNA answered call lights. There were currently four call lights on. Staff member H stated it was common that they did not get any breaks or lunch throughout the day because they felt if they took a break they would get even farther behind and then leave even later at the end of their shift. Staff member H stated they would often leave 30 minutes to an hour late every day. Staff member H stated they tried to answer a call light in five minutes or less, but due to insufficent staffing, the high number of residents requiring lifts, and the tasks required each shift, they often found it difficult to uphold this standard. Staff member H stated they felt the the resident's needs were not always being met to the best of staff member H's abilities, and the residents were waiting a long time for help. During an observation on 10/21/24 at 5:38 p.m., resident #18's call light was still on, for a total time observed of 27 minutes. During an interview on 10/21/24 at 5:39 p.m., resident #19's call light was turned off a few minutes prior to this time, and resident #19 stated, Yeah, they took me now. Resident #19 was now laying calmly in his bed. Resident #19's call light was answered in approximately 25 minutes. During an interview on 10/21/24 at 5:44 p.m., staff member I stated they usually had to help the other staff member as one hall was worse than the other, and there were not enough CNAs for the acuity of residents, and the number of residents requiring mechanical lift transfers. Staff member I stated they were aware of call lights being on for more than 40 minutes at times. During an interview on 10/21/24 at 5:50 p.m., staff member J stated she felt we (staff) are often running around, due to low staffing numbers and consistent call lights going off. During an interview on 10/22/24 at 7:48 a.m., staff member K stated, C wing definitely needs more help, due to high call light times and the resident to staff ratios. During an interview on 10/22/24 at 11:22 a.m., staff member K stated she was pulled from her wing to help the A and B wings catch up on call lights. Staff member K stated this happened often. During an interview on 10/22/24 at 12:04 p.m., resident #8 stated, There are not enough of them (CNAs). They need more CNAs . I get a shower when they get to me. Review of resident #8's EHR showed an admitted [DATE]. Review of resident #8's EHR showed: Bathing/Shower days are Wednesday and Sunday and as necessary. There was no documentation for the shower scheduled on 10/13/24. Resident #8's bathing task showed a refusal on 10/17/24 (Thursday) and Not Applicable on 10/20/24. Showers were not always provided as scheduled. During an interview on 10/22/24 at 12:07 p.m., resident #1 stated her last shower was sometime last week. Resident #1 stated she never refused showers, and she felt she did not receive enough of them. During an interview on 10/22/24 at 3:09 p.m., staff member F stated they were going to put their feet up for ten minutes as they would not be able to get their full 30-minute break to eat. Staff member F stated this happened often. When asked why staff member F was not going to be able to get their full 30 minute break, they stated there were too many tasks to be completed still for the day and the staff member that called off earlier in the morning only added more tasks for staff member F to complete. Review of the document, Facility Assessment, dated 4/26/24, showed: - .1.2. Average facility daily census: (range) 65-75 . - .Staffing plan - [Facility Name] is very conscientious to the needs of the resident including the facility staff, the nursing staff and resident ratio is monitored daily to achieve the highest practicable well-being of the resident . - CNAs 6 a.m.-6:00 p.m. 1:14 CNA per resident ratio - CNAs 6 p.m.-6:00 a.m. 1:14 CNA per resident ratio . Review of the Resident List, the facility census was 86 total residents upon entrance, and 18 residents resided in the dementia unit, 31 residents were in the C wing, 22 residents in the A wing, and 15 residents in the B wing. Review of the Daily Staffing Schedule showed: - the dementia unit was assigned two CNAs, - the C wing was assigned two CNAs, - the A and B wings were assigned two CNAs together. - On 10/21/24, there was one call off. The C wing (31 residents) had a CNA to resident ratio of 1:15. - The A and B wings combined had a CNA to resident ratio of 1:37 with the call off considered. Without the call off considered, the A wing had a ratio of 1:22, and the B wing had a ratio of 1:15. - With 86 residents, these staffing ratios did not follow the CNA staffing recommendations identified in the Facility Assessment (1:14 CNA per resident ratio).

Based on interviews, and record review, the facility failed to provide the scheduled showers for 3 (#s 1, 3, and 8) of 6 sampled residents for hygiene care. Findings include: During an interview on 10/22/24 at 11:51 a.m., NF1 stated resident #1 visited [Facility Name] and was . so filthy our staff didn't want to touch her. NF1 stated resident #1 visited [Facility Name] on 10/11/24, had significant body odor, and her ponytail was matted at the base of her hair. NF1 stated the staff was concerned resident #1 might have hair loss because the ponytail had been in so long. During an interview on 10/22/24 at 11:25 a.m., resident #3 stated his last shower was last Saturday. Resident #3 stated, I don't seem to be asked a lot (if he wanted a shower). He stated he rarely refused showers except when the staff would offer him a shower at 9:30 p.m. or 10:00 p.m. Resident #3 stated this was too late in the day, and he wanted to go to bed at this time. Resident #3 stated he did not get asked about a shower the morning of 10/22/24 (at 3:00 a.m.). Review of resident #3's EHR showed resident #3 refused a shower on 10/22/24 at 3:00 a.m. During an interview on 10/22/24 at 12:04 p.m., resident #8 stated, I could use a shower. I get a shower when they get to me. Resident #8 stated she had never refused a shower at the facility. Review of resident #8's EHR showed an admitted [DATE]. Review of resident #8's EHR showed: Bathing/Shower days are Wednesday and Sunday and as necessary. There was no documentation for the shower scheduled on 10/13/24 (Sunday). Resident #8's bathing task showed a refusal on 10/17/24 (Thursday) and Not Applicable on 10/20/24 (Sunday). Therefore, the record showed no showers were given to resident #8 since admission. During an interview on 10/22/24 at 12:07 p.m., resident #1 stated her last shower was last week. Resident #1 stated she never refused showers. Review of resident #1's EHR showed: Bathing/Shower days are Sunday and Thursday and as necessary. The EHR showed resident #1 received four showers in the past 30 days (9/26/24, 9/29/24, 10/3/24, and 10/13/24). On 10/6/24, resident #1 showed a documentation of a shower refusal.

Based on observation, interview, and record review, the facility failed to meet professional standards of practice by administering an opioid medication in conjunction with a benzodiazepine. This deficient practice had the potential to cause an increase in respiratory depression, over sedation, increased confusion, coma, or death for 1 (#1) of 16 sampled residents. Findings include: During an interview on 8/12/24 at 1:58 p.m. NF1 stated, The nursing staff were giving [Resident #1] oxycodone and Ativan at the same time. I had asked the nurses repeatedly not to give them together because it would cause him (the resident) to be too sedated. I also worried about the possibility for other side effects, like slowed breathing. That really worried me because he (the resident) has COPD. There was one nurse that just would not listen to us. During an interview on 8/13/24 at 2:03 p.m., staff member B stated, The expectation for medication administration is following the five rights of medication administration. The nurses are expected to administer medications using the safest route. Staff member B stated if a warning comes up while administering a certain medication, the nursing staff is expected to follow the warning or recommendation. During an interview on 8/14/24 at 7:50 a.m., staff member M was administering morning mediations. Staff member M stated it was not acceptable to give an opioid medication at the same time as a benzodiazepine because of the increased risk of side effects. Staff member M stated, In the MAR, if you give medications that have potential side effects or adverse reactions, a warning will pop up and you have to acknowledge and accept it before it (EHR) will allow you to move on. Staff member M stated you can not give an opioid with a benzodiazepine because of the side effects and was not an acceptable nursing practice. During an interview on 8/14/24 at 1:25 p.m., NF5 stated when resident #1 was admitted to the facility a review of his medications was completed. NF5 stated there were no concerns with the prescribed medications. NF5 stated if there was a potential for a side effect or adverse reaction the MAR would issue a warning to the nursing staff, and nursing staff would have to address the warning. NF5 stated, We do not educate the nursing staff on the potential side effects or adverse reactions of medications, that is something that any nurse would know. NF5 stated, Due to the possibility of side effects from administering an opioid and a benzodiazepine at the same time it is not an acceptable practice. The side effects of administering those two medications can cause oversedation, respiratory depression, increased confusion and many other side effects like coma or death. The two medications should be given four to six hours apart, even on an as needed basis. The only time it is acceptable to give those two medications together is for a patient at end of life or for a patient with seizure disorder. Review of resident #1's admission diagnoses, dated 6/14/24 showed no diagnosis of seizure disorder, or a diagnosis that would require end of life care. Review of resident #1's physicians orders, dated, 6/14/24, showed: - Oxycodone 10 mg, give 1 tablet by mouth every 6 hours as needed for pain for 30 days. - Lorazepam 0.5 mg, give 1 tablet by mouth every 12 hours as need for anxiety for 14 days. Review of resident #1's MAR showed resident #1 received oxycodone 10 mg and lorazepam 0.5 mg concurrently on the following days by staff member Q. - 6/14/24 at 7:48 a.m., - 6/15/25 at 9:13 a.m., - 6/16/24 at 9:06 a.m., - 6/19/24 at 8:27 a.m., - 6/20/24 at 10:11 a.m., and - 6/24/24 at 1:15 p.m. Staff member Q was not available for interview during the survey. Review of a facility document titled, Clinical Systems and Implementation Guide, with a completion date of 6/11/24, showed staff member Q had completed the nursing competencies in medication management and opioid prevention and management. Review of a facility document titled, Medication Administration, undated, showed: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice .

Based on observation, interview, and record review, facility staff failed to identify and provide the necessary trauma services to maintain the highest well-being, for 1 (#65) of 1 sampled resident who was experiencing post-traumatic stress disorder. Findings include: During an observation and interview on 7/17/23 at 3:22 p.m., resident #65 was lying in bed. An interview was attempted with resident #65. His speech was garbled and not understandable. His appearance was disheveled, his hair was matted, and his beard was long and untrimmed. He was wearing a nasal cannula, and a CPAP (continuous positive airway pressure) device was on a table next to his bed. During an interview on 7/19/23 at 8:37 a.m., NF4 said resident #65 did have PTSD. NF4 said resident #65 was in the military and saw action overseas. NF4 said one of resident #65's main triggers were 'bundles such as backpacks, boxes, and suitcases he could not identify. NF4 said resident #65 thought they were possible IEDs (improvised explosive devices). NF4 said not all loud noises were a trigger for resident #65. NF4 said if loud noises were expected fourth of July fireworks resident #65 had no problems, but if noises were loud and unexpected they would trigger resident #65. NF4 said resident #65 did have a mental health counselor he had been seeing one time a week for the last eight years. NF4 said she did not think resident #65 had been seeing his counselor since he had been admitted to the facility. NF4 said resident #65 had also been experiencing more nightmares recently. NF4 expressed concerns of resident #65 not wearing his CPAP (continuous positive airway pressure) device at night. NF4 stated, If he doesn't wear his CPAP at night his nightmares get more frequent and worse. Review of resident #65's admission orders, dated 6/13/23, showed the resident had transferred to the facility from a veterans administration hospital. Review of resident #65's admission history and physical, dated 6/22/23, showed the resident suffered from chronic post-traumatic stress disorder (PTSD). Review of a facility document, IDT - Baseline Care Plan V-1, Section 5, dated 6/13/23, showed resident #65 had no mental health needs, no behavioral and/or substance use disorder concerns, and a trauma/depression screening was not completed. Review of resident #65's care plan, date initiated 6/13/23, failed to show a focus area, goals, or interventions for the management of his PTSD and associated triggers. Review of resident #65's respiration care plan, dated 6/26/23, failed to show interventions that included the use of a CPAP device, and/or the risk of not using the device. Review of resident #65's order summary report, dated 7/3/23, showed duloxetine 60 mg one time a day was ordered on 6/13/23 for depression. Review of resident #65 Admission MDS, with an ARD of 7/7/23, showed facility staff failed to complete Section D for Mood, and Section E for Behavior, on the resident's MDS. During an interview on 7/19/23 at 9:00 a.m., staff member N said she had not checked into having resident #65 see his counselor. Staff member N said she knew resident #65 was a veteran, and had been receiving mental health services prior to being admitted to the facility. During an observation and interview on 7/19/23 at 4:13 p.m., when asked if resident #65 would like to see his counselor, the resident nodded yes. Resident #65 was observed to be teary eyed when he responded to the question.

Based on interview and record review, the facility failed provide consistent care, monitoring, and treatment of pressure ulcers, for 1 (#3) of 1 sampled resident. This deficient practice had the potential to cause worsening of wounds and infections for the resident. Findings include: Review of resident #3's skin assessments, dated 3/22/23 - 7/18/23 showed inconsistencies in the wound classifications, and missed weekly nursing skin assessments, which were: - 3/22/23 - The weekly nursing skin assessment showed one wound: Right buttock other skin condition consisting of partial thickness skin loss and size in cm of 1.1 x 1.8 x 0.1. The wound was documented as being first observed on 3/21/23. - 4/7/23 - The weekly nursing skin assessment showed one wound: Right buttock abrasion consisting of partial thickness skin loss, serous drainage, and size in cm of 1.3 x 1.5 x 0.1. The wound was documented as being first observed on 3/21/23. The wound was classified differently than previously identified, despite similiar characteristics and size. - 4/26/23 - The nursing weekly pressure ulcer report showed: Right buttock pressure wound Stage II. Date of initial observation 4/26/23. Size in cm 1.9 x 2.2 x 0.1 with partial thickness skin loss, serosanguinous drainage, and bright beefy red granulation tissue. - 4/26/23 - The nursing weekly pressure ulcer report showed a new wound: Left buttock pressure wound Stage II. Date of the initial observation was 4/26/23. Size in cm 1.3 x 1.9 x 0.1 with partial thickness skin loss, serosanguinous drainage, and bright beefy red granulation tissue. - The pressure wounds to the right and left buttock were never documented in the month of May, 2023. - There was no nursing skin assessment documentation for the month of July 2023, for any abrasions, other skin conditions, or pressure ulcers to the resident's right or left buttock. Review of resident #3's physician note, dated 7/13/23, showed, Has baseball size open wound right hip that is draining same fluid color as right leg (yellow/bright green/bloody discharge) . everytime culture and sensitivity's are done on her infections she is becoming more and more resistant to all antibiotics. [sic] This wound was never documented in the nursing skin checks. During an interview on 7/18/23 at 2:47 p.m., resident #3 stated she had a wound on her right hip. She declined to roll to her side for observation. During an interview on 7/19/23 at 9:44 a.m., staff member D stated the nurses were doing wound care to areas on resident #3's wounds to her leg, hip, buttocks, and shoulder. During an interview on 7/19/23 at 2:06 p.m., staff member B stated there should be orders and assessments for the hip wound. She stated wound documentation was an area needing more training.

Based on observation, interview, and record review, facility staff neglected to ensure system processes were in place to comprehensively assess all residents in the facility; neglected to complete Admission, Annual, and Significant Change MDS assessments which would identify medical and health concerns and care needs, and assist with the development of individualized care plans; neglected to develop and implement comprehensive care plans to address all residents' care concerns for 14 (#s 1, 3, 5, 20, 23, 34, 42, 47, 48, 73, 77, 78, 79, and 80) of 14 sampled residents; neglected to delegate or employ a staff member to complete facility residents' MDS assessments; and neglected to revise resident care plans in a timely manner with residents' care concerns the facility had identified; neglected to monitor for rectal bleeding for 1 (#79) of 1 sampled resident; neglected to assess and document progression of a wound for 1 (#48) of 1 sampled resident; neglected to identify an insidious severe weight loss for 1 (#73) of 6 sampled residents; and neglected to have a process in place to identify severe weight loss for 2 (#s 44 and 78) of 6 sampled residents. Findings include: On 9/15/22 at 8:00 a.m., an Immediate Jeopardy was announced to the facility administrator for the area of Abuse/Neglect - F600, which put all 58 residents at significant risk of harm, therefore was cited at a scope and severity of L. 1. During an observation on 9/13/22 at 11:01 a.m., resident #73 was in bed, and covered by a sheet. A bedside table was over the resident's lap. The resident appeared to be asleep. Resident #73's complexion was very pale. The resident had a long, unkempt beard, and long hair. Resident #73's arms were on top of the sheet, and the resident was not wearing a shirt. The resident's arms appeared flaccid, and without muscle tone. During an observation on 9/15/22 at 3:25 p.m., resident #73 was in bed, and appeared to be asleep. The resident was covered by a sheet. The resident was pale and unkempt. During an observation on 9/16/22 at 7:38 a.m., resident #73 was being wheeled from the elevator onto the main floor by a staff member. The resident appeared to be unkempt. Resident #73 did not respond to a morning greeting. During an interview on 9/14/22 at 10:33 a.m., NF2 expressed concerns regarding resident #73. NF2 said resident #73 was in bed all the time, and resident #73 would mess himself and it took staff a long time to come change resident #73. NF2 said resident #73 was not eating his meals. Review of resident #73's monthly weight record from January 2022 to June 2022 showed: - 1/9/22 230.0 pounds, - 1/23/22 202.6 pounds, - 2/14/22 177.6 pounds, - 3/20/22 167.8 pounds, - 3/22/22 171.8 pounds, - 3/28/22 170.8 pounds, - 4/4/22 172.0 pounds, - 5/16/22 171.0 pounds, and - 6/23/22 163.0 pounds. Resident #73 lost 40 pounds from 1/9/22 to 6/23/22. This was a severe weight loss of 19.7 % in six months. Facility staff neglected to identify an insidious severe weight loss for the resident. During an interview on 9/14/22 at 2:38 p.m., staff member G was not aware of resident #73's insidious, severe weight loss. Staff member G did not know if resident #73's physician had been notified of the severe weight loss. Staff member G said nursing staff were supposed to notify the physician of weight changes. Review of resident #73's MDS (minimum data set) showed the facility had started an Admission MDS, with an ARD (assessment reference date) of 11/24/21, showed it was still in progress. The Admission MDS had not been completed. The facility failed to complete a comprehensive assessment of resident #73 at any point during the resident's stay at the facility. This failure led to the facility's inability to develop, and implement an effective, person-centered care plan for resident #73. 2. During an observation on 9/12/22 at 4:22 p.m., resident #78 was in his room watching television. When asked how the resident was doing he responded with Okay. The resident did not respond when further questions were asked. Review of resident #78's monthly weight record, from 5/10/22 to 6/23/22, showed the resident had lost 14 pounds in one month. This was a severe weight loss of 6.74 % in one month. During an interview on 9/14/22 at 2:38 p.m., staff member G was not aware of resident #78's severe weight loss. Staff member G did not know if resident #78's physician had been notified of the severe weight loss. Staff member G said nursing staff were supposed to notify the physician of weight changes. Review of resident #78's Admission MDS, with an ARD of 5/14/22, showed it was still in progress. The Admission MDS had not been completed. The facility failed to complete a comprehensive assessment of resident #78 at any time during the resident's stay at the facility. This failure led to the facility's inability to develop, and implement an effective, person-centered care plan for resident #78. During an interview on 9/14/22 at 2:38 p.m., staff member G said nutritional assessments were supposed to be completed on a resident's admission, quarterly, annually, and with a significant change. Staff member G said he completed Section K of the MDS, and in the normal course of things he would write the nutritional care plan. Staff member G said the facility used to have a nutrition at risk team that met weekly to review resident weights to check for resident weight losses or weight gains. Staff member G said that team had not met in a long time. Staff member G said for the nutrition at risk meetings he would run a weight summary report, and it would show if residents triggered for weight loss or gain for the last 30, 60, and 90 days. Staff member G said he was not aware of the insidious severe weight loss experienced by resident #73. Staff member G said he was not aware of the severe weight loss resident #78 had experienced. During an inteview on 9/15/22 at 9:16 a.m., staff member B said she understood completion of Admission, Annual, and Significant Change MDS care area assessments was an important component to developing accurate, effective, person-centered care plans. Staff member B said she understood if this process was not completed facility staff would not be able to identify and provide the care needed for the residents residing in the facility. 3. During an observation on 9/12/22 at 12:31 p.m., resident #44 was seated in the secured unit dining room. A tray of food was placed in front of resident #44, two full sized corn dogs were in a bowl, not sliced. Resident #44 picked up one of the corn dogs and began hitting her left cheek with the corn dog. She then became very vocal, placed the corn dog on the meal tray, and got up. Resident #44 then wandered out of the dining area and up and down the halls of the secured unit. She was very vocal, repeating the same words over and over, and laughing. She returned to the table containing her meal tray multiple times through the dining observation. She did not take a bite of the corn dog, and did not eat any of the food from the tray. Staff member M tried multiple times, without success, to redirect resident #44 back to the table and to eat her meal. During an interview on 9/13/22 at 12:59 p.m., staff member M said resident #44 would wander through the unit while she ate. Staff member M had tried to have resident #44 sit at a table in the dining room to eat, and resident #44 would not stay seated to eat. During an interview on 9/13/22 at 2:07 p.m., staff member F stated resident #44 would wander through the secured unit while she ate. Staff member F said resident #44 was to have her foods cut and placed in a bowl so she could carry her food while wandering in the unit. Food was to be cut up by dietary and sent up to the unit for the resident. During an interview on 9/14/22 at 11:18 a.m., staff member I said the dietician had not make it up to the secured unit recently. Staff member I said she was not aware of any dietary supplements ordered for resident #44 and if she liked things, she would eat them. During an interview on 9/14/22 at 2:39 p.m., staff member G stated resident #44's weight loss was identified in August 2022, and it was being discussed. Staff member G said resident #44 was not on any supplements and the POA was contacted. The facility had not heard back from the POA. Staff member G said nutritional assessments should be done quarterly and annually. He would then do a word document that was submitted to the EMR. If a concern was identified, a significant change would be done in the MDS. Staff member G stated, MDS is a mess here. When we had a coordinator, they would give me a list and I would do section K. Staff member G said he would generate a weight summary report weekly from the EMR, and there would be a meeting to discuss residents at risk for weight loss. Nursing would notify the physician and put in any orders for supplements. Record review of resident #44's weight chart, showed the resident weighted 117.8 pounds on 6/21/22 and 108.2 pounds on 9/12/22. This was a 9.6-pound weight loss which resulted in a 8.15% weight loss. Supplemental addition of ensure with meals was initiated on 9/14/22. A request was made for resident #44's physician notification and physician notes on 9/12/22 and 9/14/22. No documentation was provided by the facility by the end of the survey. 4. Record review of a facility document, ED Provider Notes, dated 7/26/22, showed resident #79 was seen and evaluated in the ER for rectal bleeding. Record review of resident #79's nurses note, dated 7/26/22, showed, Resident sent back from the hospital. Wife POA decided not to do anything about bleeding and resident was sent back from hospital. Will continue to monitor. A request was made on 9/13/22 for resident #79's monitoring notes for his rectal bleeding. No notes were provided by the facility by the end of the survey. Record review of resident #79's blood pressures, showed resident #79 had multiple days of low blood pressure readings following his diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . No documentation of additional monitoring, no documentation of physician notification, or additional interventions were found in the resident's EMR. Record review of resident #79's care plan, initiation date 1/10/22, bowel and bladder were not addressed. Monitoring for rectal bleeding was not addressed in the care plan. During an interview on 9/13/22 at 1:42 p.m., staff member F said no record of follow-up monitoring for resident #79 was found. Staff member F said resident #79 should have been monitored for the rectal bleeding and any changes should have been reported to the physician. 5. During an observation on 9/12/22 at 11:23 a.m., resident #48 was wandering up and down the hall in the secured unit. Resident #48 had a kerlix dressing wrapped around her right ankle. The resident was complaining of pain and warmth to her ankle, and was looking for someone to help her. Staff member L was found by staff member M and came to assist resident #48. Staff member L donned gloves and checked resident #48's dressing to see if it was intact. Resident #48 was complaining of pain. Staff member L asked if she would like anything for the pain. Resident #48 declined any pain medication. During an interview on 9/14/22 at 12:33 p.m., staff member J stated resident #48's leg wound was present on admission. The order was to rinse the wound and change the dressing every three days, or as needed, with xeroform and kerlix. Staff member J said the wound had gotten better, but was now angry again, and the doctor had put resident #48 on [MEDICATION(S)]. Staff member J said the wound had not been cultured to her knowledge. Resident #48 was admitted on [DATE]. During an observation and interview on 9/14/22 at 1:38 p.m., staff member J changed the dressing on resident #48's right lower calf. The soiled dressing was removed, and the wound was rinsed with saline. The wound was estimated to be approximately 1.5 inches in diameter with an inflamed and reddened area around the wound. Resident #48 was complaining of pain but declined pain medication. Staff member J stated the resident should be sent to the wound clinic and did not know why it had not been done. Staff member J said no wound education on wound evaluation and treatment had been provided by the facility. Staff member J said she had not always been good about documenting because she got busy with other residents. During an interview on 9/14/22 at 1:58 p.m., staff member B said the secured unit was opened in April 2022. The facility had identified an issue with the assessment and implementation process. The facility had been working to implement the new process, but had difficulties due to staffing. Record review of resident #48's Admission MDS, with an ARD of 8/8/22, showed, In Progress. The Admission MDS had not been completed. The Medicare five-day assessment dated [DATE], showed, In Progress, and the end of part A stay dated 9/1/22 showed, In Progress. Record review of resident #48's care plan, showed focus area of chronic venous status ulcer to right calf was added on 9/12/22, after a request for documentation was made by the State Survey Agency. Review of a facility document titled, Wound Care, dated October 2010, showed: . Documentation The following information should be recorded in the resident's medical record: 1. The type of wound care given. 2. The date and time the wound care was given. 3. The position in which the resident was placed. 4. The name and title of the individual performing the wound care. 5. Any change in the resident's condition. 6. All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound. 7. How the resident tolerated the procedure. 8. Any problems or complaints made by the resident related to the procedure. 9. If the resident refused the treatment and the reason(s) why. 10. The signature and title of the person recording the data. No wound documentation was found in the facility's EMR or was provided by the facility for resident #48. During an interview on 9/12/22 at 1:21 p.m., staff member F said no one had been onsite to do MDSs since February of 2022. Staff member F said the facility did not have an MDS coordinator. Staff member F said the MDS coordinator would also initiate and revise resident care plans. During an interview on 9/13/22 at 9:46 a.m., staff member B said the completion of MDS assessments and care plans were identified as a concern in February (2022), but staffing had been an issue. Staff member B said the facility had not been able to keep an MDS coordinator on staff. Staff member B said the MDS should be used to identify care concerns for residents. Staff member B said part of an admission, annual, or significant change MDS was the completion of the CAAs (care area assessments), and this would assist in generating a person-centered care plan.

Based on interview and record review, the facility failed to ensure an effective Quality Assurance Performance Improvement (QAPI) plan and process was in place to track, monitor, analyze data, and re-evaluate their plan of action to address systemic deficiencies throughout the facility as identified below: - ensure the accurate and timely comprehensive assessments, including admission, annual, and significant changes, were completed for all residents in the facility and resulting in the neglect of care for 5 (#s 44, 48, 73, 78, and 79); (see F600) - ensure the development and implementation of comprehensive care plans were completed, to address all residents' care concerns, based on the comprehensive assessments; (see F656) - ensure revisions to resident care plans were performed in a timely manner with residents' care concerns identified; (see F657) - ensure a system was in place for consistent monitoring of resident's weights to identify severe weight loss for 3 (#s 44, 73, and 78); (see F600) - ensure nursing staff consistently performed and documented skin assessments to identify altered skin integrity related to wounds for 1 (#48); (see F600, F684) - ensure nursing staff performed the admission assessment on newly admitted residents; - ensure the Infection Preventionist provided supervision and oversight of the laundry services related to proper infection prevention and control practices; (see F880) and - ensure staffing levels were adequate to meet the needs of all the residents in the facility. (see F741) Findings include: During an interview on 9/15/22 at 9:11 a.m., staff member B stated when the State Survey Agency was in the facility in July of 2022, it was discussed how the facility had identified MDS and care plan problems in February 2022. Staff member B stated the facility had not been able to get a handle on it. During an interview on 9/15/22 at 1:31 p.m., staff member A stated the QAA committee had been meeting quarterly but would now be meeting monthly. During an interview on 9/15/22 at 1:43 p.m., staff member B stated the facility currently had a performance improvement project (PIP) in place related to the MDS problem, which had been open since February of 2022. Staff member B stated three people had been in the position of MDS coordinator since February of 2022 and a new, experienced RN had started in August of 2022. She stated they had not started the evaluation and summary of the trends for the residents' MDS. Staff member B stated herself and staff member F were involved in the project and knew they were behind. During an interview on 9/15/22 at 1:46 p.m., staff member B stated care plans had been identified as a systemic problem. She stated they started with the review of memory care plans, specifically with wander risk and the secure unit placement. Staff member B stated audits had been performed for catheter, [CONDITION(S)], and hospice care plans and they were now completed. No further evaluations of the remaining care plans had occurred at this time. During an interview on 9/15/22 at 1:51 p.m., staff member B stated they did not have a PIP in place for skin assessments. Staff member B stated wounds were an area of concern and a PIP was started in February of 2022. She stated they had an issue where nursing administration was reporting wound care had been done by the nurses, but they were not doing it. Staff member B stated these previous DONs had quit without notice. Staff member B stated they were aware of nurses not documenting their skin checks. She stated leadership did a skin sweep on residents (last performed in July of 2022) to make sure nurses were doing the skin checks. Staff member B stated they did not have a formal process for monitoring weights. She stated two weeks ago (approximately 9/1/22), staff member F had a meeting with all staff and baseline weights were performed on all the residents. During an interview on 9/15/22 at 1:57 p.m., staff member F stated baseline care plans and nursing admission assessments were to be performed by the nurse assigned to that unit. Staff member F stated nursing admission assessments were being performed sporadically and stated many of them were not being done upon admission. During an interview on 9/15/22 at 2:04 p.m., the inadequate infection control practices observed in laundry services related to proper PPE use and an established, contained, separate, soiled laundry area were explained to the group. Staff member B stated they were unaware of these identified concerns. Staff member B stated housekeeping/maintenance oversaw the laundry services, not the Infection Preventionist. During an interview on 9/15/22 at 2:09 p.m., staff member B stated the facility was working through a plan and process on all the areas discussed, except laundry services. Review of the facility's CASPER report, last updated 9/7/22, with a comparison to the CMS form 672, dated 9/13/22, showed the following inconsistencies: - Total number of residents residing in the facility was 43 on the CASPER report. The resident census documented on CMS form 672 showed 58 residents on 9/13/22, which was not due to new admissions. This difference in data showed the failure of timely assessment submissions. - Number of residents with an unplanned significant weight loss/gain was seven on the CASPER report. The facility reported on the CMS form 672 there were 0 residents identified with an unplanned significant weight loss/gain. This difference in the data showed the failure to identify changes in condition which had the likelihood of negative outcomes., and - Number of residents with pressure sores, excluding stage one, was one on the CASPER report. The facility reported on the CMS form 672 there were 4 residents identified with pressure ulcers which excluded stage one.

Based on interview, and record review, the facility failed to complete accurate Admission and Quarterly assessments for 3 (#'s 48, 49, and 73) of 6 sampled residents. This deficient practice had the potential to affect resident care and safety. Findings include: During an interview on 9/14/22 at 12:33 p.m., staff member J stated it was the admitting nurse's responsibility for completing the initial nursing assessment on new admissions. Staff member J said the admitting nurse refused to do the admission assessment for resident #49, and left it for day shift to complete. Staff member J said she was the day shift nurse and was unable to complete the assessment back in the secured unit because she was too busy out on the floor with other residents. 1. Record review of resident #49's Admission/Readmission Assessment, nursing admission assessment, showed an admitted [DATE], and an admission assessment completion date of 9/13/22, after the document was requested. Resident #49 did not have an admission nursing assessment completed to establish a baseline for directing care for resident #49. 2. A record review of resident #48's MDS showed, a Entry date of 7/26/22. A request was made for resident #48's nursing admission assessment documentation on 9/14/22. No documentation was provided by the end of the survey. Resident #48 did not have an admission nursing assessment completed to establish a baseline for directing care for resident #49. The wound on resident #49's right lower leg was not assessed for size and type to direct the care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of a facility policy, Admission Notes, dated September 2020, showed: . Preliminary resident information shall be documented upon a resident's admission to the facility. Policy Interpretation and Implementation 1. When a resident is admitted to the nursing unit, the admitting Nurse must document the following information (as each may apply) in the nurses' notes, admission form, or other appropriate place, as designated by facility protocol: a. The date and time of the resident's admission; b. The resident's age, sex, race, and marital status; c. From where the resident was admitted (i.e., hospital, home, other facility); d. Reason for the admission; e. The admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] f. The general condition of the resident upon admission; g. The time the Attending Physician was notified of the resident's admission; h. The time the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] i. Description of any lab work completed or the time specimens were sent to the lab; j. The presence of a catheter, dressings, etc.; k. The time the Dietary Department was notified of the diet order; l. The time medications were ordered from the pharmacy; m. A brief description of any disabilities (i.e., blind, deaf, [CONDITION(S)], speech impairment, paralysis, mobility, etc.); n. Any know allergies; o. Prosthesis required (i.e., glasses, dentures, hearing aid, artificial limbs, eye, etc.); p. The height and weight of the resident; q. A statement indicating that the nursing history and preliminary assessment is completed or has been started; r. Notation of any signs or symptoms of infectious or communicable disease; s. Notation as to whether or not advance directives apply; and t. The signature and title of the person recording the data. 3. Review of resident #73's Medicare- 5 Day MDS, with an ARD of 1/3/22, Section K, showed the resident weighed 204 pounds. Review of resident #73's Quarterly MDS, with an ARD of 8/23/22, Section K, showed the resident weighed 164 pounds, and the section was marked unknown if resident #73 had a weight loss. Resident #73 had lost 40 pounds or 19.61%, an insidious, severe weight loss between the 5 day MDS and the Quarterly MDS. Facility staff failed to identify the severe weight loss for resident #73 on his Quarterly MDS, with an ARD of 8/23/22. During an interview on 9/13/22 at 9:46 a.m., staff member B said MDS assessments were identified as a concern in February (2022), and the facility was trying to employ an MDS coordinator. During an interview on 9/14/22 at 2:38 p.m., staff member G said he completed section K of the MDS. During an inteview on 9/15/22 at 9:16 a.m., staff member B said she understood if facility staff failed to complete the assessment process for a resident facility staff would not be able to indentify and provide the care needed for the residents residing in the facility.

Based on interview and record review, the facility neglected to revise care plans to ensure a person-centered care plan with appropriate goals and interventions for a severe weight loss was in place for 2 (#s 73 & 78) of 6 sampled residents; and failed to ensure appropriate focus areas for anxiety and side effects of an anticoagulant medication were in place for 1 (#34) of 6 sampled residents. Findings include: 1. Review of resident #73's weight record, from 1/9/22 to 6/23/22, showed, the resident had lost 40 pounds in six months. This was a severe weight loss of 19.7%. Review of resident #73's Nutrition Care Plan, date initiated 11/24/21, and date revised 11/24/21, showed: - Focus -Nutrition: Potential for alteration in nutritional status r/t (related to) history of [CONDITION(S)], upper and lower dentures (currently fit with concerns). - Goal: - Maintain weight without significant weight change through the review period. Date initiated 11/24/21, revised on 8/8/22, with a target date of 11/8/22. - Interventions/Tasks: - 2 Liter Fluid restriction. Date Initiated: 11/24/2021, - Allow enough time for the resident eat, date initiated 11/24/21, - Boost or Ensure BID (twice a day), prefers strawberry flavor best, date initiated 1/5/22, - Dietitian (sic) consults prn (as needed), date initiated 11/24/21, - Encourage resident to eat 75-100%, date initiated 11/24/21, - Offer sandwich and additional snacks daily to ensure adequate protein and calorie intakes, dated initiated 12/29/21, - Offer substitute if less that 50% of meal consumed, date initiated 11/24/21, and - Provide regular diet, date initiated 11/24/21, and Weigh per facility order, date initiated 11/24/21. Resident #73's severe weight loss was not identified by facility staff. Facility staff neglected to update and implement a person-centered care plan with measurable goals and interventions for resident #73's severe weight loss. During an interview on 9/15/22 at 3:30 p.m., staff member V said there was a sign posted on the wall, by the nursing station, to tell staff to give residents a supplement if they only ate a percentage of their meals. Staff member V said she did not have access to resident care plans in the EMR. 2. Review of resident #78's monthly weight record, from 5/10/22 to 6/23/22, showed, the resident had a weight loss of 14 pounds in a month. This was a severe loss of 6.74%. Review of resident #78's care plan failed to show a nutrition care plan with focus, goals, and interventions to address the severe weight loss for the resident. Resident #78's severe weight loss was not identified by facility staff. During an interview on 9/14/22 at 2:38 p.m., staff member G said he ran weight reports, showing 30, 60, and 90 day weights for the residents with trending of weight losses or gains for the nutrition at risk team. Staff member G said the nutrition at risk team had not met in a long time. Staff member G said he completed Section K of the MDS, and he wrote the nutrition care plans for the residents. 2. Review of resident #34's MAR, printed on 9/15/22 at 10:19 a.m., showed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of resident #34's MAR, printed on 9/15/22 at 10:19 a.m., showed: - [MEDICATION(S)] tablet 20 mg, to be given by mouth, three times a day, for Anxiety Disorder, started on 5/5/22, and - [MEDICATION(S)] tablet 5 mg, to be given by mouth, one time a day, for Pulmonary Embolism, started on 8/1/22. Review of resident #34's care plan, as of 9/12/22, did not show any focus areas, goals, or interventions for Anxiety or possible bleeding side effects for the anticoagulant medication ([MEDICATION(S)]). During an interview on 9/12/22 at 1:21 p.m., staff member F stated no staff had been onsite to complete the MDS's since February of 2022. Staff member F stated the same staff would also update the care plans, and since February it had been spotty.

Based on observation, interview, and record review, the facility failed to complete assessment and documentation for wounds present on admission for 2 residents (#s 48 and 52) of 2 sampled residents; and failed to complete the assessments and monitoring for rectal bleeding in 1 (#79) of 1 sampled resident. This deficient practice led to the failure in the facility and staff providing the quality of care residents needed. Findings include: 1. During an observation on 9/12/22 at 11:23 a.m., resident #48 was wandering up and down the hall in the secured unit. Resident #48 had a kerlix dressing wrapped around her right ankle. The resident was complaining of pain and warmth to her ankle and was looking for someone to help her with her leg and to help her to the bathroom. During an interview on 9/14/22 at 12:33 p.m., staff member J stated resident #48's leg wound was present on admission. The order was to rinse the wound and change the dressing every three days, or as needed, with xeroform and kerlix. Staff member J said the wound had gotten better but was now angry again and the doctor put resident #48 on [MEDICATION(S)]. Staff member J said the wound had not been cultured to her knowledge. Resident #48 was admitted on [DATE]. During an observation and interview on 9/14/22 at 1:38 p.m., staff member J changed the dressing on resident #48's right lower calf. The soiled dressing was removed, and the wound was rinsed with saline. The wound was estimated to be approximately 1.5 inches in diameter with an inflamed and reddened area around the wound. Resident #48 was complaining of pain. Staff member J stated the resident should have been sent to the wound clinic and did not know why it had not been done. Staff member J said no wound education on wound evaluation and treatment had been completed by the facility. Staff member J said she was not always good about documenting wound care, because she gets busy with other residents. During an interview on 9/14/22 at 1:58 p.m., staff member B said the secured unit was opened in April 2022. The facility had identified an issue with the resident assessment process. The facility had been working to implement a new process but have had difficulties due to staffing issues. Record review of resident # 48's admission MDS showed an ARD of 8/8/22 showed in progress. The Admission MDS dated [DATE], had not been completed. The Medicare five-day assessment dated [DATE], showed In Progress, and the end of part A stay dated 9/1/22 showed In Progress. The facility had failed to complete assessments that would identify care areas specific to resident #48. Record review of resident #48's care plan showed focus area of chronic venous status ulcer to right calf was added on 9/12/22, after a request for documentation was made by the survey team. The lack of an admission assessment failed to identify the need for directed wound care on resident #48's care plan. 2. During an observation and interview on 9/14/22 at 11:27 a.m., resident #52 was complaining of pain in his right lower extremity and right toe pain. Resident #52 said he had the wound on admission on 8/2/22. Staff member J assessed resident #52's dressing, it was clean, dry, and intact and had been changed the previous evening. Staff member J left the dressing in place. Staff member J examined resident #52's right great toe and found no redness or [CONDITION(S)]. Resident #52 said he had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #52 declined the need for pain medication. Record review of resident #52's EMR showed no documentation of weekly skin checks were performed since admission on 8/2/22. A weekly skin check was performed on 9/15/22 after a request was made by the State Survey Agency. A request was made on 9/15/22 for resident #52's history and physical and physician notes for wound evaluations. No documentation was provided by the end of the survey. During an interview on 9/14/22 at 1:58 p.m., staff member B said the secured unit was opened in April 2022. The facility had identified an issue with the assessment process. The facility had been working to implement of a new process but had difficulties due to staffing issues. Review of a facility document, Wound Care, dated October 2010, showed: . Documentation The following information should be recorded in the resident's medical record: 1. The type of wound care given. 2. The date and time the wound care was given. 3. The position in which the resident was placed. 4. The name and title of the individual performing the wound care. 5. Any change in the resident's condition. 6. All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound. 7. How the resident tolerated the procedure. 8. Any problems or complaints made by the resident related to the procedure. 9. If the resident refused the treatment and the reason(s) why. 10. The signature and title of the person recording the data. No wound documentation was found in the facility EMR or provided by the facility for resident #48 and #52. 3. Record review of a facility document, ED Provider Notes, dated 7/26/22, showed resident #79 was seen and evaluated in the ER for rectal bleeding. Record review of resident #79's nurses note, dated 7/26/22, showed, Resident sent back from the hospital. Wife POA decided not to do anything about bleeding and resident was sent back from hospital. Will continue to monitor. A request was made on 9/13/22 for resident #79's monitoring notes for his rectal bleeding. No notes were provided by the facility by the end of survey. Record review of resident #79's blood pressures showed resident #79 had multiple days of low blood pressure readings following his diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . No documentation of additional monitoring, physician notification, or interventions were found. Record review of resident #79's care plan, initiation date 1/10/22, bowel and bladder were not addressed. Monitoring for rectal bleeding was not addressed in the care plan. During an interview on 9/13/22 at 1:42 p.m., staff member F said no record of follow-up monitoring for resident #79 was found. Staff member F said resident #79 should have been monitored for the rectal bleeding and any changes should have been reported to the physician.

Based on observation, interview, and record review, facility staff neglected to identify, and re-assess nutritional needs for severe weight loss for 3 (#s 44, 73 and 78) of 5 sampled residents. Findings include: 1. During an interview on 9/14/22 at 10:33 a.m., NF2 said expressed concerns about resident #73 not eating his meals. Review of resident #73's monthly weight record from January 2022 to June 2022 showed: - 1/9/22 230.0 pounds, - 1/23/22 202.6 pounds, - 2/14/22 177.6 pounds, - 3/20/22 167.8 pounds, - 3/22/22 171.8 pounds, - 3/28/22 170.8 pounds, - 4/4/22 172.0 pounds, - 5/16/22 171.0 pounds, and - 6/23/22 163.0 pounds. Resident #73 lost 40 pounds from 1/9/22 to 6/23/22. This was a severe weight loss of 19.7 % in six months. Facility staff neglected to identify an insidious, severe weight loss for the resident. Review of resident #73's nutritional assessments showed one, dated 11/24/21, was completed at the time of the resident's admission to the facility. A second nutritional assessment, dated 9/14/22, was provided by facility staff on 9/15/22. Review of resident #73's EMR failed to show any other nutritional assessments had been completed between 11/24/21 and 9/14/22. Review of resident #73's nursing progress notes, dated 6/20/22 to 9/13/22, failed to show the facility staff had identified a severe weight loss for the resident. Review of resident #73's nursing progress notes, dated 6/20/22 to 9/13/22, failed to show the facility had notified the resident's physician of an insidious, severe weight loss. Review of resident #73's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician ordered an increase in resident #73's supplements. Review of resident #73's Nutrition Care Plan, date initiated 11/24/21, and date revised 11/24/21, showed: - Focus - Nutrition: Potential for alteration in nutritional status r/t (related to) history of [CONDITION(S)], upper and lower dentures (currently fit with concerns). - Goal: - Maintain weight without significant weight change through the review period. Date initiated 11/24/21, revised on 8/8/22, with a target date of 11/8/22. - Interventions/Tasks: - 2 Liter Fluid restriction. Date Initiated: 11/24/2021, - Allow enough time for the resident eat, date initiated 11/24/21, - Boost or Ensure BID (twice a day), prefers strawberry flavor best, date initiated 1/5/22, - Dietitian (sic) consults prn (as needed), date initiated 11/24/21, - Encourage resident to eat 75-100% date initiated 11/24/21, - Offer sandwich and additional snacks daily to ensure adequate protein and calorie intakes, dated initiated 12/29/21, - Offer substitute if less that 50% of meal consumed, date initiated 11/24/21, and - Provide regular diet, date initiated 11/24/21, and Weigh per facility order, date initiated 11/24/21. Resident #73's nutrition care plan was not revised with new focus, goals, or interventions to address his insidious, severe weight loss until 9/14/22. 2. Review of resident #78's monthly weight record showed the resident weighed 207.8 pounds on 5/10/22, and weighed 193.8 pounds on 6/23/22. That was a weight loss of 14 pounds or 6.74% in one month. That was a severe weight loss not identified by the facility. Review of resident #78's EMR failed to show a nutrition assessment had been completed for this resident. A nutritional assessment, dated 9/14/22, was provided by facility staff on 9/15/22. Review of resident #78's EMR, from 6/20/22 to 9/13/22, failed to show the resident's physician had been notified of the resident's severe weight loss. Review of resident #78's nursing progress notes, dated 6/20/22 to 9/13/22, failed to show facility staff had identified a severe weight loss for the resident. Review of resident #78's care plan, date initiated 5/10/22, and revised on 5/17/22, failed to show nutritional concerns had been identified for the resident. During an interview on 9/14/22 at 2:38 p.m., staff member G said nutritional assessments were supposed to be completed quarterly, annually, and with a significant change. Staff member G said he would complete a nutritional assessment at the time of a resident's admission. Staff member G said he completed Section K of the MDS, and in the normal course of things he would write the nutritional care plan. Staff member G said in the past he had gotten notifications from the MDS coordinator when the MDSs, nutritional assessments, and care plans for residents were due. Staff member G said the facility did not have an MDS coordinator at the time and there had not been one for quite some time. Staff member G said the facility used to have a nutrition at risk team that met weekly to review resident weights to check for resident weight losses or weight gains. Staff member G said that team had not met in a long time. Staff member G said for the nutrition at risk meetings he would run a weight summary report, and it would show if residents triggered for weight loss or gain for the last 30, 60, and 90 days. Staff member G said the facility provided various nutritional liquid drinks to residents that did not complete their meals or had weight loss, but these would be ordered by the physician after discussion with staff. Staff member G said the facility had not provided fortified diets to at risk residents in the past, but it was something facility staff had recently discussed. 3. During an observation on 9/12/22 at 12:31 p.m., resident #44 was seated in the secured unit dining room. A tray of food was placed in front of resident #44, two full sized corn dogs were in a bowl, not sliced. Resident #44 picked up one of the corn dogs and began hitting her left cheek with the corn dog. She then became very vocal, placed the corn dog on the meal tray and got up. Resident #44 then wandered out of the dining area and up and down the halls of the secured unit. She was very vocal, repeating the same words over and over, and laughing. She returned to the table containing her meal tray multiple times throughout the dining observation. She did not take a bite of the corn dog and did not eat any of the food from the meal tray. Staff member M tried multiple times, without success, to redirect resident #44 back to the table and to eat her meal. During an interview on 9/13/22 at 12:59 p.m., staff member M said resident #44 would wander through the unit while she ate. Staff member M had tried to get resident #44 to sit at a table in the dining room to eat. Resident #44 would not stay seated to eat. During an interview on 9/13/22 at 2:07 p.m., staff member F stated resident #44 would wander throughout the secured unit while she ate. Staff member F said resident #44 was to have her foods cut and placed in a bowl so she could carry it while wandering in the unit. During an interview on 9/14/22, at 11:18 a.m., staff member I said she was not aware of any supplements dietary supplements ordered for resident #44 and if she likes things, she would eat them. Staff member I said resident #44 had not been eating well for the last month. She had not reported it to nursing staff. During an interview on 9/14/22 at 2:39 p.m., staff member G stated resident #44's weight loss was identified in August, and it was being discussed. Staff member G said resident #44 was not on any supplements and the POA was contacted. The facility had not heard back from the POA. If a concern was identified, a significant change would be done in the MDS. Record review of resident #44's weight chart showed the resident weighted 117.8 pounds on 6/21/22 and 108.2 pounds on 9/12/22. This was a severe weight loss that resulted in a 8.15% weight loss. A request was made for resident #44's physician notification and physician notes on 9/12/22 and 9/14/22. No documentation was provided by the facility by the end of the survey. Review of a facility document, Nutritional Assessment, dated 9/14/22, showed: . Nutritional history: Weight, diet, dining habits: Resident intake remains variable between 25-75% of meals as charted. Able to feed self at most times with minimal assistance. Weight has significantly decreased over 6 months with weight loss of 12.7 lbs. or 10.4%. Resident ordered finger foods and she typically will eat while pacing. . Summary: Resident has had significant weight loss of 10.4% over 6 months. Switched to finger foods at RN's request due to consistently moving while eating and resident unable to intake most meals requiring utensils. All food is ordered to be served in bowls as resident is able to carry food and eat while pacing. Resident reviewed at nutrition at risk meeting on this date, intervention of ensure with meals initiated. Review of resident #44's care plan with an initiation date of 11/9/19 and revision date of 8/22/22, under focus area showed: Nutrition: Potential for alteration in nutritional status . .At risk for Inadequate Nutrition r/t: history of variable po intake; dementia dx; constant movement/pacing. . Goal: Resident will consume 75% or greater at meal times. Resident will maintain weight at 120lbs +/- 10 lbs. Revision on 8/22/22 . .Interventions: -All meals to be served in bowls, cut up meat, (resident #44) prefers finger foods if available. Initiated: 4/19/21 . .Monitor for changes in nutritional status (change in po intake ability, feed self, unplanned wt loss/gain, abnormal labs) and report to RD/MD as indicated. Initiated 11/9/2019 . Resident #44's care plan showed resident #44 was to receive her meals cut up and in bowls and any change in intake was to be reported to the registered dietician and the physician. Resident #44's food was not always cut up and her decrease in intake was not reported to the registered dietician or the physician. Review of the facility's policy Weight Assessment and Intervention, revised on September 2008, showed: - Weight Assessment- . 5. The Dietitian (sic) will review the unit Weight Record by the 15th of the month to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for significant weight change has been met. 6. The threshold for significant unplanned and undesired weight loss will be based on the following criteria [where percentage of body weight loss = (usual weight - actual weight) / (usual weight) x 100]: a. 1 month - 5% weight loss is significant; greater that 5% is severe. b. 3 months - 7.5% weight loss is significant; greater than 7.5% is severe. c. 6 months - 10% weight loss is significant; great than 10% is severe. - Care Planning- 1. Care planning for weight loss or impaired nutrition will be a multidisciplinary effort and will include the Physician, nursing staff, the Dietitian (sic), the Consultant Pharmacist, and the resident or resident's legal surrogate. 2. Individualized care plans shall address, to the extent possible: a. The identified causes of weight loss; b. Goals and benchmarks for improvement; and c. Time frames and parameters for monitoring and reassessment. - Interventions- 1. Interventions for undesirable weight loss shall be based on careful consideration of the following: a. Resident choice and preferences; b. Nutrition and hydration needs of the resident; c. Functional factors that may inhibit independent eating; d. Environmental factors that may inhibit appetite or desire to participate in meals; e. Chewing and swallowing abnormalities and the need for diet modifications; f. Medications that may interfere with appetite, chewing, swallowing, or digestion; g. The use of supplementation and/or feeding tubes; and h. End of life decisions and advance directives.

Based on interview and record review, the facility administrative staff, who were identified and participated in the oversight of the facility QAPI program and daily operations, failed to ensure a system and staff were in place for the timely completion of resident MDS assessments, for all residents in the facility. This failure led to the lack of the development, implementation, and revision of comprehensive care plans to address residents' care needs; and failed to identify these quality of care, system failures and act on them timely for correction. These combined deficient practices placed all 58 residents residing in the facility at risk of harm. Findings include: During the QAPI interview on 9/15/22, which started at 1:29 p.m., administrative staff members A, B, F, S, and T were present. During the interview, the administrative staff members stated they were aware of the various areas of concern and identified deficiencies, except for the infection control problems in laundry services. The administrative team failed to have an effective action plan and system process in place to track, monitor, analyze data, and re-evaluate their plan of action to address these systemic deficiencies throughout the facility. Due to the administrative team's failure to act upon and correct these areas of concerns, numerous areas of noncompliance, to include at harm level, which included (not all inclusive): - F600 - Free from Abuse and Neglect, - F636 - Comprehensive Assessments & Timing, - F641 - Accuracy of Assessments - F656 - Develop/Implement Comprehensive Care Plan, - F657 - Care Plan Timing and Revision, - F684 - Quality of Care, - F692 - Nutrition/Hydration Status Maintenance, - F741 - Sufficient/competent Staff -Behav Health Needs, and - F865 - QAPI Programming - F880 - Infection Prevention & Control. During an interview on 9/15/22 at 2:09 p.m., staff member B stated turnover in staffing was their biggest problem. Staff member B stated the turnover of staff included department managers also. Staff member B stated staff member T was added to the administrative team as the new administrator. During an interview on 9/15/22 at 2:11 p.m., staff member S stated because of the staff turnover, it had placed a hardship on the facility. During an interview on 9/15/22 at 2:14 p.m., staff member S stated the problems at the facility were not due to lack of oversight, but were due to the lack of good leadership at the department level.

Based on interview and record review, the facility failed to prevent, identify, and follow Wound Clinic treatment orders for an Unstageable pressure injury on the right heel, resulting in a below-the-knee amputation; and failed to identify and treat necrotic pressure injuries on the sacrum, for 1 (#6) of 1 sampled resident. Findings include: 1. Review of resident #6's August 2021 TAR showed two weekly skin checks were missed on 8/11/21 and 8/18/21. Review of resident #6's Physician Note, dated 8/18/21, showed the resident had a heel wound (right) and would go to the Wound Clinic. Review of resident #6's Nursing Progress Notes, from 7/2021 through 9/2021, did not include information regarding the (right) heel wound, or how it was identified by the physician. During a phone interview on 1/5/22 at 12:44 p.m., NF2 stated the wound on resident #6's heel had started as a small blister. She stated she did not know if there were any pressure reducing interventions in place for resident #6, prior to the identification of the blister. Review of resident #6's Nursing Progress Notes and Weekly Skin Checks, from 7/2021 through 9/2021, did not identify a blister on resident #6's right heel. Review of resident #6's Wound Clinic note, dated 8/19/21, showed the (right) heel was black eschar. The wound clinic order showed to use [MEDICATION(S)] gauze and light kerlix. During an interview on 1/4/22 at 10:50 a.m., staff member H stated she did not know much about resident #6's heel pressure sore. She stated the heel was a tough spot to have a wound vac placed. She stated resident #6's bottom looked worse after he returned from the hospital on 11/19/21. During a phone interview on 1/5/22 at 9:54 a.m., NF4 stated the wound clinic chose to keep eschar in place using the [MEDICATION(S)] gauze. Review of resident #6's Nursing Progress Note, dated 8/22/21, showed the resident was seen at the wound clinic but had no dressing change orders, So will put xeroform covered with border dressing. Review of resident #6's Weekly Skin check, dated 8/25/21, showed right heel- 5.5 x 3 cm. No description of the wound was included. Review of resident #6's Wound Clinic note, dated 8/26/21, showed Pt did not have a [MEDICATION(S)] dressing on his heel to help dry this out and keep the wound stable. Instead he had a xeroform over his heel which made his stable eschar no longer stable. This was deroofed today and will now need a wound vac authorized by CCR SNF. Cleanse wound with normal saline and a thin layer of [MEDICATION(S)], then foam dressing. Please authorize wound vac for his next wound clinic appt on 9/9/21. Review of resident #6's August 2021 TAR showed this order was not implemented. During an interview on 1/5/22 at 9:10 a.m., staff member H stated NF2 was responsible for wound care, but was no longer working at the facility. She stated wound clinic orders got missed because the paper work was given to staff member Q for scheduling the next appointments. She also stated the nurses in the facility had not been provided training on the use of the wound vac. Review of resident #6's Nursing Progress Note, dated 8/26/21 showed, No orders received from wound clinic thus far. New dressing applied to lower right leg. Review of resident #6's Weekly Skin Check, dated 9/1/21, showed the area to the right heel was debrided last week at wound clinic. No description of the wound was included in the skin check. Review of resident #6's Nursing Progress Note, dated 9/9/21, showed the Resident returned with wound vac to right heel, awaiting order from wound clinic. Review of resident #6's Wound Clinic note, dated 9/9/21, showed orders for black foam, skin prep, apply negative pressure wound therapy to right heel. Review of resident #6's September 2021 TAR, dated 9/11/21, showed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The order did not include 'wound vac.' The wound vac was initiated on 9/14/21, and not 9/11/21. Review of resident #6's Nursing Progress Note, dated 10/9/21, showed the resident was found to not have the wound vac applied. The resident stated he had removed it several days ago and was told not to reapply it by the wound clinic. He did agree to a dressing change with an alginate/sterile dressing. Review of resident #6's TAR, dated 10/9/21, did not reflect this dressing change. Review of resident #6's Wound Clinic note, dated 10/14/21, showed the wound vac was to be discontinued. The new order was for lodafoam, and was sent to the facility with the patient. Review of resident #6's Nursing Progress note, dated 10/14/21, showed the resident returned from wound clinic with a new dressing on right heel, no new orders received yet. Review of resident #6's Physician orders, dated 10/18/21, showed, Cleanse wound with NS, lodafoam inserted to wound, apply ABD and kerlix. Review of resident #6's October 2021 TAR showed the wound vac and dressing change were not discontinued, and nursing staff continued to sign the TAR showing the treatment was being completed until 10/30/21. The new dressing change from 10/18/21 was not carried over to the November 2021 TAR. Review of resident #6's November 2021 TAR showed a dressing change order dated 11/22/21; Change every other day, clean with NS, apply ABD, wrap with kerlix. The order did not specify what the dressing change should include, as in the lodafoam. It did not include the site of the wound. The TAR showed only one skin check was completed that month. Review of resident #6's Weekly Skin Check, dated 10/20/21, showed the heel pressure injury was bigger at 6.5 x 3.5 x 1 cm depth, with yellow slough in the middle. The Skin Check did not include the pressure ulcer Stage (severity classification). Review of resident #6's Nursing Progress Notes, dated 10/23/21, showed the wound dressing was changed and the wound had a 'strong smell of rotting flesh/ammonia.' Review of resident #6's wound clinic note, dated 10/25/21, showed, Dressing on patients heel was not appropriate. He had [MEDICATION(S)] and silicone bordered foam that was heavily saturated with significant odor present. Will switch order to [MEDICATION(S)] gauze, this will need to be done daily. Review of resident #6's Physician orders, October 2021 TAR, and Nursing Progress Notes, showed the order change from the wound clinic on 10/25/21 was not implemented. Review of resident #6's Nursing Progress Note, dated 11/8/21, showed the resident's wound was necrotic, foul smelling and pus flowing. The provider requested a picture of the wound, and believed the extremity needed to be amputated. Review of resident #6's Nursing Progress Note, dated 11/9/21, showed the resident was admitted to the hospital for a right below-the-knee amputation. Review of resident #6's care plan did not include the right heel pressure injury, the use of the wound vac for treatment, dressing changes, or the interventions for the resident to wear a green off-loading boot, and to prevent the heel from getting wet in the shower. 2. Review of resident #6's Wound Clinic note, dated 10/7/21, showed the resident had an 8 x 8 Deep Tissue Injury on his sacrum, and would need an off loading cushion to protect this from worsening. Review of resident #6's Weekly Skin Check, dated 10/20/21, did not show the resident had a pressure injury to his sacrum. Review of resident #6's Wound Clinic note, dated 10/25/21, showed the resident now had a Stage II wound on his sacrum. Today his [seat cushion] in his chair is completely flat. Review of resident #6's Weekly Skin Check, dated 10/27/21, noted an '8 x 8 wound with yellow slough' to the sacrum. Review of resident #6's After Visit Summary from the hospital discharge, dated 11/19/21, showed dressing to sacrum - [MEDICATION(S)] to necrotic areas. Review of resident #6's November 2021 TAR did not include the physician treatment order. Review of resident #6's Weekly Skin Checks showed no skin checks were provided/documented by the facility after 10/27/21. Review of resident #6's November 2021 TAR did not include sacrum wound care until 11/22/21. Review of resident #6's December 2021 TAR showed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The wound dressing change was to occur every Monday, Wednesday, and Friday. The dressing changes were not completed seven days out of the month of December. During an interview on 1/4/21 at 1:30 p.m., NF1 stated resident #6 had complained he was not getting turned every two hours. Sometimes he stated it was 12 hours of no repositioning. NF1 stated on 11/29/21 she had requested the facility keep a log of resident #6's turning schedule with initials from staff, and refusals from the resident. NF2 had told NF1 the resident refused to be turned. The turning schedule was found in resident #6's room and showed a log that was initiated on 12/13/21. One position change was initialed on 12/13/21, nine out of 12 position changes were initialed on 12/14/21; one position change was initialed on 12/15/21. Days 16 through the 23rd were all incomplete. The turning log did not continue past the 23rd of December, 2021. Review of resident #6's care plan, dated 11/26/21, showed the resident was readmitted to the facility from the hospital with pressure areas to the buttocks. It did not include the Stages of the pressure areas (severity classification), or descriptions. Review of resident #6's Wound Clinic notes, dated 10/7/21 and 10/25/21, showed the buttocks/sacral pressure ulcer had originated on 10/7/21. Review of resident #6's Nursing Progress Note, dated 12/31/21, showed the resident was sent to the hospital with possible aspiration pneumonia, and could not be interviewed.

Based on observation and interview, the facility failed to protect residents from abuse by staff members for 1 (#10) of 18 sampled residents. This failure caused ongoing feelings of resident #10 being scared and had the potential to affect all residents residing in the facility. Findings include: During an observation on 7/19/21 at 9:04 a.m., in the hall across from the nursing station, resident #10 told staff member E that she had been mistreated on Friday, 7/16/21, and forced to stay in bed. She stated she had woke up and wanted to get out of bed, and staff members G and O told her no. Staff members G and O said she had to stay in her bed and that she was not going to get any dinner. Staff member E told resident #10 he would fill out a grievance and inform staff member B. During an interview on 7/19/21 at 1:32 p.m., resident #10 stated staff members G and O told her they were not going to get her up after her nap and they were not going to bring her supper. Resident #10 said she was scared and she had called her son, and told him about this when it happened. Resident #10 stated her son had to call the facility in order for her to get supper. During an interview and observation on 7/20/21 at 7:30 a.m., resident #10 was sitting in the hall across from the nursing station. Resident #10 stated staff members G and O were there and she was scared. She stated staff members E and B had not talked to her yet. During an interview on 7/20/21 at 8:15 a.m., staff member B stated resident #10 told her yesterday about the incident. She stated resident #10 told her the two staff members would not let her get up. Staff member B stated she was going to talk with staff members G and O that day as they had not been on shift. She stated the facility had not started the investigation. During an observation on 7/20/21 at 8:24 a.m., resident #10 was sitting in the dining room finishing her breakfast. Staff member O was in the same dining room assisting another resident with her meal. During an interview on 7/20/21 at 8:28 a.m., resident #10 stated she was afraid that staff members G and O were going to retaliate against her because she had said she had been mistreated. The facility failed to protect resident #10 from alleged abuse. The facility was notified of the allegation on 7/19/21 at 9:04 a.m., and failed to act on the allegation. The facility allowed staff members G and O to work with resident #10 on 7/20/21, without an investigation or interviewing resident #10 or other residents on the unit about abuse. Resident #10 continued to voice to the surveyor that she was scared.

Based on observation, interview, and record review, the facility failed to prevent one Stage 4 pressure ulcer for 1 (# 2); one Stage 2 pressure ulcer for 1 (#6); and one Stage 2 pressure ulcer for 1 (#10), of 17 sampled residents. All of these pressure ulcers, which may have been avoidable, developed during the residents' stays in the facility. Findings include: A. During an interview on 3/2/20 at 4:15 p.m., resident #2 stated she developed a Stage 4 pressure ulcer in the facility a few months ago. Resident #2 stated staff had not been turning and repositioning her prior to the development of the ulcer, and she felt the ulcer could have been avoided if she had been turned and repositioned appropriately. During an interview on 3/3/20 at 2:42 p.m., staff member B stated she was not working in the facility when resident #2 first developed the pressure ulcer in October of 2019. Staff member B stated staff had started turning and repositioning in December of 2019. During an interview on 3/4/20 at 9:28 a.m., staff member P stated she thought resident #2's pressure ulcer developed in the facility because she would sit in her wheelchair for several hours at a time. Staff member P said staff had been much better about turning and repositioning resident #2 recently. During an interview on 3/4/20 at 10:15 a.m., resident #2 stated her pressure ulcer had caused her to stay in bed more often. Resident #2 stated she could only be up out of bed and in her chair for one hour at a time, and her mood had been bad because of that. During an interview on 3/4/20 at 6:45 p.m., staff member M stated she was concerned about resident #2's skin integrity. Staff member M stated she had asked the CNAs to put her to bed first after dinner, so she did not have to stay in her chair for more than an hour at a time (to prevent skin breakdown). Staff member M stated CNAs have been too busy to put her to bed right away, and so resident #2 has had to sit in her wheelchair for hours after dinner. During an interview on 3/5/20 at 12:55 p.m., staff member T stated pressure ulcers were a common issue in nursing homes, especially for residents who rely on staff for mobility, such as resident #2. Review of the CNA Kardex, under Turning and Repositioning, which showed how frequently resident #2 was turned and repositioned, which reflected resident #2 was turned and repositioned every 2 hours for the following: -65% of the time in March of 2020; -48% of the time in February of 2020; and -60% of the time in January of 2020. There was no documentation in the Kardex showing resident #2 had refused care. Review of Nursing Progress Notes, for resident #2, from October-November of 2019 showed the resident's wound developed sometime between late October and early November of 2019. The wound continued to deteriorate throughout November and December of 2019. One Nursing Note, dated 12/8/19, showed, Resident's wound on right gluteal fold continues to deteriorate. Noted that a second tunnel is in wound bed .(medical provider) ordered her to be sent to the Wound Clinic. B. During an interview on 3/4/20 at 8:45 a.m., resident #6 stated he had to wait thirty minutes to one hour to be assisted into or out of bed, or to the restroom. During an interview on 3/4/20 at 9:12 a.m., staff member P stated she had observed resident #6 scooting around in his wheelchair, which she thought may have contributed to his recent skin breakdown. During an interview on 3/5/20 at 9:30 a.m., staff member S stated she had concerns about residents who rely on staff for positioning and mobility because the facility did not have sufficient staffing to get (residents) up and down so they end up in the same positions for long periods of time, which can negatively affect skin integrity. Review of resident #6's care plan, dated 1/3/20, showed resident #6 relied on his wheelchair for locomotion, and was at a risk for skin breakdown related to incontinence. The intervention for this goal was turning/repositioning every 2-3 hours. Review of resident #6's skin assessment, dated 2/28/20, showed: new buttock abrasion on the upper right side, in addition to coccyx area red with a 0.5 cm diameter superficial open area. The assessment also noted a superficial open area (on the left buttock) 1.3 cm x 0.6 cm which is surrounded by a 6.2 x 4.5 cm red area that blanches to touch. C. During an interview on 3/5/20 at 7:35 a.m. resident #10 stated he thought he had a sore on his buttocks because it felt painful. During an observation on 3/5/20 at 9:10 a.m., staff members S and C provided skin care for resident #10. As resident #10 rolled over to his left side, staff member S noted a 1 cm circular opening on his coccyx. Staff member S provided A&D ointment to the area. During an interview on 3/5/20 at 9:15 a.m., staff member C stated she would notify the medical provider about the new skin breakdown, and for the meantime, would continue to apply A&D ointment to the area. Review of resident #10's care plan, dated 2/12/20, showed: risk for impaired skin integrity related to limited mobility. Refer to 725-Sufficient Staffing

Based on interview and record review, the facility failed to prevent an elopement for 1 (#13) and the resident had a [DIAGNOSES REDACTED].#7) of 17 sampled residents. Findings include: A. During an interview on 3/3/20 at 7:45 a.m., staff member L stated resident #13 had been discharged from the facility and had eloped during her stay in January of 2020. Staff member L stated resident #13 had a Wanderguard on her wrist when she eloped, and was residing on hall A (not the memory care unit) when she walked out the front doors with her walker. Staff member L explained staff had found resident #13 on the other side of the building, which was concerning to her, because resident #13 had a dementia diagnosis. Staff member L stated resident #13 was likely outside for 20-30 minutes in below freezing temperatures. Staff member L stated the facility decided to move resident #13 to the memory care unit two or three days following the incident. During an interview on 3/3/20 at 8:00 a.m., staff member B stated resident #13's elopement occurred during the night shift, and she was missing for about 15 minutes before staff found her in the courtyard towards the back of the building. Staff member B stated a Wanderguard had been placed on resident #13 the morning of the elopement. Staff member B explained staff determined resident #13 had walked out of the building into the courtyard from a side door, not the front doors; however, the Wanderguard alarm went off at the front doors only. Staff member B explained there was not a Wanderguard alarm system on the side door that led out to the courtyard. During an interview on 3/3/20 at 9:00 a.m., staff member B stated resident #13 had admitted to the facility on [DATE], and eloped on 1/29/20 during the night shift. Staff member B stated resident #13 was not mobile her first few days in the facility; however, she became progressively more mobile throughout her first week and would wander the halls with her walker. Staff member B stated resident #13 had not triggered for a elopement risk evaluation when she first admitted to the facility. Staff member B stated resident #13 did not seem to be exit seeking, but she was confused and did have a dementia diagnosis. Staff member B stated a Wanderguard was placed on resident #13 on 1/29/20 in the morning. Staff member B added that resident #13 did not appear to be anxious or angry, But she did find a door and go out. During an interview on 3/4/20 at 11:26 a.m., staff member A stated resident #13 had not been exhibiting any concerning behaviors that would have led staff to believe she was an elopement risk. Staff member A then remembered a Wanderguard had been placed the morning of the elopement, 1/29/20, and stated, (Resident #13) must have had wandering behaviors before that (day) then. Staff member A stated staff had met to discuss the incident and determined that, because the alarm went off at the front doors (instead of the side door where the elopement happened), and staff did not see anyone at the front doors, they turned off the alarm, instead of looking for the resident. Staff member A stated staff confirmed the Wanderguard system was functioning the next day. To summarize, the facility failed to complete an elopement risk assessment prior to resident #13's elopement; failed to supervise a resident with a dementia [DIAGNOSES REDACTED]. Review of the facility's policy, Elopements, revised 12/2007, showed: If an employee discovers that a resident is missing from the facility, he/she shall: .initiate a search of the building(s) and premises. Review of a Nursing Progress Note, dated 1/29/20, showed, Unable to locate resident while doing room to room search. Last seen by staff at (9:45 p.m.). Nurse looked out into the A-wing patio area and heard resident outside of the wooden gate. Nurse opened gate and assisted resident with her rolling walker which has a seat on it back into the facility. Resident's clothes were dry and no dampness noted . After vital signs taken and resident warmed up we took her to the door and her wandergard set off alarm - unable to locate which door she went out of due to no alarms going off. Review of a Nursing Progress Note, dated 1/30/20, showed, Was transferred to (memory care unit) this afternoon for closer supervision . no ill effects of elopement of yesterday. Review of the facility's Unsafe Wandering Risk Evaluation, dated 1/29/20, and completed following resident #13's elopement, showed, Resident had wandergard (sic) placed on her wrist today 1/29/20 . she is constantly wandering all over the building and looking for her husband. B. During an interview on 3/3/20 at 5:25 a.m., staff member I stated resident #7 had fallen in December of 2019, and it was later determined at the hospital that he had sustained a [MEDICAL CONDITION]. Staff member I explained resident #7 fell around 11:30 p.m., and was transported to the hospital around 7:30 a.m., eight hours later. Staff member I stated the nurse who was responsible for resident #7 did not assess him following the fall, and assumed the fall was a behavior. Staff member I explained resident #7 had a history of [REDACTED]. During an interview on 3/3/20 at 6:10 a.m., staff member K stated she took shift report the morning after resident #7 fell and immediately assessed him. Staff member K suspected he had sustained a [MEDICAL CONDITION], and sent him to the hospital, where the fracture was confirmed. During an interview on 3/3/20 at 8:15 a.m., staff member B stated she recalled staff member K was quite upset that staff member M did not send resident #7 to the hospital immediately. Staff member B stated she did not think staff member M intervened appropriately because she had not transported resident #7 to the hospital immediately. During an interview on 3/3/20 at 9:10 a.m., NF1 stated resident #7 was not in a wheelchair prior to the [MEDICAL CONDITION]. She clarified that resident #7 had been wheelchair bound since the incident. During an interview on 3/4/20 at 6:45 p.m., staff member M stated when resident #7 fell , she had been unfamiliar with the resident's care because she usually did not work on the memory care unit. Staff member M stated she relied on the CNA's interpretation of resident #7's fall, which was that it was a behavior, and something resident #7 did frequently. Staff member M stated resident #7 would not allow her to assess him. Review of resident #7's incident report, dated 12/3/20, showed he had fallen that evening and was transported to the hospital the morning of 12/4/20. Review of a Nursing Note, dated 12/4/19, showed, at 8:30 p.m.: Female staff member was leading resident to his room and upon entering his room and explaining to him that this was his room - resident intentionly (sic) slid to the floor acting like he fell according to staff member and started yelling loudly call the ambulance. This nurse notified by staff member and attempted to assess resident but he refused to allow this nurse to assess him. Assisted x 2 to his bed due to resident would not get up off floor after being asked numerous times. Resident refused to get up off the floor. He complained of his right leg hurting and I could not get him to straighten his leg. When another staff member came into his room he complained of his left hip and side hurting. Unsure if he is truly hurt (due to) he would not allow this nurse to perform active or passive (range of motion). But according to staff he has done this before dramatically lying on the floor as though hurt. Notified (medical provider) of situation via answering service . Review of Nursing Notes, dated 12/4/19, showed, at 2:09 a.m., Resident has been lying in bed and refused to place weight on either of his legs so staff could assist him to toilet. Resident confused at this time as is his normal baseline . Review of Nursing Notes, dated 12/4/19, showed, at 7:05 a.m., This writer came on shift at (6:00 a.m.), report given to this nurse, assessed resident, left leg shorter than right and it is externally rotated. Call to (Director of Nursing) and also (Medical Provider). Review of resident #7's care plan, dated 2/29/20, showed resident #7 .is at a high risk for falls and injuries. Review of resident #7's MDS, with an ARD of 12/19/19, showed a BIMS of 0, showing the resident had severely impaired cognition.

Based on observation, interview, and record review, the facility failed to prevent the development and worsening of a coccyx pressure ulcer, and the pressure ulcer caused the resident pain, affecting 1 (#35) of 25 sampled residents. Findings include: During an observation and interview on 8/21/18 at 10:19 a.m., staff members R and U provided perineum care to resident #35. Resident #35 had an opened area, the size of a quarter, to the coccyx. The skin had a grayish appearance and resident #35 complained of pain when staff cleansed the area with wipes. Staff member R stated resident #35's coccyx area looked worse. Staff member U stated the coccyx ulcer should have had a dressing covering the area to provide protection and comfort. Staff members R and U stated they would inform the unit nurse. Review of resident #35's facility record showed, the resident was admitted to the facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. A BRADEN skin assessment was conducted at the time of admission with a result of 14; at moderate risk for developing a pressure ulcer. Admission skin assessment notes did not mention concerns with the skin on resident 35's coccyx. Review of resident #35's Admission MDS, with an ARD of 6/25/18, showed no in section M 0210; unhealed pressure ulcers. Review of resident #35's Treatment Administration Record (TAR) showed orders for the 3:00 p.m. to 11:00 p.m. shifts to Apply [MEDICATION NAME] (sic) dressing to coccyx area every evening shift for skin care until healed. Start date 7/17/18. During an observation and interview on 8/21/18 at 10:33 a.m., staff member H cleansed resident #35's coccyx area with normal saline and applied an [MEDICATION NAME] dressing. Resident #35 complained of pain when the coccyx pressure ulcer was touched. Staff member H stated the pressure ulcer appeared to have worsened, and that she would inform staff member Q so the wound could be reassessed and remeasured by a wound certified staff member. During an observation and interview on 8/23/18 at 8:33 a.m., staff members N and T provided perineum care to resident #35. There was a 4 x 4 [MEDICATION NAME] dressing, dated 8/21/18, on resident #35's coccyx. The dressing edges had begun to roll up, and were saturated with serosanguineous fluids, the dressing was no longer covering the coccyx pressure ulcer. Resident #35 hollered out because of pain when staff members N and T attempted to cleanse the coccyx area with wipes. There was an odiferous smell coming from the coccyx area, which had not been present during the observation on 8/21/18. Staff member N stated she would have the pressure ulcer reassessed and remeasured. Staff member T stated the pressure ulcer appeared worse and the smell was new. During an observation and interview on 8/23/18 at 10:23 a.m., staff member Q removed the serosanguineous saturated dressing, dated 8/21/18 from resident #35's coccyx area. Staff member Q stated the area looked worse from the previous assessment performed on 8/18/18. Staff member Q cleansed the area with normal saline and resident #35 complained of severe pain. Staff member Q stated resident #35's physician would be informed of the worsening pressure ulcer and treatment would begin immediately. Staff member Q stated she would ensure resident #35 was given pain medication for the severe pain experienced during the pressure ulcer assessment and dressing. Staff member Q stated she had not been informed on 8/21/18, that resident #35's coccyx area looked worse. During an interview on 8/23/18 at 10:55 a.m., staff member S stated she had not changed the dressing to resident #35's coccyx pressure ulcer on 8/22/18. Staff member S stated she should have done it, but it got busy and I missed it. During an interview on 8/23/18 at 1:11 p.m., staff member Q stated resident #35 had a worsening Stage II pressure ulcer that should have been treated more aggressively since resident #35 had not been admitted to the facility with any open areas to the coccyx. A review of resident #35's nurse's notes reflected the following: - 7/2/18 at 3:09 a.m., Note: This is a follow-up from the change in condition-medical that occurred on 7/2/18. Status of condition: no change. Data: dressing to coccyx area intact; slept this shift. Action: will continue to monitor. Response: no s/s of pain noted. - 7/2/18 at 8:47 a.m., .Pressure Area(s): Location(s): Blister to coccyx, fluid filled, purplish. Area cleansed and opti-foam gentle (sic) applied . - 7/3/18 at 3:09 a.m., Data: blister intact. - 7/8/18 at 10:02 a.m., Observations: Wound to coccyx c/d/I (clean, dry, intact) and good granulation noted. pink (sic) margins . - 7/10/18 at 1:41 p.m., Note: treatment to coccyx and both legs, all are improved turned and repositioned. Will on occasion turn self back on to back. - 8/5/18 at 10:00 p.m., Observations: [MEDICATION NAME] to coccyx area looking better . - 8/6/18 at 7:20 a.m., MASD: Location(s): Coccyx improved, healing. - 8/23/18 at 12:53 p.m., resident c/o pain upon cleansing of wound but does display decreased pain upon cessation of wound care. Wound measures 2 cm x 1.3 cm x 0.2 cm. Wound has macerated edging and visualized sloughing in wound bed. Notified MD at approximately 1050 (sic) awaiting further instruction. Also notified residents (sic) husband (his name) of residents change of condition/wound worsening. A review of a Skin Integrity Reports for resident #35 showed: - 7/16/18: a 50% granulated, 1.7 cm x 0.3 cm wound draining serous fluids with healthy surrounding tissue and wound edges. The wound was not odorous. - 7/24/18: stage zero, 50% granulated, 1.3 cm x 0.2 cm wound draining serous fluids with healthy surrounding tissue and wound edges. The wound was not odorous. - 8/1/18: stage zero, 75% granulated, 1 cm x 1 cm wound draining serosanguineous fluids with healthy surrounding tissue and wound edges. The wound was not odorous. - 8/10/18: stage zero, 75% granulated, 0.5 cm x 0.5 cm wound draining serosanguineous fluids with healthy surrounding tissue and wound edges. The wound was not odorous. - 8/18/18: non-staged, 50% granulated, 1.2 cm x 1.0 cm wound draining serosanguineous fluids with healthy surrounding tissue and wound edges. The wound was not odorous. A review of Verbal Orders from resident #35's physician, dated 8/23/18 at 2:10 p.m., read, Cleanse affected area (coccyx) with NS/WC (normal saline/wound cleanser), pat dry, apply silver alginate to wound bed, cover with foam dsg. every evening shift for wound care for 14 days. Cleanse affected area (coccyx) with NS/WC, pat dry, apply silver alginate to wound bed, cover with foam dsg. Review of the facility policy, Skin Integrity Management, read, The implementation of an individual patient's (sic) skin integrity management occurs within the care delivery process. Staff continually observes and monitors patients (sic) for changes and implements revisions to the plan of care as needed. Notify Medical Director, Center Nurse Executive, and Center Executive Director if deviation from protocol is requested by physician/advanced practice provider, managed care company, or others .3.4. Perform daily monitoring of wounds or dressings for presence of complications or declines and document .11. Document daily monitoring of ulcer site, with or without dressing .11.2 For wounds requiring daily dressing change or wounds without a dressing, monitor for signs of decline in wound status. 11.2.1 If unanticipated decline in wound, surrounding tissue, or new or increased wound pain, complete the Skin Integrity Report and notify physician/APP (sic).

Based on interview and record review, the facility failed to ensure a resident received treatment and care to avoid obstipation resulting in the resident being sent to the emergency department to be evaluated for fecal impaction, and the resident admitted to the hospital, for 1 (#61) of 25 sampled residents. Findings include: During an interview on 8/22/18 at 3:16 p.m., staff member M stated the facility did not have a policy and procedure for a bowel protocol. She stated she received a report every morning from the Dash Board on the EHR, and she gave it to the nurses if a resident did not have a BM within 72 hours. She stated staff were to start with MOM and then a suppository. She stated if the suppository did not work within two hours, then the nurse called the doctor and would give a Fleets enema or other prescribed orders. Staff member M stated the admission physician's orders [REDACTED]. Resident #61 was admitted to the facility with [DIAGNOSES REDACTED]. Review of resident #61's medical record showed she had a discharge to the hospital on [DATE], and was readmitted to the facility on [DATE]. Review of resident #61's emergency room medical records, dated 8/12/18, showed she presents by ambulance from a local nursing home with complaint of 'not feeling well' and not having a bowel movement for 9 days. The patient is very confused and when I asked how long her abdomen has been hurting she said 'forever.' She also thought it was 1988. According to nursing home she has had vomiting a couple times in the past 24 hours. She states she has been passing gas. The emergency room Exam notes showed resident #61 had, liquid stool at the anus and on digital exam there is hard impacted stool in the rectal vault. Documented under the heading Final Impression was, 1. Fecal impaction 2. Acute kidney injury. Resident #61 was admitted to the hospital from the Emergency Department. Review of resident #61's hospital Discharge Summary, dated 8/15/18, under the heading Hospital Course, showed resident #61, Presented from the nursing home in which she lives for complaining of not feeling well and not having a bowel movement for 9 days. On admission she was very confused and could not give an adequate history. She was nauseated and was vomiting frequently, so he (sic) was placed while aggressive bowel protocol was undertaken, and patient had several large bowel movements. At that point the NG was removed and patient was able to tolerate an oral diet. She was also diagnosed with [REDACTED]. Finally, she had significant [MEDICAL CONDITION] on presentation likely secondary to hypovolemia with vomiting, and this progressively improved during the course of her stay. On the day of discharge, the patient had returned to her mental baseline. She was ambulating, tolerating oral diet, and having multiple bowel movements . Review of resident #61's nurse's notes, dated 8/11/18 at 11:37 p.m., showed, Resident had x 3 episodes of emesis this evening. VS: 99.7, 92 HR, 14 RR, 168/80. Resident has hypoactive bowel sounds, last BM charting was 8/2. Digital rectum exam done and felt hard stool. Suppository given to resident. Resident resting at this time, no further episodes of emesis at this time. Review of resident #61's nurse's note, dated 8/12/18 at 3:33 a.m., showed, Resident with no results from previous [MEDICATION NAME] suppository -Fleet enema administered as per protocol. Rectal check with hard, firm stool noted. Review of resident #61's nurse's note, dated 8/12/18 at 4:51 a.m., showed, No results from Fleet Enema- resident had moderate dark brown liquid emesis. Abdomen soft, non distended, hypoactive BSx1 in left upper quadrant only. Resident C/O not feeling well. Dr (name) notified- order to send to ER for evaluation. Daughter (name) called and made aware. Review of resident #61's EHR task for bowel incontinence showed resident #61 had no BM from 7/27/18-8/2/18 then a medium BM was recorded on 8/2/18. The record showed resident #61 did not have a recorded BM from 8/3/18 until her discharge on 8/12/18. Resident #61 did not have a recorded BM for ten days, including the day she was sent to the emergency department for nausea and vomiting and hard stool in the rectum. During an interview on 8/23/18 at 2:40 p.m., staff member M stated the facility started a new process for concerns that will show on the dashboard for residents who did not have a BM for 72 hours. She stated the CNAs can not go back and look at the BM record on their EHR entries to see a history of events. She stated the facility realized resident bowel records were not being tracked and they needed to find another process to track residents' BMs to avoid what happened to resident #61.

Based on observation, interview and record review the facility failed to keep the head of the bed elevated immediately after a tube feeding which resulted in coughing, labored breathing, complaints of heartburn and hiccups for 1 (#10) of 15 sampled residents. Findings include: Resident #10 was admitted to the facility with [DIAGNOSES REDACTED]. A review of a quarterly MDS, with an ARD of 5/12/16, showed the resident required extensive assistance with bed mobility, transfers, dressing, eating, toileting and bathing. The resident had unclear speech but was usually understood and usually understood others, and had a BIMS of 13, cognitively intact. A review of the resident's MAR for May showed the resident received [MEDICATION NAME] 1.2 CAL at 75 ml/hour, continuously, through a feeding tube and pump. Staff were required to check for tube placement prior to administering the [MEDICATION NAME]. A review of the resident's care plan, dated 12/10/15, reflected licensed nursing staff were required to Check the patency and placement of the tube daily and before administering feedings and meds. All staff were required to ensure the head of bed was elevated 30-45 degrees during feedings. A review of the resident's care plan, dated 5/12/15, reflected nursing staff were to observe and report coughing, choking, and signs and symptoms of aspiration. A review of the resident's care plan, dated 5/11/16, reflected nursing staff were required to be aware of peg tube placement at all times. During an observation on 5/24/16 from 8:55 a.m. to 9:19 a.m., resident #10 was seated in the hallway across from the shower room. He was in his wheelchair with the head of the chair up 75 degrees and his tube feeding was on a pump at 75 ml/hour. During an observation on 5/24/16 at 9:20 a.m., staff members H wheeled the resident into the shower room and disconnected his tube feeding. At 9:30 a.m., staff members H and V transferred the resident from his wheelchair to the Arjo bed trolley via a Hoyer lift. The resident was laid flat on the bed trolley. ¹ At 9:45 a.m., the resident complained of acid reflux, had labored breathing, and began to cough. Staff member V exited the shower room. Staff member H attempted to lift the head of the bath trolley but was unfamiliar with operating the trolley. The resident remained flat on his back. He complained of reflux, had labored breathing to staff member H during his shower. At 9:51 a.m., staff member F entered the shower room, brought in a bath blanket and glanced down at the resident. The resident continued to cough, had labored breathing, and began to hiccup. Staff member F exited the shower room. The resident remained flat in the bed trolley. At 10:10 a.m., staff members H and Y wheeled the resident to his room while he laid flat in the bed trolley; the resident continued to cough. At 10:11 a.m., staff member F entered the resident's room while he laid flat in the bed trolley. The resident continued to cough and his face turned red. Staff members H and Y rolled the resident onto his right side and staff member F put a dressing on an IT pressure ulcer. The resident remained flat in bed, coughing, and his face turned darker red. Staff member F exited the resident's room. At 10:20 a.m., staff member Y elevated the resident's head of the bed to 10 degrees. At 10:28 a.m., staff member H reconnected and turn on the pump to the resident's feed tube. The pump was administering [MEDICATION NAME] 1.2 CAL at 75 ml/hour. The resident coughed a few times and attempted to clear his throat and mouthed thank you to the staff. During an interview on 5/24/16 at 10:31 a.m., staff member H stated she had not received any instructions on disconnecting and reconnecting a feeding tube from the facility. The staff member was unaware of the signs and symptoms of aspiration and stated she should not have disconnected or reconnected the feeding tube. During an interview on 5/24/16 at 10:35 a.m., staff member F stated CNA's had been disconnecting and reconnecting feeding tubes since her employment with the facility. The staff member stated she assessed the resident's feeding tube fluid residual earlier that morning, but had not checked prior to the resident being laid flat in the bed trolley in the shower room. She stated the resident's head of the bed should have been elevated to 35 degrees or more. During an interview on 5/24/16 at 2:05 p.m., staff member BB stated resident #10 was at a very high risk of aspiration and should always have the head of his bed elevated 30-45 degrees. During an interview on 5/24/16 at 2:15 p.m., staff member B stated CNAs should not be disconnecting and reconnecting any feeding tubes. The staff member stated licensed staff were required to check for tube placement prior to reconnecting a continuous feeding tube. During an interview on 5/24/16 at 2:05 p.m., staff member V stated she has occasionally disconnected a resident's feeding tube but has never reconnected it. The staff member stated licensed staff were responsible for reconnected feeding tubes. During an interview on 5/24/16 at 2:30 p.m., staff member F stated she had not received training regarding feeding tubes while in this facility. Staff member F stated an in-service training was given today regarding feeding tubes. The staff member reported her understanding that removal and replacement of feeding tubes was a duty only to be performed by nursing staff. When asked about the incident earlier in the day with resident #10's feeding tube, staff member F stated she did not know who had removed the tube, but assumed it was one of the staff called in to help with the survey process. Staff member F stated staff member H replaced the tube following resident #10's bath. During an interview on 5/24/16 at 2:15 p.m., staff member G stated she had been taught a resident with a feeding tube should be kept at a 30-35 degree incline at all times. The tube should be flushed with the prescribed amount of fluid and the site should be checked daily to confirm proper placement. Staff member G stated her last training on feeding tubes occurred sometime in July 2015. Staff member G stated only a licensed nurse was qualified to work with a feeding tube. During an interview on 5/24/16 at 2:25 p.m., staff member W stated only a licensed nurse could connect and disconnect a feeding tube. Staff member W stated a resident with a feeding tube was to be kept at a 30 degree incline. A review of the facility's Enteral feeding: Administration by Pump policy, revised on 1/2/14, reflected, 6. Position patient in semi-or high Fowler's position. Head of bed to remain elevated 30-45 degrees continuously during feeding. 9. Verify tube placement. (9.1.3)- Check for residual using syringe to: (9.1.3.1)- Aspirate stomach contents; (9.1.3.2)- measure amount of residual. 13. Keep head of bed elevated for at least 30 minutes after medication administration. References ¹ www.nursingcenter.com > Journal Articles <http://www.nursingcenter.com/JournalIndex> Practice recommendations to prevent aspiration required the head of patients' beds to be maintained at 30(degrees) to 45(degrees) at all times during feeding and for 30 to 60 minutes after feeding is completed or stopped for any reason.