Every finding on record at Grand View Care CTR

Based on observation, interview and record review, the facility did not ensure that snack/nourishment refrigerators on the Memory Care Unit (MCU) were maintained with the proper temperatures, and food items are dated and labeled to prevent the potential for food-borne illness. The facility did not ensure the snack/nourishment refrigerators on the [NAME] Wing Lobby (WWL) were maintained with food items dated and labeled to prevent the potential for food-borne illness. This has the potential to affect all 45 residents in the facility.According to the US Food and Drug Administration (FDA) Food Code 2022: Annex 3-123 .Date marking is the mechanism by which the Food Code requires active managerial control of the temperature and time combinations for cold holding. Industry must implement a system of identifying the date or day by which the food must be consumed, sold, or discarded. Date marking requirements apply to containers of processed food that have been opened and to food prepared by a food establishment, in both cases if held for more than 24 hours, and while the food is under the control of the food establishment .According to the US FDA Food Code 2022: Annex 3-164 to 165: .A permanent temperature measuring device is required in any unit storing time/temperature control for safety food because of the potential growth of pathogenic microorganisms should the temperature of the unit exceed Code requirements. In order to facilitate routine monitoring of the unit, the device must be clearly visible .The required incremental gradations are more precise for food measuring devices than for those used to measure ambient temperature because of the significance at a given point in time, i.e., the potential for pathogenic growth, versus the unit's temperature. The food temperature will not necessarily match the ambient temperature of the storage unit; it will depend on many variables including the temperature of the food when it is placed in the unit, the temperature at which the unit is maintained, and the length of time the food is stored in the unit . The facility policy untitled states: Objective to ensure that cooler and freezer units are routinely monitored and maintained to ensure the safety of items stored in these units.Policy/Procedure: .2. Refrigerator .temperatures are to be recorded daily. Temperature records from facility owned units holding resident/patient food or beverage are to be returned to dietary and will be kept on file for two years.4. Outdated/improperly packaged items will be removed. All refrigerated items intended for resident/patient consumption must be dated and discarded by Use by or expiration date. Five days is the maximum length of time any item may be kept.5. Items placed in the resident cooler must be labeled with the resident's name and an expiration date 5 days out from the day it is brought in.On 06/17/26 at 8:13 AM, Surveyor observed the snack/nourishment refrigerator located on the Memory Care Unit (MCU) with the noted following observations: *The Refrigerator Temperature Log labeled: Location: MCU - June 2026 with missing daily refrigerator temperature logs missing on 6/9/26 through 6/14/26 and 6/16/26. (total of 7 days). *An open container approximately 3/4 empty of nonfat yogurt with a label date of 05/27.*A 1/2 pitcher of orange juice dated 06/05.*A sippy cup with 1/2 filled with a clear liquid unlabeled and undated.*An opened/used container of coffee creamer unlabeled and undated. On 06/17/26 at 8:18 AM, Surveyor observed a refrigerator/freezer in common area of [NAME] Wing Lounge (WWL) with the following observations:*An opened/used container of Thick & Easy unlabeled and undated.*An open/used container of Coffee Mate Cold Foam unlabeled and undated.*An opened/used container of Power Aide Lemon Lime unlabeled and undated.* A sandwich size plastic bag of fresh strawberries undated.On 06/17/26 at 8:25 AM, Surveyor interviewed Certified Nursing Assistant (CNA) F who stated any resident items can be stored in refrigerator indicating the proximity of the resident's room location regarding items in WWL or MCU refrigerator/freezer and CNA F confirmed items in WWL refrigerator were not labeled/dated. On 06/17/26 at 8:43 AM, Surveyor showed and interviewed the Nursing Home Administrator (NHA) A the WWL and MCU unit resident and shared observation of unlabeled/undated opened items and missing temperature logs. NHA A stated staff is expected to label the items with the resident's name and the open date. Any food items over 5 days would be discarded. On 06/17/26 at 9:05 AM, Surveyor interviewed CNA G regarding contents of the MCU resident refrigerator who confirmed items noted were unlabeled and undated.

Based on record review and interview, the facility did not ensure residents are free of significant medication errors for 2 of 4 residents (R) reviewed for medication administration (R30 and R10).R30's divalproex delayed release tablet (an anticonvulsant and mood stabilizer), omeprazole delayed release capsule (a proton pump inhibitor for gastric acid) and tamsulosin capsule (an alpha blocker to relax muscle in prostate) were opened, crushed and sprinkled into applesauce for administration. This had the potential to cause harm as medication was not intended to be immediately released.R10's omeprazole delayed release capsule was opened and sprinkled into applesauce for administration. This had the potential to cause harm as medication was not intended to be immediately released. This is evidenced by:Facility policy titled, Crushing Medications, dated 2012, states: Medications shall be crushed only when it is appropriate and safe to do so, consistent with physician orders.2. The nursing staff and/or Consultant Pharmacist shall notify any Attending Physician who gives an order to crush a drug that the manufacturer states should not be crushed (for example, long acting or enteric coated medications). The Attending Physician or Consultant Pharmacist must identify an alternative, or the Attending Physician must document why crushing the medication will not adversely affect the resident. 3. Medications that are extended release/long acting or enteric coated should not be crushed unless indicated as in #2.Example 1R30 was admitted to the facility on [DATE].R30's physician orders:03/24/25 tamsulosin HCL 0.4 mg capsule 1 cap daily for benign prostatic hypertrophy.07/03/25 omeprazole delayed release (DR) 40 mg capsule 1 cap daily for gastroesophageal reflux.05/29/26 divalproex sodium 250 mg delayed release (DR) tablet 1 tab daily for anxiety.R30's nursing orders:02/27/24 may crush meds FYI.Surveyor reviewed R30's medical record and noted no pharmacy review of appropriateness to have medication crushed for administration.On 06/16/26 at 7:34 AM, Surveyor observed Registered Nurse (RN) D preparing R30's medications. Surveyor observed RN D crush R30's divalproex sodium DR 250 mg 1 tab and place into applesauce. Surveyor then observed RN D open R30's omeprazole DR 40 mg 1 cap and tamsulosin 0.4 mg 1 cap and sprinkle the contents into the same cup of applesauce. Surveyor observed RN D administer the medications mixed in applesauce to R30.On 06/16/26 at 7:38 AM, Surveyor asked RN D if the pharmacy reviewed medications for safety in administering them in crushed or sprinkled form. RN D stated yes. Surveyor asked RN D if this is documented in R30's medical record. RN D looked at R30's electronic medical record (EMR) and showed Surveyor the nursing order, dated 02/27/24, stating 'May crush meds FYI.' Surveyor asked RN D if R30's delayed release medications were reviewed by the pharmacist giving permission to give in crushed or sprinkled form. RN D stated she was wondering about that because the medication was new but did not know if there was any review by the pharmacist.Example 2R10 was admitted to the facility on [DATE].R10's physician orders:05/14/26 omeprazole 40 mg capsule delayed release (DR) by mouth daily for gastroesophageal reflux diseaseR10's nursing orders:07/24/25 FYI May crush meds FYI in applesauce and thickened liquids nectar.Surveyor reviewed R10's medical record and noted no pharmacy review of appropriateness to have medication crushed for administration.On 06/17/26 at 8:07 AM, Surveyor observed RN E preparing R10's medications. Surveyor observed RN E open R10's omeprazole 40 mg DR capsule and sprinkle the contents into cup of applesauce. Surveyor observed RN E administer the medication mixed in applesauce to R10.On 06/16/26 at 8:23 AM, Surveyor interviewed RN E regarding observation. Surveyor asked RN E how it is determined if a resident will have their medications administered in crushed form. RN E stated either by speech therapy recommendation, provider order, or nursing judgment. Surveyor asked RN E if pharmacy reviews medications for safety prior to administering a medication crushed or sprinkled. RN E stated yes.On 06/16/26 at 9:58 AM, Surveyor interviewed Director of Nursing (DON) B regarding observations. Surveyor asked DON B what the expectation for nursing staff is when administering medications in crushed or sprinkled form. DON B stated the nurse would be expected to contact the provider to get approval if the med is in DR form. Surveyor asked if there was any documentation noting that R30's and R10's medications were reviewed and given the ok to administer in crushed or sprinkle form. DON B stated she would check and get back to Surveyor.On 06/16/26 at 3:00 PM, DON B provided Surveyor with a pharmacy review via fax, dated 06/16/26 at 2:24 PM, that stated: [R30's] divalproex 250 mg ER tablets should NOT be crushed. [R30's] tamsulosin 0.4 mg capsule should NOT be opened prior to giving.[R30's] omeprazole capsule MAY be opened and sprinkled on a spoonful of soft, cool applesauce or similar food. Do not crush or chew the pellets. DON B stated prior to the Surveyor's observations of R30 and R10's medication administration, there had not been a pharmacy review of R30 and R10's medications to be administered in crushed or sprinkled form. Surveyor asked DON B if this should have been completed prior to administering R30 and R10's medications. DON B stated yes.

Based on record review and interview, the facility did not notify the Ombudsman of a resident who was transferred from the facility to a hospital on 2 occasions for 1 of 1 resident (R) (R1). R1 transferred to an emergency department on 03/27/26 due to a change in condition and the Ombudsman was not notified of emergency transfer. R1 transferred to an emergency department on 05/06/26 due to a change in condition and the Ombudsman was not notified of emergency transfer. The facility policy titled Notice of a Transfer and/or Discharge updated 2011, does not address the requirements of notifying the Ombudsman.R1 was admitted to the facility on [DATE] and required on 2 occasions (03/27/26 and 05/06/26) due to a change in condition, transfer to an emergency department; wherein, the facility did not notify the Ombudsman via the facility's monthly email process.On 06/16/2026 at 2:38 PM, Surveyor requested Ombudsman notification of transfers for R1 during months of March and May of 2026. Social Worker (SW) C provided Surveyor with documents labeled: Discharge Notification with instructions Email: Monthly to [ombudsman] . Surveyor noted that R1's emergency room transfers that occurred on 3/27/26 and 05/06/26 were not on the logs.On 06/16/26 at 3:34 PM, Surveyor interviewed SW C regarding March and May Discharge Notification Logs sent to the Ombudsman did not include R1's 03/27/26 and 05/06/26 transfers to hospital. SW C stated was not aware that requirement included transfers to emergency rooms.

Based on interview and record review, the facility did not ensure each resident receives an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas and are knowledgeable about the resident's status, needs, strengths, and areas of decline for 1 of 1 resident (R) reviewed (R6).-The facility did not complete an accurate assessment upon admission related to R6's post-traumatic stress disorder (PTSD).Findings include:Facility policy titled, Resident Assessment Instrument, last updated in 2011, includes the purpose of the assessment is to describe the resident's capability to perform daily life functions and to identify significant impairments in functional capacity.information derived from the comprehensive assessment helps the staff to plan care that allows the resident to reach his/her highest practicable level of functioning.R6 was admitted to the facility on [DATE] with a diagnosis of PTSD.On 06/16/26, Surveyor reviewed R6's physician orders, social services progress notes, assessments, and care plan and noted no trauma-informed plan of care or assessment completed.On 06/16/26 at 2:37 PM, Surveyor interviewed Nursing Home Administrator (NHA) A about a psychosocial assessment for R6. NHA A reported the questionnaire related to PTSD was not completed upon admission. NHA A stated the expectation is for these forms to be completed for any resident requiring trauma-informed care.On 06/16/26 at 3:01 PM, Surveyor interviewed Social Worker (SW) C about trauma-informed care and assessment. SW C stated they have not been trained on how to complete the process of trauma-informed care. SW C stated they were present when R6 was admitted to the facility and had not completed the questionnaire regarding trauma-informed care due to the belief there were no issues.

Based on interview and record review the facility did not ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice for 1 of 1 resident (R) reviewed (R6).-R6 has a diagnosis of post-traumatic stress disorder (PTSD). The facility did not complete an assessment to determine the cause and triggers.-The facility did not establish a trauma-informed care plan.-No education was provided to staff related to PTSD and trauma-informed care.Findings include:Facility policy titled, Care Plans-Comprehensive, includes a policy statement which states an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychosocial needs is developed for each resident.each resident's comprehensive care plan is designed to incorporate identified problem areas, incorporate risk factors associated with identified problems.reflect currently recognized standards of practice for problem areas and conditions.R6 was admitted to the facility on [DATE]. R6's most recent minimum data set (MDS) assessment shows a Brief Interview for Mental Status (BIMS) score of 3/15 indicating severe cognitive impairment. The MDS indicated R6 has a diagnosis of post-traumatic stress disorder (PTSD).R6's care plan related to PTSD includes the statement, I have anxiety and PTSD. There is no other mention of R6's PTSD present in the comprehensive care plan. There is no noted history of what caused the PTSD, what triggers R6 may have, or interventions to prevent events from occurring or re-traumatization of R6.On 06/16/26 at 2:37 PM, Surveyor interviewed Nursing Home Administrator (NHA) A about a psychosocial assessment for R6. NHA A reported the questionnaire related to PTSD was not completed upon admission. NHA A stated the expectation is for these forms to be completed for any resident requiring trauma-informed care.On 06/16/26 at 2:48 PM, Surveyor interviewed Social Services Assistant (SSA) J about trauma-informed care assessments and care plans. SSA J stated when a resident is admitted with a diagnosis of PTSD, the diagnosis goes into the MDS assessment. SSA J stated the questionnaire for trauma-informed care gets used during admission but as time passes and questioning proceeds most residents do not feel like answering all of the questions. SSA J stated if the resident cannot or does not want to talk about it, SSA J will reach out to family members or the provider for any background information. SSA J stated whatever information is obtained would go into a well-being or psychosocial care plan. When asked about a trauma-informed care plan, SSA J stated either they weren't shown how to complete one or the care plan for trauma was not completed.On 06/16/26 at 3:01 PM, Surveyor interviewed Social Worker (SW) C about trauma-informed care and assessment. SW C stated they have not been trained on how to complete the process of trauma-informed care and care plan. SW C stated they knew R6 had previously been in the military. SW C stated they had spoken with R6's spouse who indicated there were no known issues. SW C stated if there is no known information about a resident with PTSD, the staff just learn more about the resident as time goes on. When asked if staff try to obtain medical records related to the history of PTSD, SW C stated they do not know how. SW C stated if history is known, a trauma-informed care plan would be implemented. SW C stated they were present when R6 was admitted to the facility and they had not completed the questionnaire regarding trauma-informed care due to the belief there were no issues. SW C stated the facility adds information to the care plan after watching the residents, talking with family, and observing.On 06/17/26 at 7:17 AM, Surveyor interviewed Licensed Practical Nurse (LPN) I about residents with PTSD. LPN I stated there are residents with PTSD, including R6. LPN I stated if a resident has PTSD the diagnosis will be listed in their chart. LPN I stated any information related to the resident's PTSD would be found in their care plan. LPN I stated there was no current behavior charting for R6. When asked if LPN I received any training related to PTSD or trauma-informed care, LPN I stated they had no training specific to this.On 06/17/26 at 7:44 AM, Surveyor interviewed Certified Nursing Assistant (CNA) H about residents with PTSD. CNA H stated CNA H was not aware of any residents with PTSD. CNA H stated they did not receive any training related to PTSD or trauma-informed care. When asked if CNA H was aware of R6 having PTSD CNA H stated no one told them about it, CNA H just assumed R6 did. CNA H stated staff chart behaviors on all residents including R6.On 06/17/26 at 8:16 AM, Surveyor interviewed NHA A about training related to PTSD and trauma-informed care. NHA A stated there was no formal training for floor staff, only management. NHA A stated there was no policy or procedure available for PTSD or trauma-informed care.On 06/17/26 at 10:45 AM, NHA A supplied Surveyor with a previous trauma-informed care staff training completion list, which indicated the training was retired and the most recent completion date was 02/02/25. Many current staff were not included on the list, and the training was more than a year prior to this Survey.

Based on observation, record review and interview, the facility did not ensure a medication error rate of 5% or less for 2 of 4 residents (R) (R30 and R10) observed for medication administration. The facility had 38 opportunities and 4 medication errors resulting in a 10.53% error rate.R30's divalproex delayed release (DR) tablet (an anticonvulsant and mood stabilizer), omeprazole delayed release capsule (a proton pump inhibitor for gastric acid) and tamsulosin capsule (an alpha blocker to relax muscle in prostate) were opened, crushed and sprinkled into applesauce for administration. This had the potential to cause harm as medication was not intended to be immediately released.R10's omeprazole delayed release capsule was opened and sprinkled into applesauce for administration. This had the potential to cause harm as medication was not intended to be immediately released.This is evidenced by:Example 1On 06/16/26 at 7:34 AM, Surveyor observed Registered Nurse (RN) D preparing R30's medications. Surveyor observed RN D place R30's medications - divalproex DR 250 mg 1 tab, Eliquis 5 mg 1 tab, aspirin 81 mg 1 tab, senna plus 8.6/50 mg 2 tabs, allopurinol 100 mg 1 tab, Jardiance 25 mg 1 tab, metformin 500 mg 1 tab, metoprolol 25 mg 1 tab, metoprolol 50 mg 1 tab, torsemide 10 mg 1 tab, and torsemide 20 mg 1 tab - into a medication sheath, crush medications and place into applesauce. Surveyor then observed RN D open R30's omeprazole 40 mg DR 1 cap and tamsulosin 0.4 mg 1 cap and sprinkle the contents into the same cup of applesauce. Surveyor observed RN D administer the medications mixed in applesauce to R30.On 06/16/26 at 7:38 AM, Surveyor asked RN D if the pharmacy reviewed medications for safety in administering them in crushed or sprinkled form. RN D stated yes. Surveyor asked RN D if this is documented in R30's medical record. RN D looked at R30's electronic medical record (EMR) and showed Surveyor the nursing order, dated 02/27/24, stating 'May crush meds FYI.' Surveyor asked RN D if R30's delayed release medications were reviewed by the pharmacist giving permission to give in crushed or sprinkled form. RN D stated she was wondering about that because that medication was new but did not know if there was any review by the pharmacist.Example 2On 06/17/26 at 8:07 AM, Surveyor observed RN E preparing R10's medications. Surveyor observed RN E place R10 medications - aspirin 81 mg 1 tab, vitamin D 1,000 IU-2 tabs, acetaminophen 325 mg 2 tabs, sertraline 100 mg 1 tab, sertraline 25 mg 1 tab, lorazepam 0.5 mg 0.5 tab, and lamotrigine 100mg 0.5 tab - into a medication sheath, crush medications and place into applesauce. Surveyor then observed RN E open omeprazole 40 mg DR capsule and sprinkle the contents into the same cup of applesauce. Surveyor observed RN E administer the medications mixed in applesauce to R10.On 06/16/26 at 8:23 AM, Surveyor interviewed RN E regarding observation. Surveyor asked RN E how it is determined a resident will have their medications administered in crushed form. RN E stated either by speech therapy recommendation, provider order, or nursing judgment. Surveyor asked RN E if pharmacy reviews medications for safety prior to administering a medication crushed or sprinkled. RN E stated yes.On 06/16/26 at 9:58 AM, Surveyor interviewed Director of Nursing (DON) B regarding observations. Surveyor asked DON B what the expectation for nursing staff is when administering medications in crushed or sprinkled form. DON B stated the nurse would be expected to contact the provider to get approval if the med is in ER or DR form. Surveyor asked if there was any documentation noting that R30's and R10's medications were reviewed and given the ok to administer in crushed or sprinkle form. DON B stated she would check and get back to Surveyor.On 06/16/26 at 10:55 AM, Surveyor interviewed DON B regarding R30's and R10's medication review. DON B stated prior to the Surveyor's observations of R30 and R10's medication administration, there had not been a pharmacy review of R30 and R10's appropriateness of medications to be administered in crushed or sprinkled form. Surveyor asked DON B if this should have been completed prior to administering R30 and R10's medications. DON B stated, yes.

Based on interview and record review, the facility failed to adequately assess and provide necessary care and services to attain or maintain the highest practicable physical wellbeing for 1 of 12 residents (R28) reviewed for pain management. R28 did not have an individualized pain assessment completed to monitor, assess, and evaluate for efficacy for pain management. This is evidenced by: Facility policy titled, Pain Assessment and Management, dated 2019, states in part: The purpose of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. General Guidelines 2. Pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. 3. Pain management is a multidisciplinary care process that includes the following: a. Assessing the potential for pain; b. Effectively recognizing the presence of pain; c. Identifying characteristics of pain; d. Addressing the underlying causes of pain; e. Developing and implementing approaches to pain management; f. Identifying and using specific strategies for different levels and sources of pain; g. Monitoring for the effectiveness of interventions; and h. Modifying approaches as necessary . 6. Assess the resident's pain and consequences of pain at least each shift for acute pain or significant changes in levels of chronic pain and at least weekly in stable chronic pain. R28 was admitted to the facility on [DATE] with pertinent diagnoses of malignant neoplasm of the prostate, osteoarthritis, and rheumatoid arthritis. R28's most recent quarterly Minimum Data Set (MDS) assessment, dated 02/19/25, noted a Brief Interview for Mental Status (BIMS) score of 15/15, indicating cognition intact, makes self understood and understands others. MDS noted R28 received scheduled pain medications. R28's care plan, dated 02/19/25, with a target date of 05/19/25, states: R28 has rheumatoid arthritis with joint and shoulder pain. Interventions include asking if R28 hurts, reminding R28 to take medicine, and encourage R28 to walk. Goals include maintain R28's pain at an acceptable level. Surveyor was unable to locate R28's acceptable pain level noted in the care plan. R28's physician orders: 12/1/23 acetaminophen 500 mg; 2 tabs three times daily for pain 7/17/24 diclofenac sodium 1% gel topical apply 2 g to skin 4 times daily to left knee and left shoulder four times daily for arthritis 7/23/24 hydroxychloroquine sulfate 200 mg tab daily for arthritis 10/7/24 methotrexate sodium 2.5 mg tab 3 tab 1x/wk Monday for RA 11/25/24 Humira pen (adalimumab 40 mg/0.4 ml pen sub-Q for arthritis Surveyor reviewed R28's medication administration record (MAR) and noted that administration of pain medications did not include pain assessment prior to administration and did not include a pain assessment after administration to evaluate for efficacy. R28's most pain assessment, dated 04/15/25, noted 3/10 mild pain to left shoulder; worst pain experienced over last 5 days was 5/10. -Of note: pain assessment did not include characteristics of pain, underlying cause of pain, or acceptable level of pain. Surveyor was unable to locate documentation of pain assessments, monitoring for changes in R28's chronic pain. On 04/15/25 at 8:49 AM, Surveyor observed R28 seated in recliner in room, grimacing while repositioning self in seat. Surveyor asked R28 if he was having pain. R28 began to cry and stated he is in pain all of the time because of his rheumatoid arthritis. Surveyor asked R28 if the facility was helping with pain control. R28 stated the nurses give him his medications, but that they don't help much. Surveyor asked R28 to rate his current pain. R28 stated it was 8/10 and is that level most of the time in his joints with his hands and shoulders being the worst. R28 described the pain as achy and that it makes moving very difficult. On 04/17/25 at 1:27 PM, Surveyor interviewed Director of Nursing (DON) B regarding pain management. DON B stated each resident should be assessed for pain to include characteristics of pain, location, duration, number rating of pain (if able) before and after pain medication administration, and resident's tolerable level of pain. Surveyor asked DON B why these assessments were not documented for R28. DON B stated DON B is aware this is not being completed and is in the process of auditing residents' pain assessments. DON B stated plans of re-educating staff on pain management assessments once audits are completed. DON B did not provide Surveyor documentation of this process currently in place at time of survey.

Based on observation, interview and record review, the facility did not ensure resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (R23) reviewed. R23 was left unattended while connected to mechanical lift equipment. This is evidenced by: The Food and Drug Administration (FDA) Safety Information guidance provided in Kwik points Patient Lifts Safety Guide, states in part: Do not leave patient unattended while in lift. Never keep patient suspended in sling for more than a few minutes. Facility policy titled, Lifting Machine, using a Portable, dated 2024, states in part: .#3. To transfer a resident from a bed to a chair, you should: v. Remain with the resident until he or she is comfortable and free of any adverse effects from the transfer . R23 was admitted to the facility on [DATE] with diagnoses including cerebral vascular accident with hemiplegia, atrial fibrillation, hypertension, arthritis, and depression. R23's most recent Minimum Data Set (MDS) assessment, dated 02/19/25, indicated that R23 has a Brief Interview for Mental Status (BIMS) score of 9/15, which means moderate cognitive impairment that requires cues and supervision and R23 is dependent with assist for chair to bed transfers. On 4/15/25 at 10:05 AM, Surveyor observed R23 in his room by himself in Hoyer lift sling connected to Hoyer lift, but it was not raised. R23 was covered up with towels. About 30 seconds after entering R23's room, CNA C came in and reported to R23 he is having a shower today. CNA C was just waiting for another CNA to help transfer R23. Surveyor asked CNA C what the normal process is for transferring R23 in the Hoyer lift. CNA C stated CNA C always uses 2 people to transfer via Hoyer Lift. On 04/17/25 at 7:51 AM, Surveyor observed Certified Nurse Assistant (CNA) G walking from R23's room. CNA G walked down 300 hall to nurses' station between 300 hall and 500 hall. CNA G stood around looking for assistance and then saw CNA C. CNA G asked CNA C for assistance transferring R23. Surveyor walked to the end of 300 hall where R23 is located, which is about 9 rooms down the hall away from the beginning of 300 hall. Surveyor observed R23 connected to the Hoyer lift lying in bed. Surveyor did not see any staff in R23's room. Surveyor waited outside R23's door. On 04/17/25 at 7:53 AM, Surveyor observed CNA G walk down hallway with CNA C and both CNAs went into R23's room to transfer R23. On 04/17/25 at 11:42 AM, Surveyor interviewed CNA G regarding observation. Surveyor asked CNA G why R23 was left unattended in his room while attached to the mechanical lift. CNA G indicated that CNA G only left R23 for a moment while CNA G went to get help to transfer R23 from bed to wheelchair. Surveyor asked CNA G if it is the normal process to keep R23 connected to the lift with the sling, walk out of R23's room and down the hallway leaving R23 unattended in a mechanical lift. CNA G indicated that CNA G should have just waited before connecting R23 to the mechanical lift until CNA G got help from another coworker. On 04/17/25 at 12:36 PM, Surveyor interviewed CNA C and asked if it is the normal process to keep R23 connected to the Hoyer lift with the sling and walk away, out of R23's room down the hallway leaving R23 unattended in a mechanical lift. CNA C indicated that CNA C should have just waited before connecting R23 to the mechanical lift until CNA C got help from another coworker. CNA C indicated it is not ok to leave residents unattended in mechanical lift. On 04/17/25 at 11:56 AM, Surveyor interviewed Director of Nursing (DON) B regarding observation and mechanical lift safety. Surveyor asked DON B if it would be an acceptable practice for staff to leave residents unattended while connected to lift equipment. DON B stated that other than an emergent situation, staff would be expected to stay with a resident while lift equipment is being used. Surveyor informed DON B of the two observations of R23 being left unattended while attached to the lift machine. DON B stated staff are to not leave any residents strapped in a mechanical lift alone.

Based on interview and record review, the facility did not ensure residents (R) with indwelling Foley catheters received care and treatment consistent with professional standards of practice to prevent complications or urinary tract infections from the catheter, for 1 of 2 residents (R28) reviewed with a Foley catheter. R28's Foley catheter was changed on a routine schedule without clinical indications and not following professional standards of practice. This is evidenced by: The Centers for Disease Control and Prevention (CDC), Healthcare Infection Control Practices Advisory Committee (HICPAC), Guideline for prevention of catheter-associated urinary tract infections 2009, read in part: E. Changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended. Rather, it is suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised. Facility policy titled, Catheter Care, Urinary, dated 2025, states in part: The purpose of this procedure is to prevent catheter-associated urinary tract infections .Changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended. Rather, it is suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised. R28 was admitted to the facility on [DATE] with pertinent diagnoses of malignant neoplasm of the prostate and urinary retention. R28's physician orders: 02/15/24 change indwelling Foley catheter as needed 14 French coude catheter; fill with 10 cc of sterile water (can use 16 French with 10 cc balloon if needed) as needed. 12/04/24 change indwelling Foley catheter 14 French coude catheter; fill with 10 cc of sterile water every 90 days. Record review did not identify physician rationale or clinical indications for the need to change the Foley catheter every 90 days. On 04/15/25 at 8:34 AM, Surveyor observed R28 with urinary catheter. Leg bag was secured to right lower leg. No concerns or signs/symptoms of infection observed. On 04/17/25 at 2:25 PM, Surveyor interviewed Director of Nursing (DON) B regarding rationale for R28's scheduled Foley catheter change. DON B stated that R28's original order was to change the catheter every 30 days, and the provider was contacted to have the order changed to as needed. DON B stated the provider revised the order to have the Foley changed every 90 days. DON B stated recognition that this order did not follow facility policy nor current recommendations, but the provider wanted it scheduled anyway. DON B was unable to provide the provider's rationale for having this order in place.

Based on observation, interview and record review, the facility did not ensure a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation. Facility did not determine that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. This has the potential to affect all 44 residents in the facility. Findings include: Facility policy titled, Storage of Medications, dated 2012 reviewed on, states in part, .#7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others . Facility policy titled, Controlled Substance policy and procedure, dated 03/27/25, states in part, .Shift count: #3. D. If the controlled substance count does not match, then: i. The oncoming nurse does NOT co-sign the count until the reconciliation has been completed. ii. The outgoing nurse does NOT leave the facility until the medication is accounted for and the reconciliation is completed . Reconciliation 4. If the controlled substance is not found or accounted for, the nurses must immediately notify Director of Nursing or designee . On 04/17/25 at 8:05 AM, Surveyor toured medication storage room with Registered Nurse (RN) F. Surveyor observed Tramadol, located in a metal box on top of counter in medication storage room, which was unlocked and opened. Surveyor asked RN F what the metal box was located on counter. RN F indicated the metal box is full of medications that we can sign out if we need to utilize the medications for residents, if they run out of their supply of medications. Surveyor reviewed list and noted Alprazolam 0.5mg, Clonazepam 0.5mg, Lorazepam 0.5mg, and Tramadol 50mg was in the metal box opened and not locked. Surveyor asked RN F if the controlled medications located in the metal box should be locked. RN F indicated that if there are any controlled medications in the metal box those are to be locked separately. On 04/17/25 at 11:25 AM, Surveyor interviewed Licensed Practical Nurse (LPN) D and asked if LPN D could open metal contingency box and let Surveyor count how many controlled substance tabs are in the unlocked metal box. LPN D confirmed that Alprazolam 0.5mg had 5 tabs, Clonazepam 0.5mg had 4 tabs, Lorazepam 0.5mg had 7 tabs, and Tramadol 50mg had 4 tabs located in the unlocked metal box in medication storage room. LPN D indicated that Alprazolam 0.5mg, Clonazepam 0.5mg, Lorazepam 0.5mg, and Tramadol 50mg should not be in the contingency metal box. LPN D indicated that all controlled medications are to be placed in a lock box somewhere in the medication storage room. Surveyor asked LPN D how the facility monitors the supply coming in and going out for controlled medications. Surveyor asked LPN D if staff sign out the controlled substance and what the supply amount is left in the metal box. LPN D indicated that if staff need to use a medication for a resident out of the contingency metal box, staff will fill out a slip of the medication and who it is being administered to. LPN D indicated that staff do not track what the supply was when the medication came into building from pharmacy and how many are remaining after taking a medication out for administration. On 04/17/25 at 11:53 AM, Surveyor interviewed Director of Nursing (DON) B and asked expectation for the facility to monitor the supply coming in and going out for the contingency controlled medications in the metal box. DON B indicated staff do not track what the supply is for the controlled medication coming in and how many are remaining after taking a medication out for administration in the contingency metal box. DON B indicated that DON B was unaware that controlled substances were being stored in the unlocked contingency metal box in the medication storage room. On 04/17/25 at 1:58 PM, Surveyor interviewed DON B once again and asked for DON B to explain the process for reconciliation of controlled medications. DON B admitted to the process not working well. DON B indicated that RN E gets flags in the computer system when there is a discrepancy. DON B indicated that an email chimes to RN E and then RN E will investigate and correct the discrepancy. DON B showed Surveyor examples of the medication reconciliation process that's currently being used. Surveyor indicated to DON B that Surveyor found multiple discrepancies on the reconciliation log for R7's Lorazepam that does not have a correction attached to the count. DON B indicated that Surveyor would need to speak with RN E for additional information. On 04/17/25 at 2:09 PM, Surveyor interviewed RN E and asked about reconciliation of controlled medications. RN E indicated the process starts with two nurses counting medications when they come on shift. Ultimately, nurses are verifying that medication count is correct from the previous shift. Then, if there is a discrepancy it is the obligation of the nurses on the floor to figure out the discrepancy and fix the count before leaving nurse's shifts. Once there is a reconciliation of narcotics entered in the computer system, a message will populate to RN E and RN E then reviews it and signs if the discrepancy was fixed accurately. Messages are also forwarded to DON B for review. Surveyor asked RN E if RN E physically reviews the controlled medications count that was off to confirm the issue was fixed and accurate. RN E indicated that RN E does not do that for every single discrepancy that nurses reconcile, but RN E does fill out a paper for those said items. Surveyor asked RN E to review the discrepancies for R7 with Lorazepam that was last filled and delivered to facility on 01/06/25. Surveyor noted to RN E that on the reconciliation log: On 01/06/25, the amount to start was 30ml. On 01/07/25, 0.25ml was given, with amount ending 29.75ml. On 01/07/25, another dose of 0.25ml was given, with amount ending 29.50ml. On 01/08/25, 0.25ml was given, with amount ending 29.25ml. On 01/08/25, another 0.25ml was given, with amount ending 29 ml. On 01/11/25, no amount was given, but amount ending in 14.75 ml was counted and signed off. On 01/13/25, no amount was given, but amount ending in 30 ml was counted and signed off. RN E indicated that those discrepancies were not noticed or reviewed and unsure why it occurred. Surveyor asked RN E if any of those discrepancies chimed an email in the computer system for RN E to review and correct. RN E indicated those discrepancies did not come across as a notification. Surveyor asked if RN E's process is accurate in depicting possible discrepancies in controlled medication use. RN E indicated the system is not working for the facility at this time.

Based on observation and interview, the facility did not ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles, for 4 of 5 residents (R) reviewed (R1, R24, R27, R7). -Facility did not have open date labels on controlled medications that had been opened and were located in the medication storage room refrigerator for 3 of 4 residents (R) reviewed. (R1, R24, and R27) -Observation of R7's Lorazepam, which expired on [DATE], still located in medication storage room in unlocked refrigerator. Findings include: Facility policy titled, Storage of Medications, dated 2012, states in part, .#7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others . On [DATE] at 8:05 AM, Surveyor toured medication storage room with Registered Nurse (RN) F. RN F opened refrigerator located in the medication storage room, and Surveyor observed Lorazepam 2mg/ml bottles for (R24, R1, R7, and R27) sitting on first shelf in refrigerator. Surveyor did not observe the Lorazepam locked in fridge. Surveyor asked RN F if the refrigerator is lockable or if there is a box located in the refrigerator that Lorazepam is locked in. RN F indicated the refrigerator does not lock and there is not a locked box in the refrigerator. Surveyor observed R1, R24, and R27 did not have labels of date opened or resident identifier on Lorazepam bottles that were opened. Surveyor observed R7's Lorazepam expired on [DATE] and was located in the refrigerator in the medication storage room. Surveyor asked RN F if R7's Lorazepam is still being used and what is the process for destructing an expired medication. RN F indicated that R7's Lorazepam probably should have been discarded by now and that RN F can destruct the appropriate way with two licensed personnel. On [DATE] at 9:31 AM, Surveyor interviewed Director of Nursing (DON) B and asked expectation of storage of controlled substances referring to Lorazepam being stored in the refrigerator in the medication storage room. DON B indicated that Lorazepam is in the refrigerator in medication storage room. Surveyor asked DON B if the refrigerator was locked in the medication storage room or if there was a locked box in the refrigerator. DON B indicated the refrigerator is not locked and did not realize Lorazepam needed to be double locked. Surveyor asked DON B what the expectation is for labeling resident identifiers and open date for R1, R24, and R27's bottles of Lorazepam once opened. DON B indicated expectation is that an open label is applied once Lorazepam is opened to have the date opened and expired date on label. DON B indicated that all medications are to have resident identifier on the bottle as well. Surveyor asked DON B's expectation of destruction of R7's Lorazepam expired on [DATE] still located in the refrigerator in the medication storage room. DON B indicated that R7's expired Lorazepam should have been discarded right away by two licensed personnel.

Based on observation, interview and record review, the facility did not ensure residents received the necessary treatment and services consistent with professional standards, to prevent pressure injuries (PI) from developing and promote healing for 2 of 2 residents (R1 and R2) reviewed for PIs. R1 was admitted to the facility without a PI and was assessed to be at risk for PI development. The facility failed to implement robust interventions to prevent PI development, did not assess or stage the PI weekly and did not update care plan interventions timely. R1 developed a facility acquired PI that worsened to a stage 4. The facility's failure to complete weekly comprehensive PI assessments, offer alternate repositioning schedules, update the care plan and implement interventions for R1 created a finding of immediate jeopardy that began on 01/09/25. Nursing Home Administrator (NHA) A was notified of the immediate jeopardy on 02/13/25 at 12:30 PM. The immediate jeopardy was removed on 02/19/25; however, the deficient practice continues at a scope/severity level D (potential for harm/isolated) as they continue to implement their interventions for residents at risk for PIs and as evidenced by the following example. R2 was admitted to the facility without a PI and was assessed to be at risk for PI development. The facility failed to complete comprehensive assessments, and did not offer alternative interventions or educate R2 on risks and benefits when R2 refused repositioning. R2 developed two deep tissue injuries (DTI) on the right and left buttock on 9/12/24; on 9/20/24 six PIs are identified. The multiple PIs worsened to one unstageable PI with undermining. This is evidenced by: Guidelines from the National Pressure Injury Advisory Panel (NPIAP) Quick Reference Guide 2019 indicate in part: 2.1 Conduct a comprehensive skin and tissue assessment for all individuals at risk of pressure injuries: As soon as possible after admission/transfer to the health care service .5.1 Reposition all individuals with or at risk of pressure injuries on an individualized schedule, unless contraindicated .5.5 Reposition the individual in such a way that optimal offloading of all bony prominences and maximum redistribution of pressure is achieved . NPIAP Classification Unstageable Pressure injury: Obscured full thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed . Example 1 R1 was admitted to the facility on [DATE] with diagnoses of osteoarthritis right knee, right shoulder, anxiety disorder, major depression, chronic kidney disease stage 3a, and anemia. There was no evidence that R1 had a PI upon admission. Minimum Data Set (MDS) dated [DATE], an admission assessment, documented brief interview status (BIMS) score of 13 meaning R1 is cognitively intact. R1 has impairment to one side of the upper extremities and both sides of the lower extremities. R1 requires maximum assist from staff for upper body dressing, personal hygiene, transfers and is dependent on staff for toileting, showers, lower body dressing and transfers. R1 had no behaviors of rejection of cares. R1 is at risk for PI and has no PI present on admission. R1's pain is frequent and rated at 8/10. Progress notes documented on 08/01/24 skin problems: Bordered foam removed from coccyx. Previous open area healed. All skin intact. On 08/01/24, an order for Juven supplement 1 packet with 8 oz of water b.i.d. (twice a day) for wound healing. On 08/01/24, the facility completed a Braden pressure injury risk assessment with a score of 17, indicating R1 is at mild risk for skin breakdown. On 08/11/24, a progress note for skin problems; bordered foam to coccyx restarted as area is starting to break down again. Resident denies pain to area. Pressure relief cushion in w/c and recliner. The facility did not complete a comprehensive assessment of the area to include description of the PI, stage of the PI, and measurements. On 08/21/24, a weekly skin assessment documented, Resident was in bathroom when CNA (Certified Nursing Assistant) called this writer to assess coccyx area. Length 1.7 cm, Width 0.9 cm, Tissue Type: Area appears as skin breakdown from top layer of tissue. Area is slightly moist, dressing was not intact. Wound tissue: Dark pink, slightly moist, edges defined. Physician was notified. Of note, this assessment is 10 days after the first PI was noted and the facility did not stage the PI or update the care plan with new PI interventions. Facility did not complete a weekly skin assessment on 08/28/24 to include all components of a comprehensive PI assessment. On 09/06/24, a weekly skin assessment documented 1.7 cm by 1 cm and depth appears to have cratered in, skin around site appears to be 0.3 cm higher than middle of wound bed. Wound bed appears to be covered with greater than 75% pale yellow slough with small amount of sero-sanguineous drainage. Physician was notified. Continue to observe and reposition. Note at this time the PI would be at a stage 3 or higher with slough to the wound bed. On 09/06/24, new treatment order to cleanse coccyx area wound, place collagen to fit wound bed, and cover with bordered foam daily AM. On 09/08/24, a skin problem note documented measurements of 2 cm by 2.5 cm by 0.6 cm at the deepest area, but wound bed is covered with yellow slough. Small amount brown/yellow drainage and no odor. Area cleansed, collagen applied with bordered foam. Education again with resident on moving and walking. Of note, this PI has increased in size. On 09/12/24, a late entry weekly skin assessment. Measurements of 2.6 cm by 2.8 cm by 0.4 cm, small hole like area with yellow slough. Moderate amount of pale yellow drainage. Per Gentell wound specialist recommendation, continue collagen to wound bed and into hole like area of wound, cover with super absorbent dressing daily. Resident refuses to lay down to offload pressure from coccyx during the day, prefers to sit in the recliner. Has an equa-gel cushion now in recliner. Encouraged resident to lay down during the day. Of note, this is the first time R1 has seen a wound specialist. On 09/18/24, a weekly skin assessment measurements 2.7 cm by 2.5 cm by 1.5 cm with slough. Wound bed appears as a crater, from what can be visualized that is not covered in pale yellow moist slough less than 90%. Small amount of serous drainage noted to old dressing. Resident was strongly encouraged to stay in bed to stay off of site, but resident is adamant that she needs to sit up. Physician was notified. On 09/26/24, weekly skin assessment measurements 2 cm by 2.5 cm by 1.5 cm with pale yellow slough and moist pink tissue noted at wound bed. Physician was notified, continue to observe, repositioned, infection control RN (Registered Nurse) replaced current cushion (equa-gel) with a taller equa-gel cushion that is 2.5 tall to give more support for offloading pressure. On 10/04/24, a skin problem note documented wound rounds were done with Gentell wound specialist on 10/03/24. Coccyx stage 3 measurements 2.7 cm by 2 cm by 0.8 cm with granulation tissue. Pressure relieving interventions in place, recently added to her recliner was a Equagel Protector cushion 2.5, air mattress with pump (this was added on 08/29/24), repositioning every 2 hours as resident allows, and use of wedges and pillows. She also takes Juven BID in AM/PM to promote wound healing. Collagen packed into wound bed and covered with a super absorbent dressing and all sides secured with silicone tape. Education has been provided to resident by this writer on the importance of repositioning. Of note, the positioning schedule of every 2 hours added on 10/4/24 is not current standard of practice for repositioning with a PI on the coccyx. On 10/03/24, a new treatment order to cleanse coccyx area, pack a 2x2 collagen (folding) into wound bed, skin prep to intact surround skin, cover with a super absorbent dressing, and secure all edges of dressing with silicone tape to prevent stool from undermining dressing every three days and as needed AM. The facility did not complete a weekly skin assessment that covers a comprehensive assessment of a PI on 10/11/24. On 10/18/24, skin problem note documented measurements of 2 cm by 2.4 cm by 0.9 cm with slough. Undermining present from 9 o'clock - 1 o'clock of wound bed measuring 1.5 cm at this time. Small amount of light gray-yellow drainage noted. Informed resident the area is not improving and needs to offload pressure from site. Physician was notified. Of note, this PI has now worsened with undermining and the facility has not staged the PI since first identified and did not add new PI interventions to the care plan when the PI is worsening. On 10/25/24, weekly skin assessment measurements of 2 cm by 2.1 cm by 1 cm with pale white-yellow slough at base of wound. Undermining 9 o'clock - 1 o'clock of wound bed measuring 1.5 cm. Small amount of serosanguineous drainage noted. Treatment hydraferra blue dressing to fit wound bed, skin prep to surrounding area and cover with absorbent dressing and secure with silicone tape. Physician was notified. Added to care plan to use pillow in recliner to offload pressure from coccyx while in chair. Of note, using a pillow will compress and would not be an effective offloading device. Again, the facility did not stage the PI. Consistently staging the PI is important in determining if interventions are successful or if interventions need to be altered. On 10/25/24, a new treatment order. Remove old dressing to coccyx area, including old hydra-[NAME] blue dressing at wound bed. Cleanse wound with wound cleanser. Use cotton tipped applicator to rub very inner edges at surface of wound as intervention to epibole effect. Cut new hydra-[NAME] blue dressing to fit wound bed, re-hydrating it with normal saline and squeezing out the excess. Place on wound bed base. Place skin prep to intact surround skin, cover with a super absorbent dressing, and secure all edges of dressing with silicone tape to prevent stool from undermining dressing every three days and as needed. Care plan dated 11/08/24 documented, I didn't meet my goal because: has area to the coccyx that is being treated as current area open with slough 2cm by 2.1cm and depth 1cm in size on coccyx My goal remains appropriate. Continue my goal for 3 months. 01/21/25 I need to reposition frequently and reminders to reposition often, to keep pressure off of the coccyx area. I need my aides to help me with hygiene and general skin care .help me reposition at least every 1-2 hours while I'm in bed help me reposition at least every 1 hour when I'm in a chair and not to sleep in my chair .Goal Time: Three months. (08/29/24 air mattress with pump, 09/28/24 Equagel Protector cushion - 2 .5 to w/c and recliner, (Equagel cushion is adequate for all stages) 10/25/24 use pillow at either side (one or the other) while in recliner to offload pressure from coccyx area, 01/09/25 limit time in recliner and do not sleep in recliner, off load pressure to the wound on coccyx follow up with wound clinic as needed. Of note, this is the first care plan related to skin integrity. On 11/01/24, a new order for Med Pass 2.0 a food supplement to be given at AM and PM. Of note, this is the last updated nutritional intervention for R1. On 11/10/24, a weekly skin assessment measurements 2.2 cm by 2.1 cm by 0.9 cm with white/yellow slough, undermining remains measuring 1.5 cm. small amount of brown drainage noted. There was no evidence that staff documented the stage of the PI during this assessment. The physician was not updated with the increase in size. On 11/15/24, a weekly skin assessment measurements 2 cm by 1.9 cm by 1.1 cm with white/pale yellow slough at center, undermining noted to approximately 11 o'clock measuring 1.4 cm. Small amount of pale yellow drainage. Physician was notified. Resident encouraged to off load pressure from site by laying on sides, even when in recliner to try and offload pressure. Of note, the PI is worsening with undermining and drainage. New PI interventions are not added to the care plan to promote healing. On 11/21/24, a weekly skin assessment measurements 2.1 cm by 1.9 cm by 0.9 cm with scattered white-pale slough near center. Undermining continues to the 11 o'clock area measuring 1.1 cm. Small amount of pale yellow-tan drainage. Physician was notified. Resident encouraged to reposition. On 11/27/24, a weekly skin assessment measurements 2 cm by 1 cm by 1.4 cm with 50% granulation tissue and 50% pale yellow-white slough. Undermining noted slightly at edges of wound longest at 12 o'clock with 1 cm. Physician was notified. On 11/27/24, new treatment change to dry blue foam dressing to fit wound bed. On 12/3/24, a late entry for 10/31/24, a skin problem note documented measurements of 1.5 cm by 1 cm by 1 cm with 80% slough. On 12/05/24, a weekly skin assessment measurements 1.9 cm by 1.1 cm by 1.1 cm with pale yellow slough marbled throughout wound. Undermining continues at approximately 12 o'clock with approximately 1.1 cm in length. Small-moderate amount of serous drainage. No odor. Physician was notified. Resident educated to reposition and off-loading. On 12/11/24, a weekly skin assessment measurements 1.9 cm by 1.1 cm by 1.0 cm with light amount of pale white-yellow slough marbled throughout wound bed. Undermining remains at 12 o'clock with approximately 1 cm in length. Small-moderate amount of serous drainage. Physician was notified. Resident encouraged to rest and reposition. The facility did not complete a weekly skin assessment on 12/18/24. On 12/27/24, a weekly skin assessment measurements 1.8 cm by 1.1 cm by 0.7 cm with pale yellow slough marbled throughout. Undermining remains at 12 o'clock area at approximately 1.5 cm in length. Moderate amount of light tan serous drainage. Resident encouraged to reposition. On 12/31/24, a new order for Acetaminophen 650 mg daily prn for pain. This order was discontinued on 02/11/25. On 01/03/25, a weekly skin assessment measurements 1.9 cm by 1.1 cm by 2.1 cm with 75% slough that is pale yellow to shades of green to area at 9 o'clock with tan-brown color. Peri wound is noted to be reddened and inflamed. Resident states area is sore. A foul odor is noted. Undermining approximately 1.5 cm noted at 12 o'clock. Message left for provider. Of note, the PI is showing signs of infection and increased undermining, no new interventions were added to the care plan. On 01/03/25, new order for antibiotic Keflex 500 mg daily for 7 days for wound infection. No culture of the wound was obtained. On 01/03/25, a new treatment order. Remove old dressing to coccyx area. Cleanse wound with wound cleanser, wound should be thoroughly flushed, removing foreign material and dead tissue. After soaking 4x4 gauze in 20-30 ml Dakins solution, squeeze excess solution from gauze so that it is not dripping, gently pack into all wound bed area. Ensure Dakins soaked gauze is not touching any healthy tissue, only wound tissue. Cover wound area with absorbent dressing, ensuring all wound pockets are crevices are covered. Apply silicone tape to dressing edges to prevent stool from undermining dressing bid AM and PM. On 01/03/25, Nurse Practitioner placed a wound consult order. On 01/09/25, a late entry for 01/08/25 weekly wound assessment. Measurements 2.2 cm by 1.1 cm by 1.5 cm. Wound bed noted to be more red vs slough. No odor today. Undermining ranging in varying lengths form 9 o'clock to 1 o'clock, with longest depth at 1.5 cm. Treatment of Dakins wet to dry dressing BID. Resident stated area is tender. Physician notified. Resident encouraged to offload pressure from site. On 01/09/25, a new order Tramadol HCL 50 mg stat for pain going to wound clinic for wound, having pain in wound. On 01/09/25, a wound center new patient progress note documented in part: She reports that she does have pain around the coccyx area where the wound is. She reports that she has significant musculoskeletal pain, and that lying on her right side is generally more uncomfortable than lying on the left side. She spends most of the day in a recliner, including napping at times. Impression: Pressure Ulcer - Stage IV Deep, but clean wound to fascia overlying sacrum. No exposed, rough bone. Wound likely consequence from prolonged time up in recliner, limited mobility and pain with osteoarthritis. On the MDS, dated [DATE], a significant change assessment, R1 had no behaviors of rejections of cares provided by staff. R1 is dependent on staff assistance for bed mobility. R1 requires maximum assistance from staff for transfers. MDS documented R1 is at risk for PI and has a non-healed stage 4 PI. The facility did not complete a weekly wound assessment on 01/16/25. On 01/17/25, new treatment order. Remove old dressing to coccyx area. Cleanse wound with wound cleanser, wound should be thoroughly flushed, removing foreign material and dead tissue. Loosely pack wound with calcium alginate Silver and cover daily AM. On 01/25/25, a weekly wound assessment measurements 2.0 cm by 1.1 cm by 1.5 cm with some white to yellow slough at the base of the wound. No odor noted. Undermining from 9 o'clock to 1 o'clock with longest depth of 1.5 cm. Treatment of Calcium alginate with silver. Resident did not complain of pain. On 01/31/25, a weekly wound assessment measurements 2 cm by 1.6 cm by 1.5 cm with 10% white-yellow slough to wound base. Undermining continues at 12 o'clock with approximately 3 cm of depth. Note PI has increased in size. Undermining from 9 o'clock to 3 o'clock with varying length with 12 o'clock is the longest. Treatment changed to hydroferra blue foam packed to fit in wound bed. Resident had no c/o pain. Physician notified. Resident encouraged to reposition. Message sent out to staff to educate on importance of changing the dressing when there is breakthrough drainage noted or if the dressing is not sealed/intact at the edges. On 02/05/25, a new treatment order. Remove old dressing to coccyx area. Cleanse wound with wound cleanser, wound should be thoroughly flushed, removing foreign material and dead tissue. Loosely pack wound with blue foam so that it touches wound bed and walls, cover with absorbent dressing daily and prn. On 02/07/25, a weekly wound assessment measurements 2.1 cm by 1.0 cm by 1.3 cm with granulation tissue and no slough noted. Periwound is pink, maceration noted to the 3 o'clock to 5 o'clock area at wound edges. Undermining from 11 o'clock to about 3 o'clock with longest/deepest measurement of approximately 3.2 cm with yellow-tan serous drainage. Note the PI undermining has increased in size. No odor. Physician notified. Resident encouraged to rest, reposition. Of note, the facility does not stage the PI from the time first observed on 8/11/24 through 02/07/25, to determine worsening. On 02/11/25, a new order for Acetaminophen 650 mg daily prn for pain. On 02/11/25 at 11:27 a.m., Surveyor observed R1 lying in bed with a pillow under right side of lower back to buttocks. R1 is not offloaded of the coccyx area. On 02/12/25, a new order for Tramadol HCL 75 mg t.i.d. 6:00 a.m., 12:00 p.m., 6:00 p.m. for pain. On 02/12/25 at 10:52 a.m., Surveyor observed wound care. The wound observed to be a stage 4 with undermining. The wound bed had very minimal slough with the wound bed beefy red. On 02/12/25 at 11:54 a.m., Surveyor interviewed R1 about the wound and repositioning. R1 stated she has pain and asked if she could move. Resident was just transferred to recliner for lunch. R1 stated every 2 hours but she does have pain and would like to be positioned in another position. On 02/12/25 at 2:50 p.m., Surveyor observed R1 in bed with head of bed elevated slightly and had a wedge cushion placed on R1's back right side. The wedge cushion was positioned from mid back to distal buttocks. At 2:53 p.m., Surveyor asked Director of Nursing (DON) B to assess R1's positioning and asked if the coccyx area is offloaded to be able to insert hand between resident and wedge without touching R1. DON B inserted her hand and stated R1 was not off loaded. On 02/12/25 at 11:58 a.m., Surveyor interviewed Nurse Practitioner (NP) I asking if the wound was avoidable. NP I indicated in a sense it is avoidable and also unavoidable as the resident does not want to reposition and has been educated and the family also educated numerous times. Surveyor asked if there were any medical indications that would make the resident at risk for further decline in skin and healing. NP I indicated there is no medical issues to cause decline to make it unavoidable. R1 has lost weight per resident wishes as her diet before coming to the facility was very poor and now she is getting a balanced diet. On 02/13/25 at 9:50 a.m., Surveyor interviewed NHA A about the air mattress. NHA A indicated the mattress for R1 is rated up to a stage 3 pressure injury. Of note, the air mattress on R1's bed was appropriate for up to a stage 3 PI. However, the wound clinic staged R1's PI as a stage 4. There is no indication the mattress was changed to provide additional pressure relief. The failure to ensure that nurses and CNAs had the appropriate training and knowledge to prevent and care for pressure injuries created a finding of immediate jeopardy for R1. The immediacy was removed on 02/21/25 when the facility completed the following: 1. Full facility skin assessment sweep completed by facility nursing leadership. Wound Care Consultant (Gentell) rounded on 2/14/25 for residents with areas of wound concerns all but one resident who was out for a procedure. Wound Consultant returns Thursday 2/20/25. First wound rounds is Tuesday 2/18/2025 at 10am. 2. Full facility Braden Scale Sweep competed by nursing leadership. 3. Interventions put in place based on Braden scale score. 4. All care plans for residents with any skin concerns reviewed for appropriate interventions and updated. 5. For all pressure injuries identified or current, review each resident's nutrition, appetites, weights, blood sugar, hydration competed by nursing leadership to make sure appropriate interventions are in place for those residents. 6. Inventory of all mattresses and cushions that residents utilize and identify the stages for each. Changes made to these to make sure they are appropriate for the needs of the residents. 7. Get a Alternating Air Mattress ordered that supports up to a Stage IV wound. - Ordered 2/17/2025, ETA 2-3 days. 8. Obtain mattress and cushion information from manufacturer or supplier to make sure they meet the correct needs of the residents. 9. Hydration assessments on residents whom are identified for Pressure Ulcers. 10. Training for RNs and LPNs was initiated on 2/15/2025, to be complete by 02/21/25. -Admission Checklist and Re-Admission Checklist and implementing a base-line care plan for skin break down interventions based on the Braden Scale. -Wound assessments, staging, types of ulcers, and documentation provided by Nursing Leadership. -Implementation of wound rounds and the responsibilities of the floor nurses related to this, notifications for MD, RN, and POAs. -New pressure ulcer checklist, the expectations of assessment, notifications, and documentation. -Completing Braden Scale assessments correctly. Education on interventions that need to be put in place based off of the Braden Scale Score. 11. Training of RN, LPN, and CNAs -On positioning devices, mattresses, and cushion to ensure they know the correct item needed based on residents' pressure ulcer. -Positioning and repositioning. How to do it correctly and appropriate timing of repositioning including documentation of refusals and acceptance. -Intake documentation policy for meal and fluid intakes and snacks. 12. Implement weekly Wound Rounds to be completed on Tuesday Mornings at 10am. Team will consist of Wound Nurse, DON, MDS Coordinator, Infection Preventionist, Floor Nurse, and CNA. working with resident as needed. During these rounds wounds will be assessed and measured. Current care plan will be brought with to rounds. Teams will assess that all listed interventions are in place, cushions, mattress, repositioning, no kinked tubing, proper inflation of cushion if needed. After round assessment the nursing leadership team and culinary manager will meet to review the care plan, review all interventions are appropriate and initiate new interventions. Team will also review Braden scales, hydration, appetites, supplements, and current treatment orders for appropriateness and to initiate new interventions. Will also review nursing and CNA documentation for accuracy and that it is completed. Update Admission and Re-admission checklist to clarify the expectations upon admission for the Skin assessment, braden scale, and interventions implemented in the baseline care plan. Implement checklist for nursing to use when a new skin concern; pressure or ulcer area. (Not for skin tears or abrasions). The checklist will have all assessment and interventions that should be considered or put in place when a new area is indicated to make sure that proper assessment and interventions are put in place immediately. The checklist will then be given to DON to review. Checklist will also have examples of interventions that can be put in place. Implement new documentation for meals, fluids, and snacks. Implement provider and resident representative being updated weekly after wound rounds with current wound measurements and wound assessment. Update policy and procedures related to skin, wounds, Braden scales, and repositioning Monitoring, audits, Quality Assurance and Performance Improvement Plan DON or designee will receive new pressure ulcer checklist to review. Skin Care interventions will be reviewed during wound round assessments and meeting. Skin documentation will be reviewed for accuracy during this meeting and education provided to staff if inaccuracies are noted during monitoring. Audits will be completed to review braden scale assessment, wound documentation, dressing competencies, care plans, and resident repositioning. - Nursing Leadership will conduct audits daily for 2 weeks, weekly for 8 weeks, and monthly for 3 months of residents with pressure injuries. QAPI will review all residents with wounds monthly for 1 year. QA will review all resident with wounds quarterly for 1 year and review/update skin care policies as needed. Facility Assessment will be updated related to any wound resident care requirements. The deficient practice continues at a scope/severity of D (potential for harm/isolated) as evidenced by: Example 2 R2 was admitted to the facility on [DATE] with hospice care starting on 08/30/24. R2's diagnoses include dementia with psychotic disturbance, chronic pain syndrome, urinary incontinence, severe protein-calorie malnutrition, cerebral infraction with residual deficits, Alzheimer's disease, anxiety, and major depressive disorder. The MDS, dated [DATE], an admission assessment, documented a BIMS score of 6 out of 15, meaning severe cognitive impairment. R2 has physical and verbal behaviors and rejection of cares. R2 requires maximum assistance of staff for eating, oral care, bed mobility and transfers. R2 is dependent on staff for toileting hygiene, showers, and personal hygiene. R2 has physical impairments to one side of upper and lower extremities. R2 is at risk for PI and has no open PI. On 09/06/24, the facility completed a Braden pressure injury risk assessment with a score of 17, indicating R2 is at mild risk for skin breakdown. Physician orders Orders on 08/29/24 for meal supplement of Ensure vanilla with all meals, acetaminophen 650 mg three times a day for pain, gabapentin 100 mg daily in AM for left hand pain, gabapentin 300 mg daily at bedtime for left hand pain. Orders on 08/31/24 for methadone HCL 15 mg three times a day for chronic pain. Orders on 09/16/24 for lidocaine 4% patch to lower back 12 hours on and 12 hours off. Orders on 10/10/24 an order for Juven a nutritional supplement packet by mouth b.i.d. (twice a day) AM and HS for wound healing. Orders on 12/17/24 Morphine Sulfate 20 mg solution by mouth 1 ml / 20 mg every hour for pain and dyspnea (for end of life). The care plan, revised dated 12/03/24, read, I have the potential to have a skin injury .interventions (pressure relieving mattress with pump, use pillows and wedge to reposition me, encourage resident to adhere to repositing care, plan, providing education on the importance of preventing further skin breakdown, turn and reposition resident at least every 2 hours while in bed - as she allows) (10/04/24 Equagel protector cushion - 2.5 to recliner/wheelchair) (10/14/24 Encourage resident to wear podus boot to left foot while in bed for left heel redness as she allows) (10/25/24 Side to side positioning when in bed as resident allows, educate resident on importance of offloading from coccyx.) On 09/12/24, a skin problem note documented a late entry for 09/11/24. Deep dark red-purple area of tissue noted to left inner buttock, as well as right inner buttock. Left site measure 5 cm x 5 cm. has round edges and is purple like in color at inner most area. Outer area is dark red, neither area blanches upon touch. Right site (right buttock) noted to be dark red in color, does not blanch upon touch and measures 1.5 cm x 1.5 cm. No open areas present at this time. Resident has been noncompliant with repositioning since admission, and likes to sit/lay flat on back/buttocks while in bed. Does have air mattress, will ask hospice to bring their own as well as any repositioning tools . applied Lantiseptic and strict offloading of area encouraged. Provider NP updated, No New Orders. Hospice nurse updated. Floor nurse to update POA. DON updated, as well. The facility did not complete a comprehensive PI assessment. Of note, an air mattress was in place on 09/12/24. NPIAP definition of a Deep Tissue Injury: Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Of note, the above skin description on 9/12/24 meets the NPIAP definition for a DTI. The facility did not stage the wound when first noted on 9/12/24. On 09/20/24, a weekly skin assessment: Note this assessment was 2 days late. Left inner buttock measurements 3.5 cm by 0.5 cm, closed scabbed over, no drainage, dark red-purple in color. Lower spine, center above sacral area measurements 1.5 cm by 1.8 cm, closed area is dark pink tissue, non-blanching. Bordered foam for protection to be changed every 3 days. Left upper buttock to coccyx measurements 5 cm by 7 cm, skin is red and non-blanching upon touch. Left of sacrum, redness non-blanching measurements 3.5 cm by 2.5 cm closed. Right of sacrum measurements 5 cm by 4 cm closed and non-blanching. Right of sacrum below large area measurement 2.5 cm by 1.5 cm closed. The open areas above are not staged, bu [TRUNCATED]

Based on observation, interview, and record review, the facility did not ensure the resident environment remained as free of accidents as possible for 1 of 3 residents (R7) reviewed for accidents. R7 has a history of falls and has had 8 falls since admission. On 01/27/25, the facility failed to ensure that R7's fall interventions were in place resulting in R7 having a fall with injury requiring staples to the head, as well as a skin tear. This is cited at actual harm. Findings: The facility's Fall - Clinical Protocol policy dated 04/03/23 states in part, Assessment and Recognition 1. As part of the initial assessment, the physician will help identify individuals with a history of falls and risk factors for subsequent falling. a. Staff will ask the resident and the caregiver or family about a history of falling. b. The staff and physician should document in the medical record a history of one or more recent falls. c. While many falls are isolated individual incidents, a significant proportion occur among a few residents/patients. Those individuals may have a treatable medical disorder or functional disturbance as the underlying cause . Cause Identification: For an individual who has fallen, staff will complete root cause analysis. a. Causes refer to factors that are associated with or that directly result in a fall; for example, a balance problem caused by an old or recent stroke. b. Often, multiple factors in varying degrees contribute to a falling problem . Treatment/Management: 1. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling . 2. If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation (for example, if the individual continues to try to get up and walk without waiting for assistance). R7 was admitted to the facility on [DATE] with a diagnosis of end-stage Alzheimer's disease and on hospice. R7's most recent minimum data set (MDS) dated [DATE] indicated that R7 did not have a fall in the last month and had five falls in the last 2-6 months. R7 has a Brief Interview for Mental Status (BIMS) of 3 out of 15, indicating severe cognitive impairment. R7 requires setup/cleanup assistance with eating, requires substantial/maximum assistance with oral hygiene, toileting hygiene, upper and lower body dressing, and personal hygiene, and R7 is dependent on staff for putting on and taking off footwear. R7 walks 10, 50, and 150 feet with substantial/maximum assistance of staff. R7 requires partial/moderate assistance with rolling left to right, sit to lying, lying to sitting and sit to stand. R7 requires substantial/maximum assistance with toileting and chair/bed-to-chair transfers. R7 is occasionally incontinent of urine and always continent of bowel. Fall Risk Assessment for R7 completed on 06/05/24 shows a score of 18 indicating R7 was at risk for falling. Assessment indicates R7 has decreased awareness, poor recall and judgement for mental factors. Fall Risk Assessment for R7 completed on 09/05/24 shows a score of 25 indicating R7 was at a risk for falls. Assessment indicates R7 has decreased awareness, poor recall and judgment for mental factors. Fall Risk Assessment completed on 11/20/24 shows a score of 17 indicating R7 was at a risk for falls. Assessment indicates R7 has decreased awareness, poor recall and judgement for mental factors. R7's fall care plan was initiated on 06/04/24. Interventions included, I need my aides to make sure my important items are within my reach, give me non-skid footwear, so I don't slip, make sure my hearing aids are in and are working, remind me to wear my glasses, encourage me to use assistance, report signs that I am in pain to my nurse. Falls investigation are as follows, in part: On 06/09/24 at 8:58 PM, witnessed fall while transferring resident. Injury of skin tear to the left elbow. Immediate intervention put into place: Education provided to staff regarding transfers and making sure shoes are tied prior to standing resident. On 06/19/24 at 7:55 PM, unwitnessed fall. Skin tear to left elbow reopened. Immediate interventions put into place: Offer recliner after supper until bedtime. On 07/17/24 at 4:25 PM, witnessed fall. Has complaints of right elbow and right hip pain. Immediate intervention put into place: Reinforce to resident following each transfer that resident should not attempt to walk alone without walker. On 08/25/24 at 11:00 PM, unwitnessed fall. Hematoma to posterior head. Immediate interventions put into place: Remind resident to call for help before getting up. Place signs around room and on walker to call for help before getting up. On 09/16/24 at 1:15 PM, unwitnessed fall. Abrasion to the back of the head. Immediate interventions put into place: Bell placed on walker to alert staff when resident is moving. On 12/08/24 at 7:00 AM, witnessed fall. Laceration to left elbow and a red bump the size of a quarter to middle back of the head. Immediate interventions put into place: Hospice to adjust medication times to not wake resident for medications (per daughter). On 12/11/24 at 5:53 PM, unwitnessed fall. Irregular shaped, dark blue/purple bruising to right temple area. Immediate intervention put into place: When up in the circle she is in her wheelchair. On 01/27/25 at 7:25 AM, unwitnessed fall. Laceration/hematoma to right side of head. Educated staff on ensuring resident is wearing gripper socks at times when she is not wearing shoes. Of note: R7's fall care plan initiated on 06/04/24 indicates R7 is to have non-skid footwear. This was again listed as an intervention in all care plan revisions and following the fall on 01/27/25 when R7 was noted to not have the intervention in place at time of the fall. On 01/27/25, incident report findings: Date 01/27/25, Time 7:25 AM, Incident type: fall-unwitnessed leading to laceration. Location: Nurses station Activity at the time: Resident was seen by writer sleeping in the recliner chair 5 minutes prior to the fall. Equipment involved: recliner chair. Possible cause: Resident possibly tried to get up without assistance (she does this very often). Resident was barefoot as well. Mental state: normal for resident. Injury: laceration/hematoma to right side of head (W [sic] large amount of blood), a cut to left hand, and skin tear/bruising to R. First aid: immediately applied, transferred to emergency room . On 01/27/25, emergency room record findings: Physical examination: .HEENT: head is normocephalic, she has an inch and a half laceration to the mid scalp that is approximately 4 mm deep . Medical Decision Making: .emergency room Evaluation: Upon arrival to the ER patient is hemodynamically stable. Her skin tear and scalp lacerations were cleansed with copious amounts of chlorhexidine and saline. For her skin tear, some bacitracin applied and a sterile clean dressing place. Her scalp laceration was stapled. Sick [sic] staples were placed, patient tolerated procedure well. After stapling, good hemostasis obtained. Some bacitracin was then applied. I did obtain a head CT and cervical CT which were both negative. Cervical collar was then removed, and her neck cleared. Impression: The primary encounter diagnosis was accidental fall, initial encounter. A diagnosis of laceration of scalp, initial encounter was also pertinent to this visit. Of note: R7 did not have care planned intervention in place, non-skid footwear, not on at time of the fall on 01/27/25 that resulted in a head laceration requiring six staples. On 02/12/25 at 11:21 AM, Surveyor interviewed Director of Nursing (DON) B. Surveyor informed DON B that the root cause for the fall dated 01/27/25 was the resident tried to get up without assistance and resident was barefoot as well. Surveyor asked DON B what the facility did after this fall. DON B replied, The staff were reeducated on the use of gripper socks when the resident was not wearing shoes. On 02/12/25 at 2:00 PM, Surveyor asked DON B for a copy of any education provided to staff following fall investigation from 1/27/25. DON B replied, We had a 'Fall Huddle' and this was verbal education given based on the appropriate intervention. Surveyor asked DON B, Do you believe that staff education should have been given and documented instead of a 'Fall Huddle'? DON B replied, No, in this case I think that the last 24 hours of staff that worked with this resident should have been talked to to make sure that they were aware of what went wrong. On 02/12/25 at 12:50 PM, Surveyor asked Certified Nursing Assistant (CNA) E, If this resident's care plan was to make sure the resident had on non-skid footwear and [R7] was barefoot when the fall took place, was the care plan followed? CNA E replied, No it wasn't. On 02/12/25 at 12:51 PM, Surveyor asked CNA D, If this resident's care plan was to make sure the resident had on non-skid footwear and [R7] was barefoot when the fall took place, was the care plan followed? CNA D replied, No it wasn't. On 02/12/25 at 12:52 PM, Surveyor asked Registered Nurse (RN) C, If this resident's care plan was to make sure the resident had on non-skid footwear and [R7] was barefoot when the fall took place, was the care plan followed? RN C replied, The staff followed the care plan, but she most likely took off her nonskid footwear. On 02/12/25 at 12:59 PM, Surveyor asked DON B, If this resident's care plan was to make sure the resident had on non-skid footwear and [R7] was barefoot when the fall took place, was the care plan followed? DON B replied, No, at that time we were not following the care plan. The facility failed to ensure that R7's care planned interventions were in place to prevent falls resulting in R7 having a fall with scalp laceration that required staples.

Based on interview and record review, the facility did not ensure staff received Quality Assurance Performance Improvement (QAPI) program training. This practice had the potential to affect all 43 residents in the facility. The facility did not provide any staff with required training on the facility's QAPI plan. This is evidenced by: The facility's Quality Assurance & Performance Improvement Plan, dated 01/2024, states in part: Staff Training and Orientation In order for caregivers to become and remain proficient with quality improvement tools and techniques, QAPI principles and staff responsibilities related to QAPI, and ongoing quality improvement will also be included in orientation for all new employees. In order to become and remain proficient with quality improvement tools and techniques all staff will participate in ongoing annual QAPI training . On 02/25/25, Surveyor reviewed the facility's new orientation and annual education completed with staff. Surveyor observed no training identified as QAPI education. On 02/25/25 at 1:54 AM, Surveyor interviewed Nursing Home Administrator (NHA) A regarding QAPI training. NHA A stated the facility currently did not have QAPI education included in new orientation or annual education for all employees. NHA A stated this was identified as a missing piece of education needed for all staff and would be working on creating a new orientation and annual QAPI training program.

Based on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law for 1 of 1 incidents reviewed. R10 alleged being physically abused by Certified Nursing Assistant (CNA) J on 02/09/25 at 11:00 PM. This was not reported to the state until 02/11/25 at 2:55 PM. This is evidenced by: Review of facility's policy titled Abuse, Neglect, and Misappropriation dated 04/02/23 read in part, All alleged violation involving abuse, neglect .are reported immediately to the State Agency, but not later than two (2) hours after the allegation is made, if the events that cause the allegation involve abuse . R10 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right side, anxiety, and depression. R10's annual Minimum Data Set (MDS) dated [DATE] recorded a Brief Interview for Mental Status (BIMS) of 12, which indicates moderate cognitive impairment. On 02/11/25 at 5:45 PM, Surveyor interviewed R10 asking if staff have ever physically abused R10. R10 indicated there was a time I was thrown against the wall. R10 reported to the nurse of the incident. R10 denied having any injuries. R10 could not recall who the staff was and could not remember when the incident occurred. R10 could not recall the specifics to the incident. A facility self report indicates that on 02/09/25 at 11:00 PM, R10 reported to Licensed Practical Nurse (LPN) K that CNA J banged R10's head against the wall during cares. LPN K assessed R10 and did not note any bruising, discoloration, or injuries. R10 denied any pain. LPN K reported immediately to Nursing Home Administrator (NHA) A and Director of Nursing (DON) B. Then LPN K sent CNA J home until the investigation was complete. CNA J reported R10 was verbally abusing CNA J when providing R10 cares. CNA J claimed R10's head did not hit the wall and believes there was a pillow between R10 and the wall. On 02/11/25 at 9:00 AM., Surveyor interviewed NHA A about reporting of the allegation of abuse. NHA A indicated staff reported immediately, within the two hours, to NHA A and DON B and assessed R10 who was found to have no injuries. NHA A went on to say, R10 has a history of not liking certain staff and making derogatory statements of minority staff. NHA A indicated it was determined the allegation of abuse did not occur, and R10 may have hit head on wall when rolled, but there was no injury to conclude R10's head hit the wall. NHA A determined this was not a willful act or an intentional act by CNA J and was not reported to the State agency as abuse. Surveyor asked NHA A if this was determined within the first 2 hours of R10 reporting. NHA A indicated it was not determined within the first 2 hours.

Based on interview and record review, the facility did not develop a compliance and ethics program that has been reasonably designed, implemented, and enforced so that it is likely to be effective in preventing and detecting criminal, civil, and administrative violations under the Act and promote quality of care. This has the potential to affect all 43 residents. Findings include: On 02/25/25, Surveyor reviewed the facility assessment dated [DATE] and revised on 02/20/24. The facility assessment does not include ethics and compliance training. On 02/25/25 at 2:00 p.m., Surveyor interviewed Nursing Home Administrator (NHA) A and asked if the facility had an ethics and compliance program. NHA A stated she knew the facility needed a program, but due to other issues/priorities that arose, this was put aside and never implemented.

Based on interview and record review, the facility did not set forth an effective way to communicate the program's standards, policies, and procedures through a training program or in another practical manner which explains the requirements under the program. This has the potential to affect all 43 residents. Findings include: On 02/25/25, Surveyor reviewed the facility assessment dated [DATE] and revised on 02/20/24. The facility assessment does not include ethics and compliance training. On 02/25/25, Surveyor reviewed three Certified Nursing Assistant (CNA) training records, and two licensed staff training records. CNA M, CNA N, CNA O, Registered Nurse (RN) H, Licensed Practical Nurse (LPN) K did not receive ethics and compliance training. On 02/25/25 at 2:00 p.m., Surveyor interviewed Nursing Home Administrator (NHA) A and asked if the facility had an ethics and compliance program and how they effectively communicate the program's standards, policies, and procedures through a training program NHA A stated she knew the facility needed a program, but due to other issues/priorities that arose, this was put aside. NHA A acknowledged there is no training.

Based on observation, interview and record review, the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. Sanitization testing was not recorded, dishwashing temperatures were not recorded, and refrigerator temperature logs were not recorded. This has the potential to affect all 45 residents who reside in the facility. This is evidenced by: The facility policy, entitled Dishwashing Machine Use, states: .A dietary personal will check the dishwashing machine for proper concentrations of sanitizer after filling the dishwashing machine and every day to reach 160 degrees F using Chem Strips .The operator will check temperatures using the machine gauge with each dishwashing machine cycle, and will record the results in a facility approved log . On 1/21/24 at 9:45 AM, Surveyor observed during the initial tour of the kitchen that there was no documentation that the staff test the sanitization levels of the chemicals used in the buckets and sink water. Surveyor asked Cook K if they test the sanitation levels for these. Cook K said they do test the sanitizer levels. Surveyor asked Cook K if they document that this was completed. Cook K said they do not have a log to document this was completed. Dishwasher used at the facility was a high temperature dish washing machine. Observation of the dishwasher temperature log hanging in the dishwash room contained missing logs. Surveyor asked Cook K about the missing logs, and she said they should be filled out at each mealtime every day. Cook K said they also send a temp gauge in the machine to test the temps. This also had missing logs. On 1/22/24 at 8:34 AM, Surveyor asked Dietary Aide (DA) J about testing the sanitization levels of the chemicals used in the buckets and sink water. DA J said we do this daily to make sure the sanitizing solution was still good to use. Surveyor asked DA J if they document this somewhere to know that it was completed and within the parameters for the sanitizing solution. DA J said no, we do not write it down. On 1/22/24 at 1:15 PM, Surveyor asked Dietary Manager (DM) I about when they test the sanitization levels of the chemicals used in the buckets and sink water. DM I said each time they are filled up with water, they are tested . Surveyor asked DM I how do you know the testing was completed. DM I said I take the staff's word that it was completed. We do not have a log to document when it was completed. Surveyor asked DM I when the dishwasher temperature log documentation should be filled out. DM I said after each meal service and the log for the irreversible temperature monitoring device needed to be completed each morning. Both logs had missing documentation. Surveyor asked DM I to see the prior month's documentation for the dishwasher temperature logs. Upon review, there were missing documentation on these months as well. DM I said she will educate staff to fill these out along with creating sanitization logs. Surveyor asked if there had been any food borne illness at the facility and she said no. On 1/22/24 at 1:45 PM, Surveyor spoke with Nursing Home Administrator (NHA) A concerning the missing temperature logs for the dishwasher and no sanitizing logs for sanitizing buckets and sinks. NHA A said DM I had talked with her about this. The dietician will be here tomorrow to help with education training for the staff. 46694 Example 2 The facility's policy titled, Refrigerators and Freezers revised 8/2016, states in part, .2. Monthly tracking sheets for all refrigerators and freezers will be posted to record temperatures. 3. Monthly tracking sheets will include temperature, initials, and action taken. The last column will be completed only if temperatures are not acceptable. 4. Food Service Supervisors or designated employees will check and record refrigerator and freezer temperatures daily with first opening and at closing in the evening . On 01/22/24 at 1:00 PM, Surveyor observed the temperature log located on the refrigerator in the family room dining missing temperatures logged: December 9th-14th, 17, 21st-24th, and 28th. January 2nd and 13th. On 01/22/24 at 1:50 PM, Surveyor interviewed Licensed Practical Nurse (LPN) D. Surveyor asked LPN D, Who is responsible for logging the refrigerator temperatures on the unit? LPN D replied, That is the night shift nursing staff's responsibility. On 01/22/24 at 1:52 PM, Surveyor interviewed Director of Nursing (DON) B. Surveyor asked DON B, Who do you expect to log the temperatures for the refrigerators on the unit? DON B replied, The night shift nursing staff would do this. On 01/22/24 at 1:54 PM, Surveyor interviewed Nursing Home Administrator (NHA) A. Surveyor asked NHA A, Who is responsible for logging the refrigerator temperatures on the unit? The NHA A replied, That is the nursing staff's job on the night shift.

Based on observation, interview and record review, the facility did not ensure 1 of 12 (R3) residents reviewed for comprehensive care plans had a developed care plan specific to the resident. This is evidenced by: The facility policy, entitled Care Plans - Comprehensive, states: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident .Each resident's comprehensive care plan is designed to: a. Incorporate identified problem areas; b. Incorporate risk factors associated with identified problems . On 1/23/24, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] with diagnoses including, but not limited to diabetes and colitis due to Clostridioides difficile (C-diff). Review of R3's Minimum Data Set (MDS) assessment, dated 12/13/23, included the diagnosis of diabetes and colitis due to C-diff. Review of R3's care plan indicated there was nothing written concerning diabetes nor colitis due to C- diff. Review of R3's nursing progress notes indicated R3 was admitted to the facility with the diagnosis of diabetes. During the months of May, June and July of 2023, R3 had high and low blood sugars needing intervention. R3 was first diagnosed with C-diff on 9/07/23. On 1/22/24 at 7:07 AM, Surveyor observed a sign on R3's door for droplet precautions and Personal Protective Equipment (PPE) outside of R3's room. Surveyor asked Licensed Practical Nurse (LPN) L why R3 was on droplet precautions. LPN L said R3 was on precautions for C-diff. On 1/23/24, Surveyor asked Director of Nursing (DON) B for the diabetes care plan for R3. DON B provided R3's care plan for diabetes that was created on this day (1/23/24). On 1/24/24 at 12:17 PM, Surveyor interviewed DON B concerning R3's care plan lacking information for the diagnosis of diabetes and C-diff. DON B said R3 should have these items included in the care plan to help guide resident care.

Based on observation, record review and interviews, the facility did not ensure that 1 of 4 sampled residents, (R) R19, who are unable to carry out activities of daily living, receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. This is evidenced by: The facility policy entitled: Repositioning, states in part .1. Repositioning is a common, effective intervention for preventing skin breakdown, promoting circulation, and providing pressure relief. 3. repositioning is critical for a resident who is immobile or dependent upon staff for repositioning. R19 was admitted to the facility on [DATE] and placed on hospice for end-of-life care on 08/29/23 related to decline in status related to a diagnosis of atherosclerotic heart disease. R19's most recent comprehensive assessment was a significant change Minimum Data Set (MDS) assessment, dated 08/23/23, which indicated that R19 is dependent for all Activities of Daily Living (ADL), totally incontinent of bowel and bladder, requires substantial to maximum assist for repositioning and is at risk for skin breakdown. R19's current care plan, dated 10/26/23, states: Prompt me to reposition often in bed and w/c. Encourage resident to lay down between meals - if resident refused reposition every 2 hours. On 01/22/24, Surveyor continuously observed R19 and noted the following: On 01/22/24 at 7:23 AM, Surveyor observed R19 being transferred to Broda chair after receiving morning cares and placed in front of the TV in R19's room. On 01/22/24 at 8:19 AM, Surveyor observed R19 brought to the dining room by staff without repositioning or toileting conducted. On 01/22/24 at 9:31 AM, Surveyor observed R19 brought back to R19's room and placed in front of the TV, without repositioning or toileting being offered or provided. On 01/22/24 at 10:37 AM, Surveyor observed R19 still sitting up in the reclining wheelchair watching TV; no staff entered room to reposition or conduct toileting needs. On 01/22/24 at 11:27 PM, Surveyor observed R19 visiting with family in R19's room; no staff entered room to reposition or conduct toileting needs. On 01/22/24 at 12:08 PM, Surveyor observed R19 taken to the dining room by a staff member, without repositioning or toileting being offered or provided. On 01/22/24 at 1:09 PM, Surveyor observed R19 brought back from the dining room and placed in R19's room and placed in front of the television. On 01/22/24 at 1:32 PM, Surveyor observed Certified Nursing Assistant (CNA) H transfer R19 to bed, wherein a urine soaked brief and reddened buttocks were noted. On 01/22/24 at 1:32 PM, CNA H confirmed noted redness of buttocks to Surveyor. On 01/22/24 at 3:35 PM, Surveyor interviewed Director of Nursing (DON) B, regarding observation of R19 sitting in chair for 6 hours without repositioning and incontinence care. DON B stated R19 is currently on hospice and the expectation would be R19 to be repositioned and provided incontinence cares at least every 2 hours.

Based on interview and record review, the facility failed to protect a resident from verbal and physical abuse by a Certified Nursing Assistant (CNA) and the facility failed to protect a resident from a physical abuse during a resident to resident altercation which resulted in injury for 2 of 3 residents reviewed (R1 and R3). R1 was on the floor when a staff person saw another staff person kick the resident with the toe of her shoe and state, Get up fat boy. R1 suffered physical and verbal abuse. R3 was walking towards R1, who was having behaviors. R1 threw their walker, striking R3's walker causing it to tip over and R3 fell to the ground and sustained a laceration and bruising. R3 sustained physical abuse from another resident. This is evidenced by: 1.) R1 was admitted to the facility on [DATE] with diagnoses including dementia, morbid obesity, major depressive disorder, falls, age related macular degeneration, Type 2 diabetes mellitus. R1's admission minimum data set (MDS) dated [DATE] recorded a brief interview for mental status (BIMS) of 4, which indicates severe cognitive impairment. R1 is not able to be interviewed, due to the severe cognitive issues. A facility self report indicates that on 02/18/23 at 12:30 PM, R1 was on the floor, and CNA D witnessed CNA C kick R1 in the upper buttocks/lower back with the toe of her shoe and state, Get up fat boy, pissy pants. Interview with CNA D on 03/09/23 at 3:22 PM. CNA D stated that as she entered the room, R1 and CNA C were already verbally going back and forth. CNA D stated that at first she thought that R1 was just having behaviors, as he is known to verbally act out. Then she realized this was something different. CNA D stated that she witnessed CNA C kick R1 at least three times with the toe of her shoe and state, Get up fat boy, at least twice. R1 stated to CNA D, Get her the hell out of here, she's mean. CNA D stated that she told CNA C to go, and that she had it under control. At which time CNA C kicked R1 once more with the toe of her shoe in the lower back/upper buttocks and then left the room. The facility self-report also states that CNA C laughed as she did this. CNA D stated that she immediately reported the incident of verbal and physical abuse to the LPN on duty, as soon as she got R1 cleaned up and settled in bed. The facility did not protect R1 from being physically and verbally abused. R1 cognitively can't recall or express the level of psychosocial harm from this event. The reasonable person concept is utilized in this situation. Any person being kicked and verbally abused by a staff member when vulnerable, would have fear and a sense of humiliation from this event. 2.) R3 was admitted to the facility on [DATE] with diagnoses including dementia, depressive disorder, osteoporosis, hypothyroidism, and chronic kidney disease. R3's MDS dated [DATE] recorded a BIMS of 10 which indicates moderately impaired cognition. A facility self report indicates that on 03/08/23 at 6:30 PM, R1 was lowered to the floor for safety reasons due to being combative and resistive. R1 was also making noises at the time. R3 was in the area and walked with a walker closer to R1, attempting to see what was going on, due to the noises. R1 then threw their walker at R3, which struck R3's walker causing R3 to lose her balance and fall. R3 struck their head causing a small laceration, and bruising. Interview at 9 AM on 03/14/23, with nursing home administrator (NHA) A. NHA A stated that she had reviewed the resident to resident incident between R1 and R3. NHA A stated that R1 willfully threw his walker at R1, possibly attempting to get R3 to back away, and as a result of that action R3 fell causing R3 a physical injury and pain. The facility did not protect R3 from being physically abused by another resident.

Based on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law for 2 of 2 incidents reviewed. R1 was verbally and physically abused by CNA C on 02/18/23 at 12:30 PM. This was not reported to the state until 02/20/23 at 1:45 PM and was not reported to law enforcement until 03/13/23. R1 was involved in a resident to resident incident which involved harm to R3 on 03/08/23. This was not reported to the state as of 3/13/23, or to law enforcement. This is evidenced by: 1.) R1 was admitted to the facility on [DATE] with diagnoses including dementia, morbid obesity, major depressive disorder, falls, age related macular degeneration, Type 2 diabetes mellitus. R1's admission minimum data set (MDS) dated [DATE] recorded a brief interview for mental status (BIMS) of 4, which indicates severe cognitive impairment. R1 is not able to be interviewed, due to the severe cognitive issues. A facility self report indicates that on 02/18/23 at 12:30 PM, R1 was on the floor, and CNA D witnessed CNA C kick R1 in the upper buttocks/lower back with the toe of her shoe and state, Get up fat boy, pissy pants. Interview with CNA D on 03/09/23 at 3:22 PM. CNA D stated that as she entered the room, R1 and CNA C were already verbally going back and forth. CNA D stated that at first she thought that R1 was just having behaviors, as he is known to verbally act out. Then she realized this was something different. CNA D stated that she witnessed CNA C kick R1 at least three times with the toe of her shoe and state, Get up fat boy, at least twice. R1 stated to CNA D, Get her the hell out of here, she's mean. CNA D stated that she told CNA C to go, and that she had it under control. At which time, CNA C kicked R1 once more with the toe of her shoe in the lower back/upper buttocks and then left the room. The facility self-report also states that CNA C laughed as she did this. CNA D stated that she immediately reported the incident of verbal and physical abuse to the LPN on duty, as soon as she got R1 cleaned up and settled in bed. The facility self report indicates that the above incident occurred on 02/18/23 at 12:30 PM. The facility self report was not submitted to the state until 02/20/23. The facility did not report the incident of abuse of R1 to law enforcement until 03/13/23. The surveyor observed a law enforcement officer responding to the facility and meeting with the NHA to discuss the incident, 23 days after it occured. 2.) R3 was admitted to the facility on [DATE] with diagnoses including dementia, depressive disorder, osteoporosis, hypothyroidism, and chronic kidney disease. R3's MDS dated [DATE] recorded a BIMs of 10 which indicates moderately impaired cognition. A facility self report indicates that on 03/08/23 at 6:30 PM, R1 was lowered to the floor for safety reasons due to being combative and resistive. R1 was also making noises at the time. R3 was in the area and walked with a walker closer to R1, attempting to see what was going on, due to the noises. R1 then threw their walker at R3, which struck R3's walker causing R3 to lose her balance and fall. R3 struck their head causing a small laceration, and bruising. Interview at 9 AM on 03/14/23, with nursing home administrator (NHA) A, who stated that she had reviewed the resident to resident incident between R1 and R3. NHA A stated she had not self reported the resident to resident incident when it occurred, but then after further review, she decided she should report it. NHA A stated that R1 willfully threw his walker at R3, possibly attempting to get R3 to back away, and as a result of that action R3 fell , causing R3 a physical injury and pain so she decided to self report the incident to the state on 03/13/23 at 4:21 PM, 5 days after the incident occurred. The facility did not report the incident of resident to resident abuse to law enforcement. Interview with the NHA revealed that as of 4 PM on 03/13/23, the facility had not reported the incident to law enforcement.

Based on observation, interview and record review, the facility did not ensure a resident who entered the facility without a pressure injury did not develop a pressure injury, and a resident with a pressure injury receives the necessary treatment to promote healing and prevent infection. This occurred for two of three residents with pressure injuries (Residents (R) 26 and 31). 1. R26 is at high risk for developing pressure injuries. The resident has had recurrent pressure injuries to the coccyx area, which is now an unstageable injury. The facility did not follow current standards of practice to prevent pressure injuries from occurring with repositioning, and offloading. The resident's wound was not offloaded when being positioned side-to-side, the facility did not minimize exposure to bowel and bladder, and did not implement nutritional interventions to promote wound healing. 2. R31 had a pressure injury on the right sacrum which dated back to (YEAR). The facility did not ~ Consistently and correctly stage R31's wound. ~ Change R31's treatment modalities when R31's wound showed signs of deterioration and/or when the wound re-opened. ~ Re-evaluate R31's pressure redistribution mattress and wheel chair cushion to ensure they still met R31's needs. ~ Ensure R31's air mattress was set at the appropriate setting. ~ Ensure R31's wheelchair cushion was filled with the appropriate amount of air to ensure proper pressure re-distribution. Additionally, observations revealed staff were not cleansing R31's skin after incontinence. Subsequently, R31's pressure injury healed and then re-opened 5 times since 07/19/17 and was currently staged as an unstageable wound. The first example rises to a G level. The additional example is at a D level. This is evidenced by: 1. On 09/18/18, Surveyor reviewed R26's medical record. The resident has [DIAGNOSES REDACTED]. The resident is generally non-verbal, and has short and long term memory deficits. R26 is totally dependent on staff for toileting, bathing, dressing, personal hygiene, transfers and eating. The resident does not ambulate, and spends the majority of time in bed, between meals. The resident uses a full-body mechanical lift (Hoyer) for transfers. R26's Minimum Data Set (MDS), dated [DATE], indicates the resident is always incontinent of both bowel and bladder function. According to the medical record, the resident has had an air mattress since 05/11/16, a Roho wheelchair cushion (a pressure relief cushion made out of flexible air cells) since 01/27/16. Surveyor reviewed the resident's Braden assessment, dated 09/02/17. A Braden assessment evaluates the resident's risk of developing a pressure injury. R26's Braden score from this date was 13. According to the Braden assessment, a score of 13 identifies the resident is at moderate risk for developing a pressure injury. Surveyor reviewed R26's nurses' and wound care notes, from 02/22/18 to 09/18/18. The notes state the following, in part: -02/22/18: The notes identify R26 has a new skin problem with an open area to the coccyx (tailbone); which measures 0.8 centimeters (cm) in length by 0.2 cm wide. The documentation states, in part, Coccyx presents with wound bed 100% pink, dry tissue, appearing like a blister that popped, area cleaned with antiseptic . -02/25/18: The notes identify the resident's coccyx has no open area. The resident's Braden score, dated 03/08/18, was 12. According to the Braden assessment, a score of 12 identifies the resident is at high risk for developing pressure injuries. The resident's MDS, with an assessment reference date of 03/21/18, identifies R26 had no unhealed pressure injures at this time. The resident's nurses' and wound care notes continue to state, in part: -04/04/18: The notes identify R26's coccyx has opened for a second time; with the open area measuring 1.5 cm by 0.2 cm. -04/10/18: Wound rounds: Completed 4/5/18. Assessed buttock area per request of nursing. Superficial area noted at the top of buttock crease in the very middle .dry on rounds, (R26's first name) is incontinent of bowel and bladder, remains at risk for skin breakdown. Pressure reducing/relieving interventions have been in place for quite some time in P[NAME] (Plan of Care). Wound team feels area to upper buttock crease may be related to shearing possibly with repositioning in either bed or w/c (wheelchair). (R26) is dependent on staff for repositioning needs . -04/16/18: The documentation identifies the resident's coccyx is now healed. -04/17/18: The notes indicate R26's coccyx has opened, it is noted for a third time in less than two months. There are no measurements of the size of the superficial open area. -04/23/18: The documentation indicates there is no open area to the resident's coccyx. -05/17/18: Resident has a recurrent small superficial open area between buttocks .Resident has rest periods in bed between meals . On this date, the facility added a pump to the resident's air mattress. It is not identified in the record what advantage the pump provides to the pressure injury and the pressure mattress. -05/21/18: Two, stage II pressure injuries areas to the resident's coccyx are documented. The right area measures 0.2 cm by 0.2 cm; while the left open area measures 0.5 cm by 0.2 cm. -06/04/18: There is no open areas to the coccyx. -06/05/18: An Occupational Therapist evaluated the resident for proper wheelchair positioning. It was found the resident's current use of a Broda (brand name) wheelchair was appropriate. -06/06/18: Two areas to R26's coccyx have opened. This is the fourth time, since 02/22/18, a wound to the resident's coccyx has re-occurred. -06/09/18: The wound measures 0.3 cm by 0.2 cm with no depth, and is compared to the size of a pencil eraser. -06/18/18: It is documented R26 is repositioned side-to-side when in bed. -06/26/18: R26's wound is now healed. -07/12/18: R26's coccyx is open, for a fifth time. It is documented the first layer of skin is removed; which is the definition of a stage II pressure injury. -07/16/18: The wound measures 1.5 cm long by 0.5 cm wide, with small serous (clear) drainage. -07/18/18: On this date, the facility educated nursing staff to keep the resident's head of the bed elevated no more than 30 degrees, and to check the resident's positioning in the wheelchair. The documentation does not specify how to, or how often staff should check R26's wheelchair positioning. -07/24/18: The wound presents with 95% yellow slough (dead tissue). According to the National Pressure Ulcer Advisory Panel (NPUAP), if the base of the wound is covered in slough, the pressure injury is considered to be unstageable. NPUAP indicates the wound cannot be staged until enough slough is removed so the wound base is exposed to completely assess the depth of the wound. On this date, the facility changed the resident's Roho cushion from a large air cell to a small air cell cushion. The resident's care plan was updated to indicate the Hoyer sling should be removed from beneath the resident after transfers. Surveyor reviewed a physician's progress note, dated 07/25/18, which states the following, in part, Subjective .Staff report that (R26's first name) frequently sleeps through meals, so intake is poor. Nursing staff spoke with dietician previously about starting supplements, but report that dietician did not feel there were any appropriate options for (R26) due to his diabetes and need for altered textured diet and fluids, so no supplementation has been implemented. Continues to have a coccyx wound for which duoderm is being applied and changed every 3 days until healed. The medical record identifies R26 has lost #17, and 10.06% of his body weight, from 01/19/18 to 06/25/18. There is no documentation in the resident's medical record, a nutritional supplement was attempted or obtained for the resident; in order to promote wound healing, from 02/22/18 to this time. The resident's nurses' and wound care notes continue to state, in part: -07/26/18: It is documented R26 is repositioned every two hours. According to the NPUAP, the current standard of practice is to reposition and offload a person's pressure injury every 60 minutes. -08/10/18: Resident had a shower and dressing changed. Wound at coccyx is a tear shaped wound with white tissue in the base and no drainage. Wound measures 4.0 cm X 1.5cm and looks improved over last time this RN (Registered Nurse) seen it. To the right of the wound is two superficial red open areas . -08/12/18: The wound measures 3.0 cm by 1.3 cm with 95% thin, yellow tissue in the center of the wound bed with 5% light red tissue around the edges. -08/14/18: R26's wound now measures 2.5 cm by 1.2 cm by approximately 0.1 cm deep. -09/09/18: The resident's wound measures 2.2 cm by 1.0 cm by 0.3 cm -09/16/18: It is documented the resident's coccyx wound is covered in 90% slough. R26's comprehensive care plan states the following, in part: 09/18/2018 I: have a skin injury BECAUSE I: am a diabetic and can't move around well on my own I SHOW THIS BY: having and (sic) open area on my buttocks .APPROACH 09/18/2018 I need my aides to .(3/18/16) Staff to assist frequent repositioning in bed and when in broda; Also per N[NAME] (night) shift repositioning schedule (5/12/16) Staff to assist resident to lay down or sit in recliner for at least 30 minutes between breakfast and lunch and between lunch and supper. To offload pressure on buttocks . PROBLEM: [MEDICAL CONDITION] .APPROACH 01/19/2018 Nurse Aide--- Bladder Program change incontinent products around the following times: 6-7am, 10-11am, 1-2pm, 3-4pm, 6-7pm, 8-9pm 10-11pm 1-2am and 4-5am . 06/11/2018 PROBLEM: Increased metabolic needs .RELATED TO: wound to coccyx .INTERVENTION: Remind Staff to assist (R26) more at meals . 04/09/2018 Dietary---Gradual 8# weight loss in 1 month .He does have an open area on his coccyx .06/11/2018 Dietary---INTERVENTION .Staff will also continue to encourage/offer between meal and (at bedtime) nourishments . On 09/17/18 at 10:45 a.m., Surveyor observed R26 lying in bed, on his back. The resident was fully dressed and wearing pressure-relieving boots on both feet. At 2:37 p.m., resident was observed to be lying in bed, on his back and a wedge cushion was located behind the resident's left upper body. On 09/18/18 at 8:35 a.m., R26 was lying in bed, on his back, and was fully dressed. The resident was wearing pressure-relieving boots on both feet. On 09/19/18 at 10:58 a.m., Surveyor observed the resident lying in bed, on his back. The resident was fully dressed and wearing pressure-relieving boots on both feet. At this time, Surveyor interviewed Certified Nursing Assistant (CNA) L, who primarily works the AM shift. The CNA stated she checks and changes the resident's incontinent brief throughout the day, every two hours. CNA L stated R26 is always incontinent of both bowel and bladder when the incontinent brief is changed. CNA L indicated she repositions the resident every two hours. Surveyor asked how this CNA repositions the resident, to which CNA L stated the resident spends two hours on his left side, then two hours on his back, then two hours lying on his right side, then two hours on his back, etc. CNA L uses the wedge cushion to reposition the resident side-to-side. At 1:28 p.m., Surveyor interviewed Registered Nurse (RN) D. RN D stated the resident is repositioned by staff in bed, every two hours, and is only repositioned side-to-side. At 1:46 p.m., R26 was observed lying in bed, with a wedge cushion behind the resident's left upper shoulder and back. Surveyor observed the resident appears to be positioned on the resident's back, and buttocks. At 2:46 p.m., Surveyor interviewed CNA M, who primarily works the PM shift. CNA M stated she usually checks and changes R26's incontinence brief during the shift every one to two hours. The CNA indicated the resident is usually incontinent of both bowel and bladder when the resident's brief is checked. The CNA further stated she repositions the resident every one to two hours, side-to-side only. On 09/20/18 at 7:43 a.m., Surveyor observed R26 lying in bed with a wedge cushion behind the resident's left upper shoulder and back. It appears as if the resident is still lying on his buttocks and back. At 7:54 a.m., Surveyor asked RN D if the RN completes dressing changes to R26's coccyx wound; to which RN stated she does. At this time, Surveyor and RNs D and E entered the resident's room. Surveyor asked if the way the resident is currently positioned with the wedge cushion, is considered to be on his side. RN E replied, Yes. Surveyor then asked if the resident's coccyx was being offloaded. RN D approached the resident, took a gloved hand and reached beneath the resident's coccyx and back area. Surveyor observed RN D feel below the resident; and RN D stated she was unable to remember where the resident's coccyx dressing was located. Surveyor again asked if the resident's coccyx was being offloaded; and RN D removed her hand from the resident and did not answer. During the continued observation, both RNs indicated the resident's wedge cushion may have slid back, which caused R26 to now be lying more on his back. Surveyor informed RNs D and E, from 09/17/18 to 09/19/18, the resident has appeared to be lying on his back and buttocks; even with the wedge cushion positioned behind R26's upper body during other observations. At this time, RNs D and E turned the resident on his left side, and placed the wedge cushion farther behind R26's back. RN E placed a pillow between the resident's knees. At 8:26 a.m., Surveyor interviewed CNA N. The CNA stated she doesn't normally work on R26's hallway. CNA N stated when she does work with the resident, she changes the resident's incontinence brief every 1.5 to two hours; and R26 is usually incontinent of both bowel and bladder when the brief is changed. CNA N indicated she repositions the resident side-to-side, every 1.5 to two hours. The CNA stated she does not place the wedge cushion too far beneath R26, fearing the resident will flip out of bed. On 09/20/18 at 10:31 a.m., Surveyor observed R26's wound care, performed by RNs D and E. During wound care, the wound to the coccyx was observed to be filled with yellow slough, with a reddened wound edge. The peri wound (the surrounding tissue of the wound) is red and non-blanchable (white/pale). Non-blanchable tissue usually indicates there is a temporary obstruction of blood flow to this area of the skin. During the wound care observation, RN E stated the resident's coccyx wound would open, and heal prior to present time; and stated this is the longest the wound has been open. RN D measured the resident's wound to be 2.5 cm long by 1.4 cm wide. The peri wound measures 11.0 cm long by 5 cm wide. Surveyor reviewed R26's current dietary card, which is used by dietary staff to provide the proper diet and food textures to the resident. The diet card currently indicates the resident is to receive small portions for supper, as of 05/18/18. The card indicates the resident is to receive two glasses of juice for all meals, as of 09/27/17, and is to receive fruit and one-half sandwhich for a bedtime snack, as of 03/04/14. There are no current orders for any nutritional supplements for R26. From 09/17/18 at 10:45 a.m., to 09/20/18 at approximately 3:00 p.m., Surveyor did not observe any snacks provided to R26 between meals. Surveyor observed thickened juice and thickened water glasses provided at the resident's bedside, during the survey. On 09/19/18 at 1:50 p.m., Surveyor interviewed the Director of Nursing (DON). The DON indicated the resident is not repositioned during the night; in order to promote sleep and wound healing. The DON did state R26 is checked and changed by staff at approximately 1:00 a.m. and 4:00 a.m. The DON indicated the resident is repositioned, and checked and changed every two to three hours during the day. Surveyor asked if the facility considered repositioning the resident every 60 minutes, due to the open wound. The DON replied if there is a need to reposition a resident every hour, then staff would do this. Surveyor asked if the DON increased the resident's check and change schedule and/or repositioning schedule when R26 has the open wound to the coccyx. The DON replied there was no change in the resident's schedule, and CNA staff are on top of the resident's current incontinence and repositioning schedule. The DON indicated the facility follows the NPUAP standard of practice for the prevention and treatment of [REDACTED]. During the continued interview, Surveyor asked if R26 has been given nutritional or protein supplements to promote wound healing. The DON replied the facility has had better results providing foods with additional protein than providing nutritional supplements to residents. On 09/20/18 at 1:33 p.m., Surveyor interviewed DM K. The DM stated R26 has lost weight, and the facility has implemented snacks between meals, arousing the resident when he is sleepy, and has changed his food textures to promote weight gain. When Surveyor asked what nutritional interventions have been implemented for the resident's recurrent coccyx wound, DM K stated the dietician deals with the wound interventions. Surveyor asked what snacks the resident is receiving between meals. DM K replied during the 9:30 a.m. and 3:00 p.m. snack pass, R26 does not receive a snack but receives a glass of thickened water and juice. DM K stated the water and juice are not fortified with extra nutrients and are not high in calories. DM K stated at the bedtime snack, R26 receives applesauce and thickened water. DM K stated the water and applesauce are not fortified or high in calories. During the continued interview, DM K confirmed R26 receives small portions during the supper meal. Surveyor asked if R26 has been provided extra calories during meals; such as providing the resident with extra butter or gravy. DM K replied the resident has not been provided extra butter or gravy on food. Surveyor showed DM K the physician progress notes [REDACTED]. DM K stated no nutritional supplements have been tried or implemented for R26 since the resident has sustained weight loss and has had recurrent wounds. DM K stated the facility has a new Registered Dietician (RD), RD O, who started at the facility the beginning of (MONTH) (YEAR). The former facility dietician was unavailable for interview. At 2:07 p.m., Surveyor interviewed RD O, and asked if the RD was aware of R26's coccyx wound. RD O stated she is aware of the wound, and stated she receives weekly wound notes from nursing staff regarding the status of the resident's coccyx wound. Surveyor asked what nutritional interventions RD O would implement for a resident with an open area; to which RD O replied she may increase the resident's protein intake, try extra gravy or butter with meals or try snacks of the resident's choice. Surveyor discussed the resident's physician progress notes [REDACTED]. The RD stated if R26's physician spoke with RD O about starting a supplement, RD O would have started the resident on a nutritional supplement, or would have increased something with the resident's food. RD O further stated R26 is appropriate to be given a nutritional supplement now, due to the resident's weight loss and long standing wound. Surveyor completed a review of R31's clinical record and noted the following. R31 had current [DIAGNOSES REDACTED]. R31's most current MDS was dated 07/11/18. The MDS indicated R31: ~ Had both long and short-term memory problems; ~ Required total assist of 1 to 2 staff persons for all aspects of care; ~ Was always incontinent of bowel and bladder; and ~ Had one stage 2 pressure injury which dated back to 1/2/15. R31's skin care plan had the following approaches. ~ 7/21/13, .Reposition every hour while in w/c (wheel chair), recliner, or stationary chair; every 2 hours while in bed . ~ 3/20/15, .podus boots while in bed . ~ 1/4/16, .Air mattress .Roho cushion in Broda chair . Surveyor completed a review of R31's wound notes since 7/19/17 and noted the following. ~ 7/19/17, .Superficial open are to rt (right) buttock .0.5 cm (centimeters) Length and 1 cm (1.0) cm width .does have occasionally break down . ~ 7/22/17, .Superficial area remains to residents right buttock .Length: 1 cm (1.0) Width: 1.5 cm Wound Tissue: reddened . Neither wound note staged R31's wound. The measurements indicated R31's wound had deteriorated and gotten larger. There were no changes made to R31's plan of care. The pressure injury as noted above was healed on 08/08/17. ~ 9/5/17, .Noted open area to rt buttock .1.5 cm x 3 cm (1.5 centimeters by 3.0 cm) . ~ 9/7/17, .Area to right buttocks assessed .appears slightly larger and look quite 'raw' .superficial .[MEDICATION NAME] not effective .orders obtained .duoderm . R31's wound again deteriorated. While the facility obtained new treatment orders, the wound itself was not measured and not staged. ~ 9/10/17, .Duoderm was rolled at the distal portion .and open area was visible .Wound bed is reddened and pealing .Also noted purple area that is non blanchable to the distal portion of the wound .measured 1.5 cm x 2 (1.5 cm x 2.0 cm) . Non blanchable purple tissue was indicative of a Deep Tissue Injury (DTI). DTIs develop due to prolonged pressure due to damage to underlying soft tissue. This indicated R31's wound had deteriorated. There were no changes made to R31's plan of care. ~ 9/15/17, .Right inner buttock .2 cm (2.0 cm) long .1 cm (1.0 cm) wide .95% red moist tissue and 5% yellow slough . This was the first notation of yellow slough. Slough is devitalized tissue. This indicated R31's wound had again deteriorated. The wound was not staged. There were no changes made to R31's plan of care. On 10/03/17, R31's right sacral wound was noted as healed. ~ 10/10/17, .Superficial open area noted to resident's right buttock .wound bed .100% red tissue .1.5 cm x 0.5 cm . ~ 10/13/17, .Right medial buttock .Length: 1.6 cm Width 2 cm (2.0 cm) .Wound Tissues 100% dark pink tissue . On 11/3/17, R31's right sacral wound was noted as healed. ~ 2/13/18, .There is an area 0.5 cm by 1 cm (1.0 cm) of black tissue. Area is not blanchable and is hard .Area around that is pink and blanchable . Black tissue was indicative of eschar or dead tissue. This was a deterioration of R31's historical wounds. The wound was not staged. There were no changes made to R31's plan of care. ~ 2/16/18, .Right buttock Length: 2 cm (2.0 cm) Width 3 cm (3.0 cm) .Wound tissue: Red .Surrounding tissue: Darkened/tan . R31's wound deteriorated. There were no changes made to R31's plan of care. ~ On 3/15/18, the wound was noted as healed. ~ 4/16/18, .open area was visible when assessed . R31's wound had re-opened. There were no measurements completed, the wound was not staged, there was no description of the wound characteristics, there were no changes made to R31's plan of care. There were no measurements completed or wound characteristics until 4/27/18, 11 days later. ~ 4/27/18, .Right Inner Buttock Length 3 cm (3.0 cm) Width 2.5 cm .Superficial .100% pink granulation tissue . ~ 5/4/18, .Right buttock Length 0.5 cm Width 0.5 cm .Duoderm found very moist and peeling .Foul smelling drainage noted . Foul smelling drainage was indicative R31's wound had deteriorated. There were no changes made to R31's plan of care. ~ 5/11/18, .buttock .Length 1 cm (1.0 cm) Width 0.5 cm Drainage yellow . ~ 5/22/18, .No duoderm had been noted upon AM (morning) cares. Wound noted to be nearly healed . ~ 5/25/18, .right buttock .2 cm x 3 cm. wound bed 80% pink moist tissue, 20% dark purple tissue. Strong 'dead' odor . This was indicative R31's wound had deteriorated. There were no changes made to R31's plan of care. ~ 6/6/18, .Open area present to right inner buttocks .30% yellow slough in the center and surrounding the slough 70% of wound bed was pink/red tissue .Moderate amount of sanguineous drainage present . R31's wound was noted to have yellow slough. There were no measurements completed. The wound was not staged. There were no changes made to R31's plan of care. ~ 6/15/18, .Right buttock .Length .wound bed 1.4 cm .Width .open area 1.1 cm .open wound bed 100% yellow slough with red around the edges in a thin line . R31's wound presented with 100% yellow slough. This was indicative R31's wound deteriorated. The wound was not staged. According to current standards of practice R31's wound would have been considered an unstageable wound. There were no changes made to R31's plan of care. ~ 7/2/18, .Wound Rounds completed 6/28/18, .buttock area .1.3 cm x 1.4 cm. Wound bed .80% yellow slough and 20% red granulation tissue. Depth of wound at red granulation tissue was 0.2 cm .Periwound intact . R31's wound note indicated there was depth to R31's wound. This was a change indicative of the wound deteriorating. There were no changes made to R31's plan of care. 7/11/18, .rt buttocks .wound area is moist. 90% yellow slough and 10% red tissue .maceration noted .Depth noted to the red tissue .Calcium alginate to wound bed along with .duoderm . This was the first time the facility changed R31's treatment since with wound re-opened on 4/16/18. ~ 8/2/18, .Right buttock .Length 1.1 cm Width 1.2 cm .Wound bed 100% yellow sough .faint odor . ~ 8/28/18, .R (right) inner buttock .1.0 cm in length and 1.8 cm in width. Wound bed is 100% yellow slough . R31's wound had become larger. The wound bed was still 100% yellow slough. There were no changes made to R31's plan of care. On 09/18/18 at 10:12 AM, Surveyor observed Licensed Practical Nurse (LPN) B complete a dressing change on R31's wound with the assistance of CNA A. LPN B indicated wound rounds were done weekly by the wound team; however, the wound team did not typically measure wounds. LPN B indicated all wounds were measured every Friday by the nurse on the floor. LPN B gathered her supplies and removed the old dressing on R31's right sacrum. Surveyor noted a small amount of sero-sanguinous drainage. Surveyor noted the wound was an upside down V shaped. The wound itself measured approximately 0.4 cm by 2.0 cm and was 100% covered with yellow slough. The immediate peri wound encircled the wound bed and was whitish in color. The whitish colored peri wound and wound bed measured 2.5 cm in diameter. Surveyor noted a bluish colored ring around the lateral side of the peri wound which measured approximately 1 cm. LPN B applied the physician ordered dressing. Surveyor asked LPN B about R31's wound. LPN B indicated the wound had healed and re-opened several times. LPN B indicated she was not sure why but thought it could be related to R31 not eating well and being very thin. During the observation of R31's dressing change, Surveyor noted R31's adult brief was soiled with urine. This was also noted by CNA A. Both LPN B and CNA A indicated R31 voided a large amount when R31 was incontinent. CNA A and LPN B removed R31's soiled adult brief and placed a clean one. Surveyor as well as LPN B noted an area on R31's right labia CNA A referenced as caked powder. LPN B obtained pre-moistened cloths and gave them to CNA A. CNA A removed the caked powder. CNA A applied to adult brief. There was no frontal or posterior peri care completed in order to remove all urine from R31's skin. This practice had the potential to affect R31's wound healing. On 09/19/18 at 1:27 PM, Surveyor spoke with RN C. RN C indicated R31's wound had been a troubled spot for years. RN C indicated the wound would heal up and then re-open. RN C stated the wound was not healing as of late. RN C stated R31 had scar tissue and there was usually a purple hue around it. Surveyor asked RN C about the practice of not cleansing skin after an incontinent episode. RN C indicated both frontal and posterior peri care should be completed with any incontinent episode. RN C indicated inappropriate incontinence care could potentially cause a wound to not heal. On 09/20/18 at 7:45 AM, Surveyor noted a Roho cushion in R31's Broda chair. Surveyor pressed down on the cushion and noted little air in the cushion. On 09/20/18 at 8:21 AM, Surveyor asked RN C who checked Roho cushions to ensure they were properly inflated. RN C indicated they were checked by the Minimum Data Set Coordinator (MDSC) or therapies. On 09/20/18 at 8:22 AM, Surveyor noted R31's air mattress. The air mattress was noted as a Pressure Guard APM2. The air mattress had settings from 1 to 5 with 1 being the softest and 5 being the most firm. Surveyor noted R31's air mattress setting was set a 5. On 09/20/18 at 8:25 AM, Surveyor spoke with CNA F about R31's air mattress setting. CNA F indicated she was not sure where it should be set but indicated it should be on R31's care plan. CNA F obtained R31's care plan, looked for the correct setting for the air mattress, and indicated there was no indication on R31's care plan of the correct setting. CNA F stated it should be on the care plan. CNA F then indicated it should be somewhere in the middle. On 09/20/18 at 8:30 AM, Surveyor spoke with the MDSC. The MDSC indicated she did not check Roho cushions for appropriate inflation. The MDSC stated they were checked during weekly rounds by the wound team. Surveyor requested the MDSC ask someone from the wound team to check R31's Roho cushion. On 09/20/18 at 3:28 PM, Surveyor spoke with RN E. RN E indicated she was on the wound team. RN E indicated she had checked R31's Roho cushion and it was not appropriately inflated. RN E indicated she needed to add air. On 9/20/18 at 9:41 AM, Surveyor spoke with the Director of Nursing (DON). The DON indicated she was wound certified. Surveyor asked the DON about R31's pressure injury. The DON indicated R31 had nutritional and mobility issues and was on hospice. The DON stated she felt all appropriate interventions were in place for R31. The DON stated R31's air mattress and Roho cushion had been in place since 1/4/16. The DON indicated she felt both were the best for R31 therefore had never attempted to try another mattress or cushion. Surveyor asked the DON about R31's air mattress. The DON indicated it should be in the middle setting. Surveyor asked the DON why their charting did not include the stage of a pressure injury. The DON indicated she wanted to be the first to measure any wound, felt like the nurses on the floor were afraid to stage, however the DON did not stage due to time constraints.

Based on observation, interview, record review, and policy review the facility failed to maintain adequate nutritional status for 3 of 19 residents reviewed. Resident #4 experienced a weight loss greater than 12% in 2 months. There were no nutritional interventions put in place to prevent weight loss. Medication review, including psychiatric medications, was not looked at as a possible contributing factor of the weight loss. Resident #15 experienced a 6.6% weight loss between January and February 2013. There were no nutritional interventions put in place to prevent weight loss. Medication review, including psychiatric medications, was not looked at as a possible contributing factor of the weight loss. Resident #13 had weight loss noted in January 2013, the weight loss continued to be a total of 13 (8.4%) pounds in the past 3 months. There were no new nutritional interventions put in place as the weight continued to decline for Resident # 13. This is evidenced by: A reveiw of the facility "Weight Assessment and Intervention" policy states: "The multidisciplinary team will strive to prevent, monitor and intervene for undesirable weight loss for our residents." "Policy Interpretation and Implementation: Weight Assessment:... 3. Weight increase or decrease are discussed at IDT Stand up meeting. 4. Weight loss and gains (5% or more in 1 month or 10% or more in 6 month) are discussed at CQI meetings monthly. 5. The dietician will review the weight record to follow individual weight trends over time... 6. The treshold for significant unplanned and undesired weight loss will be based on the following criteria.. a. 1 month - 5% weight loss is significant; greater than 5% is severe 6 months - 10% weight loss is significant; greater than 10% is severe Analysis: 1. Assessment information shall be analyzed by the multidisciplinary team and conclusions shall be made regarding the:... b. approximate calorie, protein, and other nutient needs compared with the residents current intakes... 2. The physician and the multidisciplinary team will identify conditions and medications that may be causing anorexia, weight loss or increasing the risk of weight loss for example: a. cognitive function or decline... d. medication-related adverse consequences f. increased need for calories or protein i. inadequate availability of food or fluids Care Planning... 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:... b. nutrition and hydration needs of the resident f. medications that may interfere with appetite, chewing, swallowing, or digestion g. the use of supplementation EXAMPLE #1 Resident #4 was admitted to the facility on [DATE] from another facility. Her [DIAGNOSES REDACTED]. The initial nurses note indicates that resident #4 requires one aide assist for eating to prepare plate and food and to feed the resident. Resident #4's admission weight was 133 pounds. Resident #4 recieves [MEDICATION NAME] for anxiety, [MEDICATION NAME] for depression and [MEDICATION NAME] for [MEDICAL CONDITION]. One of the side effects for [MEDICATION NAME] is drowsiness and a side effect of [MEDICATION NAME] is decreased appetite and weight loss. The care plan dated 1/6/13 indicate a problem "poor eating habits and will refuse to take medications." The approaches include "make referrals, reorient, encourage activities, provide homelike environment, allow to share topics of interest." The nurses note on 1/6/13 directs to "offer nourishment between meals and HS." On 1/11/13 a nurses note states "wt. (weight) down 7# from last week will recheck tomorrow." The weight recheck confirmed a 7# weight loss since admission (8 days). "[MEDICAL CONDITION] improved, appetite fair to poor." The doctor was update on 1/14/13 with no changes. A nurses note on 2/22/13 states "wt 120 down 13 pounds, less [MEDICAL CONDITION], refuses meals and snacks. Update MD." No changes were made to medications or the care plan. This is a 9% weight loss in less than 2 months. On 3/20/13 nurses notes indicate the weight was discussed with the doctor. Descibed as gradual and steady, not eating well. No changes were made to medications or the care plan. On 3/23/13 Resident #4 weight is 116 pounds, this is greater than 12% in 3 months (severe weight loss). A speech therapy order was obtained. The next doctors note regarding weight concerns in on 4/10/13. Note states "may d/c 7:00 a.m. [MEDICATION NAME] may contribute to drowsiness." Speech therapy "functional maintenance/restorative program" suggests "offer nutritional supplements between meals - prefers juice, bananas, sweet flavors, finger foods." Surveyor reviewed dietary notes. The initial dietary note written on 1/10/13 indicates a weight of 133 pounds. Interventions include skim milk all meals, section plate all meals. The next dietary note is on 3/19/13 stating "currently 117#; decreased 16# in 2 months (a significant 12% weight loss due to frequent meal refusals and almost consistant refusals of breakfast... will try sending a healthshake with breakfast and dinner." The dietary note also states "Progressive weight loss especially at this alarming rate is undesirable and can impact resident's quality of life adversely." The dietary care plan was reviewed by surveyor # on 4/12/13 and 4/15/13. On 4/14/13 the care plan had been update by Dietician M. The care plan states: Problem "4/14/13 Problem: Significant weight loss. Alteration in nutrition (less than body requirements) Leaves 25% of most meals... Approach 1/10/13 Nurses--monitor weights, administer medications as ordered, observe for side effects and effectiveness Monitor food intake, monitor elimination pattern, note skin turgor 4/14/13 Nurse aide-- weigh weekly record food intake offer snacks give food supplement 4/14/13 Dietary-- provide ordered diet, 2gm cardiac. Provide lip plate with all meals, skim milk all meals, small portions and a healthshake B and D; large portions and banana plus dessert for S. Provide extra bananas per resident request for HS and night eating. Offer replacement food offer extra snacks provide food supplement, provide pleasant meals Goal: 4/14/13 No evidence of weight loss, will maintain weight at 115# (+/-5#). Eats; >50% of meals and drink >750ml in TID meals." Observations on the 400 wing (where resident #4 resides) include 4/10, 4/11, and 4/15. On 4/10/13 surveyor reviewed charts on the unit starting at 1:00 p.m. During the time between lunch and supper a drink cart was observed on the unit. Residents were served a drink of choice including soda, juice or alcoholic beverages. No snack was observed to be offered. Supper was served to Resident #4 at approximately 5:38 p.m. The meal included chipped beef over biscuits, olives, strawberries, yogurt, coffee, milk and water. CNA's attempted to assist Resident #4 with her meal, however Resident #4 would not open her eyes and wake up. Her meal was placed in the fridge at 5:40 p.m. in case she wanted it later. On 4/11/13 surveyor observed the breakfast meal. Resident #4 was served her meal at 8:09 a.m. At 8:15 a.m. CNA R assisted Resident #4 to eat. Resident #4 ate her cream of wheat, coffee and milk. Observations continued on the unit until lunchtime. No additional snacks or nourishments were offered. Surveyor interviewed CNA R (she worked both the evening of 4/10 and the morning of 4/11). CNA R was asked if Resident #4 ate anything on the evening of 4/10/13. CNA R stated that Resident #4 ate a banana, juice and cookie later in the evening. CNA R stated that Resident #4 will yell for bananas at night when she gets hungry. CNA R stated that Resident #4 sleeps thru most meals. On 4/15/13 surveyor observed the 400 unit from 9:30 a.m until after lunch was served. CNA's offered juice to residents between 9:30 and 10:00 a.m. No snack was offered at this time. Resident #4 did drink 2 glasses of juice with assistance. On 4/15/13 after lunch a snack of juice, coffee and muffins was offered to residents on the 400 wing. During the snack offering Resident #4 was asleep in bed, she did not recieve a snack. Surveyor reviewed the "Nourishment intake Sheet." This document indicated that Resident #4 received nourishments daily at a.m., p.m., and h.s. Initials were marked in spots where surveyor observed no snack or nourishment offered and when Resident #4 was observed to be sleeping. On 4/11/13 surveyor interviewed DON at 11:20 a.m. The DON stated that Resident #4 "has good days and bad days." The DON stated that the night shift has requested bananas for Resident #4 and these are provided. The DON stated supplements and interventions should be on the care plan. On 4/15/13 surveyor interviewed LPN T. LPN T usually works nights and is aware that Resident #4 requests bananas at night and they are provided. LPN T stated that reapproaching Resident #4 is important. Surveyor requested that LPN T review the care plan. LPN T agreed that the dietary note from 4/14/13 was new, however the interventions look the same. On 4/15/13 surveyor interviewed Dietician M. Dietician M stated she knew Resident #4 at her previous facility as she is also the dietician there. Dietician M stated that Resident #4 had behaviors, was refusing meals and beginning to lose weight at the previous facility. Dietician M stated that she was unsure what else to do. She stated that Resident #4 was more awake at the previous facility but she has dementia so "it is just part of the disease." On 4/15 surveyor interviewed Physicain Y. Physician Y was aware of Resident #4 weight loss and stated it is concerning but "it is part of the natural progression of dementia." Physician Y did decrease the order for [MEDICATION NAME] on 4/12/13. Following this decrease the resident experienced a siezure and Physician Y returned the [MEDICATION NAME] to the previous dose. Physician Y stated that more test needed to be reviewed prior to relooking at the [MEDICATION NAME]. Physician Y also stated that the TSH could be checked for [MEDICAL CONDITION] and added this to the order. Surveyor interviewed DO on 4/16/13. There was some confusion on what was considered a nourishment. The DON stated that the nourishment is 2.0 is usually given with med pass. It is not an order on the med sheet, but nurses give it they feel it is needed. The DON later stated that the nourishment intake sheet is recorded from snack cart in the afternoons and evenings. Surveyor shared the observations of the lack of snacks offered with the DON. The DON requested that surveyor speak to RN Z regarding the use of 2.0 for resident #4. Surveyor interviewed RN Z. RN Z stated she does occasionally use 2.0 during med pass for Resident #4 because she takes her meds easier with it. RN Z stated that if 2.0 is used for weight is is in the MAR, she did not believe it was on the MAR for Resident #4. EXAMPLE #2 Resident #15 has a [DIAGNOSES REDACTED]. Resident #15 recieves [MEDICATION NAME] for anxiety and [MEDICATION NAME] for depression. A side effect of [MEDICATION NAME] is drowsiness and a side effect of [MEDICATION NAME] is decrease appetite and weight loss. Recorded weights for Resident #15 are: 5/17/12 - 124# 8/23/12 - 122# 10/15/12 - 121# 11/15/12 - 121# 1/10/13 - 120 # 2/18/13 - 112# The dietary notes were reviewed by surveyor # . Dietary note on 5/25/12 states "No evidence of weight loss. Will continue to eat 50-75% of foods. Drinks fluids offered. Will maintain weight at 130# (+/- 5#)" Dietary note dated 9/9/12 states "provide ordered diet, regular. (whole milk with meals, extra butter and jelly at B. extra butter and gravy TID, healthshake with dinner and supper, and ice cream plus dessert for supper.) 11/23/12 Dietary notes states "Provide ordered diet, regular. (whole milk with meals) Provide 3-4 straws and clear cups with spouted lids on all trays." Between January 10, 2013 and February 18, 2013 Resident #15 lost 8 pounds, this is a 6.6% weight loss in 1 month (severe weight loss). There are no additional interventions or dietary notes until 4/14/13. The dietary note on 4/14/13 states "No evidence of weight loss. Will continue to eat 50-75% of foods. Drinks fluids offered. Will maintain weight at 115# (+/-5#). " The recorded weights for the last 3 months are: 2/7/13 - 111# 3/7/13 - 112# 4/12/13 - 112# Resident #15 has not been at a weight of 115 pounds in the last 3 months. Resident #15 CNA care plan indicates general diet, sippy cups with finger foods. Assistance needed for feeding states "assist of 1 with set up." The interdisciplinary care plan has the following information related to dietary/weight concerns: "Problem: 4/14/13 Problem: Potential for alteration in nutrition (less than body requirements) due to progressive dementia 2/17/13 Related to: multiple medical problems including advanced alzhneimer's dementia, and hx of dysphagia. Potential for inadequate intake Approach: 9/24/2009 Nurse aide--set up tray 4/11/2013 Nurse aide--family will bring in miniature candy bars for a snack. Resident likes to eat chocolate. Family will also bring in chili from Beach bar. 4/14/2013 Dietary--Determine food likes, provide ordered diet, general with healthshake dinner and supper trays. Send ice cream plus dessert at dinner and supper. Provide extra finger foods with trays. Offer replacement food Offer extra snacks provide pleasant meals 4/14/2013 Dietary--Provide ordered diet, regular. (whole milk with meals) Provide lip plate, 3-4 straws and clear cups with spouted lids on all trays. Goal: 4/14/2013 No evidence of weight loss, will continue to eat 50-75% of foods. Drinks fluids offered will maintain weight at 115# (+/-5#)" The above interventions on 4/14/2013 had been in place since 11/23/2012 (they were not on the care plan). No additional interventions were added to address the weight loss between January and February 2013. Observations by surveyor on 4/15/13 included a lunch observation. Resident #15 was asleep with his head on the table when his tray was served at 11:40 a.m. At 11:50 one of the CNA's approach Resident #15, rubbed his back and attempted to wake him to eat with no success. At 12:05 p.m. a different CNA approached Resident #15 and attempted to wake him with no success. At 12:15 p.m. Resident #15 is still asleep with his head on the table. At 12:20 p.m. Resident #15 did wake up and was assisted to pick up his barbeque. He then ate it independantly. At 2:00 p.m. on 4/15/13 Resident #15 was asleep in one of the recliners on the 400 wing (where he resides). A snack of muffins was being served to the residents. A muffin was set in Resident #15's lap. Resident #15 was unaware the muffin was there, continued to sleep and as he moved in the recliner the muffin was crumbled in his lap. No assistance or encouragement was offered. Surveyor interviewed the DON at 8 a.m. on 4/16/13. The concerns with the care plan and dietary notes not addressing the weight loss were shared. The DON acknowledged that Resident #15 often sleeps through meals. The last reduction of psychiatric medications was in [DATE]. Surveyor interviewed Dietician M. Dietician M stated the weight loss has trailed off over the last 3 months. Dietician M stated that Resident #15 has end stage dementia and this is a natural progression. EXAMPLE #3 Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The minimum data set with a reference date of 01/18/13 has a weight recorded of 156# and shows that resident needs some assistance at meal time. The nutritional care plan dated 08/01/11 has the problem Potential for alteration in nutrition--more than body requirements. approaches: Nurses-Monitor weights, monitor food intake, monitor elimination pattern, note skin turgor Nurse aide--Record food intake Weight weekly encourage fluids 04/12/12- dietary--Provide ordered diet, general with small portions per resident request. Offer replacement food. Offer extra snacks Provide pleasant meals. Goal--01/11/13 No evidence of weight gain. Will maintain at 155# (+/-5#). Eats 75-100% offered Drinks fluids offered Evaluation: Goal of no weight loss and to maintain weight @155#+or-5# was met. Current weight is at 158#. goal to eat 75-100% offered was met. She eats about 86% of her small portion meals. Goal to drink fluids offered was not always met...Continue goals for the next 3 months. The certified nursing assistant kardex has Dietary: Mechanical soft For eating I need: set up: eats in main dining room. There is no mention of weight loss or new interventions needed to help maintain nutritional status for Resident #13 as she experiences the ongoing weight loss in the nutritional care plan or dietary notes. Weights 01/26/13, 154# Re-weigh documents the resident is down 3#. Resident has been on contact precautions and has not had much of an appetite. Will update MD with weight loss. 01/31/13 155# 02/07/13 157# 02/14/13 156# 02/21/13 154# 02/28/13 145# Notify supervisor 03/01/13 147# 03/07/13 145# 03/14/13 146# 03/21/13 144# 03/28/13 143# 04/04/13 142# 04/11/13 141# The dietary notes state in part: 10/11/12- quarterly review weight is stable Current weight is at 158#...good appetite. 01/11/13- weight 156# Low risk, no weight change, intake meets 76-100% of estimated needs currently eating 100% of meats...Comments: Currently doing well-with good intakes of foods on her regular diet. Will continue care plan and goals. 03/15/13 Nutrition risk charting Current weigh 145#, weight down 12# over past month due to decreased appetite and fluid balance issues. Resident does complain of poor appetite and she requires more assistance from staff with set up, supervision and encouragement to eat. She does have improved fluid status due to daily diuretic use was is thought to contribute to weight change. Currently resident is receiving small portions all meals per her request and milk with all meals. She receives chocolate milk between meals. Will continue interventions per her choice and continue to monitor her progress. There are no dietary notes after the weight loss identified on 02/28/13 that says notify supervisor. Surveyor interviewed the Director of Nursing (DON) on 04/15/13 at 2:00 p.m. to ask about the process for reporting weight loss. The DON stated they meet daily and discuss weight loss if it is a problem. The DON states that the Culinary dietary manager or the dietician does the care plans and should have the new interventions put in place. Surveyor interviewed the Certified Dietary Manager (CDM ) L at 2:35 p.m. to ask if she was notified when it says, notify supervisor. CDM L said , "I am not sure what notify supervisor means, I do not think anyone notified me." Surveyor interviewed the Dietician (D) M on 04/15/13 at 2:40 p.m. about the above concerns. D M said if the resident loses 5# they address. They also have a continuous quality improvement meeting monthly when they look at weight loss. Surveyor asked how often D M was in the facility. She stated 2-3 x per week. Surveyor reviewed the nutrition care plan with D M to ask if she could see any new nutritional supplements or interventions since the weight loss started in January. D M said they send snacks to the units and the CNA's hand them out. This resident gets chocolate milk twice a day between meals. Surveyor asked if when that started, D M was not sure. The snack charts were reviewed and the chocolate milk twice a day started in January, before the weight loss was identified in January. The dietician said maybe the nurses give her a supplement with meds. Surveyor asked if there were any other new interventions put in place. D M stated, "No, I do not see any." Surveyor interviewed RN I on 04/16/13 at 8:15 a.m., asking if Resident #13 received scheduled supplements at meals or med pass. RN I reviewed the Medication Administration Record, [REDACTED]."