Every finding on record at Pioneer Valley Living And Rehab

Based on clinical record review, observation, resident interview, staff interview, and policy review the facility failed to provide food at an appetizing temperature to 3 of 5 residents ( Residents #8, #32, and #35) reviewed. The facility reported a census of 48 residents.Findings include:1. Review of Resident #8's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognitive functioning. Interview on 2/23/26 at 11:48 AM with Resident #8 revealed that she often eats in her room, and the food when it is delivered is often cold and not hot. Resident #8 then revealed that the food does taste good, but the food is just cold when it comes on the trays as it sits longer before it is delivered. 2. Review of Resident #32's MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognitive functioning. Interview on 2/23/26 at 12:25 PM with Resident #32 revealed that she prefers to eat in her room, and when the food is delivered she is lucky if it is even room temperature. Resident #32 further revealed that several of her meals have been delivered cold. Observation 2/24/26 at 12:50 PM a tray was obtained for a temperature check. Temperatures at that time were 109.2 for the hot ham and cheese sandwich, 125.2 for the green beans, french fries were 101.1, and mandarin oranges were 46.8 degrees. Interview 2/24/26 at 12:50 PM with the Dietary Manager revealed that she would like to see the mandarin oranges be a little colder, but she gets that these trays went down the hallways for delivery. Another observation on 2/25/26 at 1:06 PM another sample tray was obtained and temperatures were obtained with the caramelized butternut squash being 118.4, and the mixed vegetables being 120.9 degrees. A follow up interview 2/25/26 at 1:20 PM with the Dietary Manager revealed that food temps should be served at the appropriate temperatures. 3. Review of Resident #35's MDS dated [DATE] revealed a BIMS of 15 indicating intact cognitive functioning. In an interview on 2/23/26 at 12:42 PM, Resident #35 reported the food is cold most of the time. In an interview on 2/25/26 at 2:17 PM, Resident #35 reported that she ate meals in the dining room. When asked about today's meals, the resident stated, It was cold like most of the time. When asked to clarify what was meant by most of the time, the resident responded, Most of the days, most of the meals. The Food Preparation Area policy last revised in November 2010 included Food preparation staff will adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness. Cooking and Holding Temperatures and Times The danger zone for food temperatures is between 41 degrees and 135 degrees Fahrenheit. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness. Potentially hazardous foods include meats, poultry, seafood, cut melon, eggs, milk, yogurt and cottage cheese. The longer foods remain in the danger zone the greater the risk for growth of harmful pathogens. Therefore, PHF must be maintained at 40 degrees or below or at 136 degrees or above. Potentially hazardous foods held in the danger zone for more than 4 hours (if being prepared from ingredients at room temperature) or 6 hours (if cooked and then cooled) may cause foodborne illness. The following internal cooking temperatures/times for specific foods must be reached to kill or sufficiently inactivate pathogenic microorganisms: Poultry and stuffed foods - 165 degrees F, Ground meat, ground fish and eggs held for service - at least 115 degrees F, Fish and other meats - 145 degrees F for 15 seconds, Fresh, frozen or canned fruits/vegetables - 135 degrees F.

The facility failed to properly complete the Centers of Medicare & Medicaid form #10055 for 3 of 3 sampled residents. (Residents #4, #8 and #54). The facility reported a census of 48 residents.Findings Include: 1. The ABN form #10055 dated 1/26/26 for Resident #4 revealed the form lacked the reason Medicare may not pay and the estimated cost of services. 2. The ABN form #10055 dated 8/5/25 for Resident #8 revealed the form lacked the estimated cost of skilled nursing care. 3.The ABN form #10055 dated 10/2/25 for Resident #54 revealed the form lacked the estimated cost of skilled nursing care. The Medicare Advanced Beneficiary Notice policy Dated April 2021 identified if the admissions coordinator or business office manager believes (upon admission or during the resident's stay) that Medicare (Part A of the Fee-for-Service Medicare Program) will not pay for an otherwise covered skilled service(s), the resident (or representative) is notified in writing why the service(s) may not be covered and of the resident's potential liability for payment of the non-covered service(s). The facility issues the Skilled Nursing Facility Advanced Beneficiary Notice (CMS form 10055) to the resident prior to providing care that Medicare usually covers, but may not pay for because the care is considered not medically reasonable and necessary, or custodial. The resident (or representative) may choose to continue receiving the skilled services that may not becovered, and assume financial responsibility. The Centers for Medicare and Medicaid Beneficiary Notices website (https://www.cms.gov/Medicare/Medicare-General-Information/BNI/ABN), last modified on 12/01/2021 at 8:00 PM, provided the link to the undated document titled Form Instructions Advance Beneficiary Notice of Non-coverage that provided instruction for ABN estimated cost of services. The form instructed that notifiers must complete the column under Blank (F) to ensure the beneficiary has all available information to make an informed decision about whether or not to obtain potentially non-covered services. Notifiers must make a good faith effort to insert a reasonable estimate for all of the items or services listed under Blank (D). In general, we would expect that the estimate should be within $100 or 25% of the actual costs, whichever is greater; however, an estimate that exceeds the actual cost substantially would generally still be acceptable, since the beneficiary would not be harmed if the actual costs were less than predicted. Multiple items or services that are routinely grouped can be bundled into a single cost estimate. For example, a single cost estimate can be given for a group of laboratory tests, such as a basic metabolic panel (BMP). An average daily cost estimate is also permissible for long term or complex projections. As noted above, providers may also pre-print a menu of items or services in the column under Blank (D) and include a cost estimate alongside each item or service. If a situation involves the possibility of additional tests or procedures (such as in laboratory reflex testing), and the costs associated with such tests cannot be reasonably estimated by the notifier at the time of ABN delivery, the notifier may enter the initial cost estimate and indicate the possibility of further testing. Finally, if for some reason the notifier is unable to provide a good faith estimate of projected costs at the time of ABN delivery, the notifier may indicate in the cost estimate area that no cost estimate is available. We would not expect either of these last two scenarios to be routine or frequent practices, but the beneficiary would have the option of signing the ABN and accepting liability in these situations. In an interview on 2/25/25 at 2:54 PM, the Administrator reported that the approximate cost of services is required to be completed on ABN form #10055. The Administrator further stated, I have reviewed other forms, and it's filled out. I don't know how those were missed.

Based on clinical record review and staff interview, the facility failed to refer 1 resident with a negative Level I result for the Preadmission Screening and Resident Review (PASARR), who was later identified with newly evident or possible serious mental disorder, intellectual disability, or other related condition, to the appropriate state-designated authority for Level II PASARR evaluation and determination for 1 out of 2 residents (Resident #14) reviewed for PASARR requirements. The facility reported a census of 48 residents.Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #14 documented diagnoses of anemia, heart failure and agitation and restlessness. The MDS included a Brief Interview for Mental Status (BIMS) score of 12 indicating moderate cognitive impairment. Review of note to attending physician or prescriber from the pharmacy dated 2/17/26 requesting diagnosis that best fits the patient with the usage of antipsychotic drugs returned with an x in front of delusional disorder signed by the physician and dated 2/20/26 and noted by the facility on 2/23/26. Review of the Progress Note dated 2/23/26 at 11:21 a.m., entered by the Director of Nursing (DON) revealed the following:Received signed return pharmacy communication about olanzapine (antipsychotic medication) 5 milligram (mg) daily. Asking for a diagnosis that fits the resident. Primary care physician responds with F22, Delusional Disorder. Diagnosis list updated, Medication Administration Record (MAR) updated and filed in chart. Review of current medical diagnosis revealed a diagnosis for delusional disorders with a created date of 2/23/26. Review of the PASARR dated 1/30/26 lacked inclusion of delusional disorder diagnosis. The clinical record lacked an updated PASARR to include delusional disorder diagnosis. The facility does not have a policy on PASARR procedures. Interview on 3/2/2026 at 3:07 p.m., with the DON revealed the diagnosis should be listed on the PASARR and she would submit a new one.

Based on clinical record review, policy review and staff interview the facility failed to revise and update care plans to include hospice care for 1 out of 12 residents reviewed (Resident #6). The facility reported a census of 48 residents. Findings included: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #6 documented diagnoses of heart failure, diabetes mellitus and hypertension. The MDS showed a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. Interview on 02/23/2026 at 11:25 a.m., with Resident #6 revealed she had been started on hospice care recently to help with pain control. Review of Resident #6's Progress Notes revealed the following information:On 2/16/25 at 9:20 a.m., resident's power of attorney (POA) visited with this worker and stated that he would like a hospice consult. He elected hospice of his choice. Spoke with chosen hospice and they stated they will contact POA to discuss services. On 2/16/25 at 4:01 p.m., Hospice visited with resident, she is interested in services if qualifies, hospice reached out to primary care physician, she was going to send orders, no orders received, call placed to to office, verbal order for ok for hospice to evaluate and treat if appropriate. Order received and noted, hospice may be out today for intake. On 2/17/25 at 12:31 p.m., received signed order for ok for hospice to evaluate and treat. Filed in chart. On 2/19/26 at 8:05 p.m., resident remains on hospice. On 2/22/25 at 8:22 p.m., resident remains on hospice. Review of the care plan with a revised date 2/25/26 lacked information on hospice services and hospice care choice. Review of facility provided policy titled Care Planning- Interdisciplinary reviewed April 2016 revealed our facility's care planning interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each resident. The care plan is based on the resident's comprehensive assessment and is developed by a care planning interdisciplinary team which may include facility staff, therapy staff, contracted staff, hospice staff, physicians, ect. Interview on 3/2/2026 at 3:09 p.m., with the Director of Nursing (DON) revealed hospice care should be listed on the face sheet when you open the electronic chart and should be on the care plan. Interview on 03/03/2026 at 8:46 a.m., with the MDS coordinator revealed she normally would have put the agency and this one got missed. She is working on developing an area for hospice to add to the care plan.

Based on clinical record review, staff interviews and facility policy review the facility failed to notify the physician after resident refused ordered daily weights or were not completed for 1 of 1 residents reviewed (Resident #6) for daily weights. The facility reported a census of 48 residents.Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #6 documented diagnoses of heart failure, diabetes mellitus and hypertension. The MDS showed a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. Review of the Order Summary Report signed and dated by the physician on 1/29/26 revealed an order for daily weight. Give as needed (PRN) Bumetanide and notify the physician for weight gain of 2-3 pounds (lbs) a day or 5lbs a week with an order date of 5/7/25 and start date of 5/8/25. Review of the January 2026 Medication Administration Record revealed the following information:1/1/26-1/2/26- marked with an x and noted drug refused1/7/26- marked as NA1/15/26- marked with an x and noted drug refused1/22/26- marked with an x and noted drug refused1/24/26- marked with an x and noted drug refused1/26/26- marked with an x and noted drug refused Review of the February 2026 Medication Administration Record revealed the following information:2/5/26- marked as NA2/11/26- marked with an x and noted drug refused 2/13/26-2/14/26- marked with an x and noted drug refused2/15/26- marked as NA 2/16/26-2/17/26- marked with and x and noted drug refused2/18/26- marked as NA2/19/26- 2/23/26- marked with an x and noted drug refused2/24/26- marked as NA 2/25/26-2/28/26- marked with an x and noted drug refused Review of the March 2026 Medication Administration Record revealed the following information:3/1/26-3/2/26- marked with an x and noted drug refused. Review of the clinical record lacked notification to the physician regarding refusal of daily weights. The facility does not have a policy that addresses notifying the physician. Interview on 3/3/2026 at 8:55 a.m., with the Assistant Director of Nursing (ADON) revealed there is no documentation of notification to the physician regarding Resident #6 refusing her daily weights or weights not being completed. The ADON expects staff to be notifying the physician if the orders are not being completed.

Based on observation, clinical record review, facility policy review and staff interview the facility failed to complete skin assessments, notify the physician in a timely manner regarding a new pressure area to the coccyx area to ensure resident received necessary treatments, interventions and supplements to properly prevent a stage 2 pressure ulcer consistent with professional standards of practice for 1 of 1 residents reviewed (Resident #3). The facility reported a census of 48 residents.Findings include: The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue). may be present on some parts of the wound bed. Often includes undermining and tunneling or eschar. Unstageable Ulcer: inability to see the wound bed. Other staging considerations include:Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration. Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. These changes often precede skin color changes and 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 Minimum Data Set (MDS) assessment dated [DATE] for Resident #3 documented diagnoses of Alzheimer's Disease, diabetes mellitus and hypertension. The MDS showed a Brief Interview for Mental Status (BIMS) score of 3 indicating severe cognitive impairment. Review of Progress Notes revealed the following:On 12/30/25 at 5:27a.m., resident has a small open area to the base of the tail bone measuring 1.5x0.5 cm. Cream applied, doctor notified. Will continue to monitor. On 1/19/26 at 8:32 a.m., received return fax, signed by provided, re: open area to tailbone. New order received: apply house camo every shift and as needed then discontinue when healed. On 2/13/26 at 1:43 p.m., received a signed order for 2 Cal 80cc three times a day to promote wound healing and poor intakes. Medication Administration Record (MAR) updated and filed in chart. Review of resident's care plan with a revision date of 2/9/26 revealed the following:Pressure ulcer stage 2 to coccyx with a revision date of 2/9/26 Administer treatment per physician order with a revision date of 7/7/25 Assist with incontinence briefs and perineal care times 1 with a revision date of 3/7/25 Keep skin clean and dry as possible with a created date of 10/4/22 Monitor skin condition with daily dressing and weekly bathing with a created date of 10/4/22 Pressure reduction pommel cushion to recliner with a revision date of 3/7/25 Pressure reduction to wheelchair with a revision date of 3/7/25 Pressure reduction winged mattress to bed with revision date of 3/7/25 Assist as needed with a revision date of 8/23/24 Report any reddened or open areas with a created date of 10/4/22 Trial of tilt space wheelchair for positioning with a created date of 2/9/26 Treatment per MAR to pressure ulcer with a created date of 2/9/26 Review of Braden Scale assessment (tool used to evaluate risk of development of a pressure ulcer) revealed:On 5/7/25- which revealed a score of 17 indicated at risk for development of pressure sores. On 7/29/25- which revealed a score of 14 indicated a moderate risk for development pressure sores. On 11/18/25- which revealed a score of 14 indicated a moderate risk for development pressure sores. On 2/19/26- which revealed a score of 14 indicated a moderate risk for development pressure sores. Review of the weekly skin observation tool revealed the following:On 12/18/25- no new skin issues noted at this time. On 12/25/25- lacked documentation of assessment being completed. On 1/1/26- site- coccyx, type- pressure, 0.5 centimeters (cm) length x 0.5 cm width. Doctor notified. On 1/8/25- lacked documentation of assessment being completed. On 1/15/26- resident noted to have redness on coccyx. On 1/22/26- resident has a small open area on coccyx. Measures 0.5x1. Camo applied per order. On 1/29/26- resident noted to have open area to coccyx measuring 0.1x0.1. On 2/5/26- resident noted to have open area to coccyx measuring 0.1x0.1. On 2/12/26- resident noted to have open area to coccyx measuring 0.1x0.1 On 2/19/26- resident noted to have open sore to coccyx measuring 0.3x0.3. On 2/26/26- resident noted to have open area to coccyx measuring 0.1x0.1. On 3/2/26- site- coccyx, type, pressure, length 0.5, width 0.4, stage 2. Pressure to coccyx measure 0.5x0.4cm with healing light pink tissue. Review of the Treatment Administration Record (TAR) for January 2026 revealed an order with a start date of 1/19/26 for each shift for open area on tailbone: apply house camo every shift and as needed discontinue when healed every shift for wound. The clinical record lacked documentation of any treatment of the open area to the coccyx from 12/30/25-1/19/26. Observation on 3/3/2026 at 10:17 a.m., revealed an open area to the residents coccyx area. Review of facility provided policy titled Pressure Injury Surveillance dated 2025 revealed the following: A system of surveillance is utilized for preventing, identifying, reporting and investigating any new or worsen pressure injuries in the facility. All pressure injuries will be tracked Interview on 3/2/2026 at 3:08 p.m., with the Director of Nursing (DON) revealed the skin sheets should have been completed and they were being audited by the prior Assistant Director of Nursing (ADON). She should have been aware they were not completed and she should have known about the area. The DON revealed there is no documentation between 12/30/25 and 1/19/26 with the physician regarding the wound or treatments being completed during that time.

Based on the previous Centers for Medicare and Medicaid Services (CMS) form 2567 review, staff interviews and facility policy review, the facility failed to ensure they provided a comprehensive, effective Quality Assessment and Performance Improvement (QAPI) program. The facility reported a census of 45 residents. Findings include: A review of the Department of Inspections Appeals and Licensing website revealed that the facility had repeated deficient practices identified during the annual surveys and complaint investigations from 2/15/24, and 2/6/25. The repeated deficiencies cited include: 658 Services Provided Meet Professional Standards 684 Quality of Care 865 QAPI Program and Plan, Disclosure/Good Faith Attempt 880 Infection Prevention and Control A review of the facility Plan of Correction (POC) dated 3/6/25 revealed the following: a. POC for F658 indicated that 4 files a week would be audited. Just 2 files a week had been audited for the first 4 weeks. b. POC for F684 indicated that 4 files a week would be audited. Just 2 files a week had been done. c. POC for F689 indicated that 4 charts a week would be audited for accidents and hazards, safe transfers. Just 2 files a week had been audited for 7 weeks. On 4/3/25 at 11:30 AM the Administrator indicated that they had made progress in many areas and they continued to monitor successes along with the areas that still need work. She acknowledged that there was a misunderstanding on the POC and the number of files that would be audited weekly. The QAPI Facility Plan dated December 2024, identified the governing body and/or the facility administration would provide general oversight for QAPI activities related to resident care and services throughout the facility. The governing body was responsible and accountable for ensuring that: The QAPI program identified and prioritized problems and opportunities that reflect organizational processes, functions and services to residents based on performance indicator data, resident and staff input and other information.

Based on observations, interviews, and facility policy the facility failed to provide dignity to 1of 5 residents reviewed (Resident #6). The facility failed to provide dignity to the resident as demonstrated by the resident waiting to return to her room from the dining room while sitting in soiled garments. The facility reported a census of 45 residents. Findings Include: The Minimum Data Set (MDS) in progress for Resident #6, dated 3/31/25, identified a Brief Interview for Mental Status (BIMS) score of 15/15 indicating normal cognitive functioning. The resident had diagnoses of hemiplegia or hemiparesis (stroke with an affected extremity(ies)), depression, and muscular dystrophy, unspecified. Resident #6's Care Plan dated 3/24/25 revealed a focus area of Activities of Daily Living (ADL) self-care performance deficit with interventions including 1 staff assistance for toileting and the resident was dependent, dependent for transfers requiring 2 staff with the use of hoyer lift (non-weight bearing mechanical lift), and staff assistance for wheelchair (w/c) location in and outside of the facility. The Electronic Medical Record (EMR) Progress Notes from 3/1/24 to 2/19/25 revealed the 3 incidents of behavior including inappropriate toileting involving a Certified Nurse Assistant (CNA), accusations involving staff, and impatience regarding needing to wait for staff assistance for toileting. The EMR for bowel elimination revealed 11 of 29 entries for bowel incontinence. The EMR for bladder elimination revealed 17of 20 entries for incontinence and toileting, and 2 of 20 entries for incontinence. On 3/31/25 at 12:00 PM Resident #6 stated on 3/30/25 while in the dining room she had an incontinence episode. The resident stated she was told that the staff could not take her back to her room as they were feeding other residents. Resident #6 stated she felt bad that she needed assistance and was incontinent, but wanted to be changed. On 4/2/25 at 9:09 AM Resident #6 stated she waited approximately 30 minutes on 3/30/25 to be taken to her room to be changed. On 4/2/25 at 1:50 PM Staff GG, Certified Nursing Assistant (CNA)/Certified Medication Aide (CMA) stated if a resident stated they had an accident in the dining room and needed to leave to be changed, they would assist the resident back to their room to provide care or get assistance. Staff GG stated during meals the CNAs assist in the dining room except for 1-2 CNAs that were floats who would continue to get any residents up, pass room trays, or answer call lights. On 4/2/25 at 10:40 AM Staff J, Director of Nursing, expected if a resident requested to go back to their room due to incontinence, then the staff should take the resident back and assist them. The facility's policy, Rights of Residents in Long-Term Care Facilities by the Office of the State Long-Term Care Ombudsman, revealed residents have the right to receive adequate and appropriate care. It further revealed the residents should be treated with consideration, respect, dignity and have control of their life.

Based on facility record review and staff interviews the facility failed to complete a Significant Change Minimum Data Set (SCMDS) within 14 days of the facility recognizing the resident had a significant change for 1 of 1 resident reviewed (Resident #1.) The facility reported a census of 45 residents. Findings include: The MDS date 2/14/25, showed that Resident #1 had a Brief Interview for Mental Status (BIMS) score of 0 (severe cognitive deficit.) He was totally dependent on staff for toileting and transfers and he was on Hospice care services. The Care Plan for Resident #1, updated on 2/19/25, showed that he had a decline in cognition and in physical condition. He was admitted to Hospice services on 1/25/25. A hand-written, Hospice admission form showed that services started on 1/25/25. The Clinical - MDS page of the electronic chart showed a quarterly MDS was completed on 12/6/24 and on 2/14/25. The chart lacked a SCMDS. On 4/3/25 at 11:30 AM, the Administrator acknowledged that Resident #1 had been admitted to Hospice in January and that they failed to complete a SCMDS. According to the Center for Medicare and Medicaid Services (CMS), Resident Assessment Instrument (RAI) Version 2.0 Chapter 2 page 2-3 revised on August 2003, a significant change in status must be completed by the end of the 14th calendar day following determination that a significant change has occurred.

Based on medical health record review (MHR) and staff interviews the facility failed to submit a comprehensive Minimum Data Set (MDS) as directed by the Centers for Medicaid and Medicare Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.19.1 October 2024, within the required timeframe for 2 out of 15 residents reviewed (Residents #3, and #10). The facility census was 45. Findings include: 1. The review of Resident #3's MDS Quarterly assessment data indicated assessment dated [DATE], was accepted on 3/11/25. 2. The review of Resident #10's MDS Quarterly assessment data indicated assessments dated 1/31/25 were completed on 3/17/25 (late), and accepted on 3/17/25. On 4/2/25 at 10:33 AM Staff J, Director of Nursing (DON), and Staff U, DON, stated they did not have a response related to the completion and submission of the MDS documents as they did not complete them. The facility provided document, RAI/MDS Policy from Clinical Procedures for Long-Term Care, revealed the facility will initiate, encode, and transmit, assessments as delineated in Chapters 2, 3, 4, 5, and 6 of the current CMS RAI User's Manual.

Based on observation, interview and record review the facility failed to update and provide resident specific care plan for 3 of 13 residents reviewed, (Resident #4, #7 and #10). Resident #4, #7 and #10 had long-standing conditions and the care plans lacked a focus area and intervention related to these conditions. The facility reported a census of 45 residents. Findings include: 1. According to the Minimum Data Set (MDS) dated [DATE], Resident #4 had a Brief Interview for Mental Status (BIMS) score of 11 (moderate cognitive deficit.) He was totally dependent on staff for toileting hygiene, lower body dressing, and transfers. The resident had Moisture Associated Skin Damage (MASD). The Care Plan last updated on 9/27/24, showed that Resident #4 had Activities of Daily Living Self-care performance deficits and he was being seen by an outside agency wound clinic. Rounds would be completed weekly and as needed. The resident required the assistance of 2 staff to the toilet and the use of the mechanical lift sit to stand for transfers. His diagnoses included diabetes mellitus, chronic kidney disease stage 3, edema, benign prostatic hyperplasia and diabetic neuropathy. The care plan lacked focus areas and interventions for edema or skin breakdown. On 4/1/25 at 9:31AM, Resident #4 was in a wheel chair, in his room. He was wearing a pair of sweat pants that fit tightly around his lower extremities. He was not wearing shoes and his feet were swollen, with the right foot much larger than the left. The resident said that he'd had a lot of trouble with fluid retention and for a while it had gotten better. The resident had two, fluid filled blisters on the front of his right leg, the entire area was red with extensive dry, pealing skin throughout both lower extremities. There was a small soiled, undated pad stuck to an open sore on the inside of the right leg. On 4/3/25 at 11:30 AM, the Administrator acknowledged that Resident #4 had extensive skin and edema issues and these concerns should have been included in the care plan. A facility policy titled: Care Planning - Interdisciplinary, reviewed in April 2016, showed that the Care Planning/Interdisciplinary Team was responsible for the development of an individualized comprehensive care plan for each resident. 49628 2. Resident #7's MDS assessment dated [DATE] revealed the resident had impairments in short term and long term memory, moderate impairment for daily decision making, inattention, and disorganized thinking as indicated by the staff. The document revealed diagnoses of Alzheimer's, Non-Alzheimer's Dementia, anxiety, and depression. The resident required substantial/maximal assistance for rolling in bed, and was dependent on staff for transfers. The document disclosed the resident was at risk for development of pressure ulcers and injuries, and treatments included pressure reducing devices for chair and bed. On 3/31/25 at 11:37 AM observed an unidentified staff member push Resident #7 to the dining room in a Broda Reclining Wheelchair (w/c) wearing Prafo boots. On 3/31/25 at 12:43 PM observed Resident #7 in the living area in the Broda Reclining w/c wearing Prafo boots. On 3/31/25 at 1:13 PM observed Resident #7 lying in bed on her back with Prafo boots. On 4/1/25 at 7:55 AM observed Resident #7 sleeping in the living area in the Broda Reclining w/c wearing Prafo boots. On 4/1/25 at 10:06 AM observed Resident #7 sleeping in the Broda Reclining w/c in the living area. On 4/1/25 at 1:22 PM Staff EE, Certified Nursing Assistant (CNA), and Staff GG, CNA/Certified Medication Aide (CMA), transferred Resident #7 to bed, removed the Prafo boots, completed care, and re-applied the Prafo boots prior to leaving the room. On 4/2/25 at 10:20 AM observed Resident #7 sleeping in the Broda Reclining w/c in the living area with the Prafo boots on. The Electronic Medical Record (EMR) revealed Weekly Skin Assessment completed on 3/27/25. Resident #7 had a pressure area on the right inner ankle that measured 1.7 centimeters (cm) long by .2 cm wide. The EMR Clinical Physician Orders dated 3/27/25 revealed an order for the right medial ankle wound treatment to be completed on Mondays and Thursdays. Resident #7 's Care Plan, dated 3/5/25, identified a focus area indicating a risk for skin impairment related to advanced dementia, decreased mobility, and incontinence. Interventions included heel lift boots on the resident when in bed (initiated on 8/22/24), pressure relieving pad in bed, pressure relieving mattress when in bed, tilt in space wheelchair with pressure reduction cushion, and monitoring/documenting location and size of skin injury. The facility failed to update the Care Plan to identify the resident's treatments for the pressure area on the right medial ankle. The facility failed to update the Care Plan to reflect the use of Prafo boots when out of bed. 3. Resident #10's MDS assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13/15 indicating normal cognition. The document revealed diagnoses of cerebrovascular accident (stroke), hemiplegia (paralysis of 1 side of the body), and depression. The resident required substantial/maximal assistance for rolling in bed, and was dependent on staff for transfers. The document disclosed the resident was at risk for development of pressure ulcers and injuries, had a diabetic foot ulcer, and had pressure reducing devices for chair, bed, applications of ointments/medications other than to feet, and dressings to feet. On 3/31/25 at 11:37 AM observed an unidentified staff member push Resident #10 to the dining room in a tilt in space w/c wearing Prafo boots. On 3/31/25 at 1:15 PM observed Resident #10 engaged with other residents seated in a tilt in space w/c wearing Prafo boots. On 4/1/25 at 12:10 PM observed Resident #10 seated in the dining room wearing Prafo boots for the noon meal. On 4/1/25 at 12:56 PM observed Resient #10 seated in the tilt in space w/c wearing Prafo boots in the living area. The EMR revealed Weekly Skin Assessment completed on 3/12/25 noted Resident #10 had no redness to buttocks or boggy heels. The EMR Clinical Physician Orders dated 12/18/25 revealed an order for Prafo boots for pressure avoidance, every shift for intervention to pressure dated 12/10/24. Resident #10's Care Plan, dated 3/3/25, revealed the resident was at moderate risk for pressure ulcers. The document provided interventions for staff including pressure relieving cushion to the recliner, pressure relieving device to w/c, and an air mattress. The facility failed to update the Care Plan to identify use of Prafo boots for pressure avoidance as per physician orders. 4. Resident #15's MDS assessment dated [DATE] revealed the resident had a BIMS score of 15/15 indicating normal cognition. The document revealed diagnoses of diabetes, anxiety, and hypertension (high blood pressure). Resident #15's Care Plan, dated 8/26/24, revealed the resident had 16 focus areas with target dates, and interventions. The target date identified on all focus areas was 12/23/24. The facility failed to review the Care Plan and update the target dates for all focus areas. On 4/2/25 at 10:37 AM Staff J, Director of Nursing (DON), and Staff U, DON, did not have a response to the Care Plans required to be updated. The staff did indicate both Resident #7 and Resident #10 did wear Prafo boots. The facility's policy Quarterly Review of Care Plans revealed the care planning/interdisciplinary team was responsible for the periodic review and updating of the care plans.

Based on observation, interviews and record review the facility failed to follow physician's orders for blood pressure parameters and daily weights for 2 of 6 residents reviewed (Resident #2 and #3.) The facility reported a census of 45 residents. Findings include: 1) According to the Minimum Data Set (MDS) dated [DATE], Resident #2 had a Brief Interview for Mental Status (BIMS) score of 13 (moderate cognitive deficit). She required set up assistance for dressing and tub transfers, and was independent with transfers and toileting. The Care Plan for Resident #2, updated on 3/12/25, showed that she had bariatric surgery, she was diabetic and on anticoagulant therapy. Staff were directed to monitor for medication side effects such as significant or sudden changes in vital signs. The resident had diagnoses that included chronic kidney disease, weakness and adult failure to thrive. On 3/31/25 at 11:07 AM, Resident #2 was in her recliner with her feet elevated. She had supplemental oxygen running but the nasal cannula tubing was sitting next to her and not on her nose. Resident #2 said she would take it off herself. She said that she didn't have much energy lately and the oxygen helped but sometimes she forgot to put it back on. An Order Audit Report showed that Resident #2 had a medication order dated 3/22/25 at 4:08 PM, for Midodrine 10 milligrams (mg) give every 8 hours for hypotension. Staff were to hold the medication if the systolic Blood Pressure (BP) was over 100. The Medication Administration Report showed that the midodrine had been given on following dates after blood pressures were taken: a. 3/18/25 BP: 114/64 b. 3/20/25 BP: 112/67 c. 3/21/25 BP: 122/64 d. 3/22/25 BP: 107/63 e. 3/29/25 BP: 124/64 f. 3/30/25 BP: 130/72 2) According to the MDS dated [DATE], Resident #3 had a BIMS score 15 (intake cognitive ability). She required partial assistance with dressing, toileting, hygiene and transfers. The resident had frequent pain and shortness of breath. The Care Plan for Resident #3, revised on 10/2/24, showed that she had Activities of Daily Living (ADL) performance deficits. The resident had hypertension, staff were to monitor for edema and use ted hose/ ace wraps as needed, and record daily blood pressure. Resident #3 used diuretic medication, staff would monitor for side effects and provide weights per schedule. Her diagnoses include diabetes mellitus, morbid obesity, edema and heart disease. An Order Audit report dated 9/9/24 at 1:50 PM, showed that the facility was to provide daily weights and to notify the primary care physician if the resident had a weight gain of 2-3 pounds overnight, or 4-5 pounds in 5 days. The Weight Summary report for Resident #2, showed that her weight had not been taken on 3/10, 3/17, 3/20, 3/22 or 3/26. From 3/24-3/25 the resident had a 13-pound weight gain and the chart lacked documentation that the doctor had been notified. On 4/3/25 at 11:30 AM the Administrator thought that staff may have started using a different scale when Resident #2 showed a 13-pound gain in one day. She said that they had started adding the blood pressures and weights directly on the MAR/TAR to help remind the nurses to address these areas. The Administrator said that they did not have policies on edema or blood pressure management.

Based on record and policy review and interviews the facility failed to implement restorative services for 1 of 2 residents reviewed (Resident #1). The facility reported a census of 45 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #1 had a Brief Interview for Mental Status (BIMS) score of 0 (severe cognitive deficit.) The resident was totally dependent on staff for toileting and transfers, and required substantial assistance with putting on and taking off footwear and lower body dressing. The resident had a stage 2 pressure injury and treatments included pressure ulcer care, application of ointments/medications and application of dressings to feet. The resident was on Hospice care. The Care Plan updated on 2/19/25, showed that Resident #1 had impairment to skin integrity related to fragile skin and a decline in his cognition and physical condition. The resident required a program to maintain strength and mobility. Staff were to monitor for ability to complete the restorative plan including use of the Nustep 15 minutes a day as tolerated and Range of Motion (ROM) all extremities as tolerated. If the resident refused the Nustep, attempt to use the arm bike. Adjust the program as indicated. According to the Point of Care Response History from 3/5/25 - 3/31/25, in the 26 days, staff had 52 opportunities to assist the resident with exercises. The document was marked 26 times as not applicable, 13 times as resident refused and 6 times as having exercised for 15 minutes. On 4/2/25 at 10:57 AM, Staff B, Director of Rehabilitation, said that she provided annual training for staff on the use of the equipment but did not train the staff on restorative services or ROM exercises to use with residents. On 4/2/25 at 7:06 AM, Staff Q, Licensed Practical Nurse (LPN) said that the restorative services were done by one aide scheduled to complete it for all of the residents. If they didn't have enough staff scheduled, the aides in the halls would try to get it done. On 4/2/25 at 8:07 AM, the Director of Nursing (DON) said they didn't have a special person to do restorative and the CNA's that are in the specific hallways are expected to offer restorative exercises. There's a list of the residents on restorative in the schedule book and they can look down the list for who gets what. She gave me a copy of the list. On 4/2/25 at 10:30 AM, Staff FF, CNA said that she was not aware of a restorative program and hadn't been trained on those expectations to exercise with the residents. On 4/3/25 at 10:00 AM, Staff P, LPN said that the restorative program wasn't getting completed very often because they didn't have enough staff. On 4/3/25 at 11:30 AM the Administrator acknowledged that the restorative program was not what should be and they have hired a couple new staff to implement the program. She indicated that they did not have a policy on restorative services. The undated Facility Assessment showed under the heading: Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies, would include the Administrator, QAPI, Infection Control and Prevention, Environmental Services, Social Services, Discharge Planning, Business Office, Finance, Human Resources. Nursing Services - DON, ADON, RN, LPN, CNA, CMA, MDS Nurse, Resident Care Coordinator, Restorative Aid, Bath Aid Food and Nutrition Services - Dietary Manager, Dietitian, Dietary Aid, Cook.

Based on the observation, staff interviews, and policy review the facility failed to reposition 1 of 3 reviewed (Resident #7). The facility reported a census of 45 residents. Findings include: Resident #7's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impairments in short term and long term memory, moderate impairment for daily decision making, inattention, and disorganized thinking as indicated by the staff. The document revealed diagnoses of Alzheimer's, Non-Alzheimer's Dementia, anxiety, and depression. The resident required substantial/maximal assistance for rolling in bed, and was dependent on staff for transfers. The document revealed the resident had a catheter, and was always incontinent of bowel. The document disclosed the resident was at risk for development of pressure ulcers and injuries, and treatments included pressure reducing devices for chair and bed. Resident #7's Care Plan, dated 3/5/25, identified a focus area indicating a risk for skin impairment related to advanced dementia, decreased mobility, and incontinence. Interventions included heel lift boots on the resident when in bed (initiated on 8/22/24), pressure relieving pad in bed, pressure relieving mattress when in bed, tilt in space wheelchair with pressure reduction cushion, and monitoring/documenting location and size of skin injury. An additional focus area, activities of daily living (ADLs) self care performance deficit, revealed the resident required 2 staff assist with dependent mechanical non-weight bearing lift transfers, 1-2 staff for bed mobility, dressing, and hygiene. The document revealed the resident was totally dependent with toileting, wore incontinence products, and occasionally used the bed pan. The Electronic Medical Record (EMR) Skin Nurse - Weekly Skin Observation Tool completed weekly 2/27/25 through 3/27/25 revealed the resident had a pressure area on the right inner ankle. Observed on 4/1/25 at 7:55 AM Resident #7 seated in a Broda Reclining Wheelchair (w/c) in the living area sleeping. Observed on 4/1/25 at 8:10 AM an unidentified staff take Resident #7 to the dining room. Continuous observation on 4/1/25 began at 9:10 AM of Resident #7 in front of the television in the living room with other residents. The Broda Reclining w/c was slightly reclined (approximately 30 degrees from upright). Observed numerous staff (Certified Nursing Assistants (CNAs), nurses, housekeeping, therapy) walk past Resident #7 in the living room with some staff glancing at the resident, others not looking at the resident. During the continuous observation Resident #7 slept in the Broda Reclining w/c with her head leaning against the right lateral wing of the chair, and the resident's position was not changed. Observed at 11:58 AM a staff member took Resident #7 to the dining room. Staff positioned the resident more upright during the meal. Observed at 12:43 PM staff placing the resident back in the living room area with the Broda Reclining w/c slightly reclined (less than 30 degrees from upright position). Observed at 1:22 PM Staff EE, CNA, and Staff GG, CNA/Certified Medication Aide (CMA) take Resident #7 to her room for care and repositioning. During the continuous observation Resident #7 was positioned in a Broda Reclining w/c without being repositioned from the chair or checked for personal needs for 5 hours 27 minutes. On 4/1/25 at 1:46 PM Staff EE stated residents were to be repositioned every 2 hours or as needed if they had pain or needed to be changed. The staff stated Resident #7 was repositioned before lunch by reclining the back of the w/c. The staff stated training had been provided that changing the position of a wheelchair was repositioning. On 4/1/25 at 1:50 PM Staff GG stated residents were repositioned every 2 hours. The staff stated change of position included not lying on a certain side, rolling for the prevention of pressure sores. The staff stated if a resident was in a wheelchair, the preferred reposition would be to lay the resident down. The staff stated a wheelchair that moves the resident back and brings the legs up could be done for repositioning. The staff did not know if Resident #7 was repositioned in the morning as she was not assigned to the hall. On 4/1/25 at 9:12 AM Staff CC, CNA, stated residents needed to be repositioned every 2 hours and checked. On 4/2/25 at 10:57 AM Staff B, Physical Therapist Assistant (PTA)/Director of Rehabilitation (DOR), contract therapy, did not know the specifics of the Broda Reclining w/c, but stated best practice was repositioning residents every 2 hours from their current position, including seated surfaces. The staff stated tilt in space seating systems changed the focus of gravity, changing pressure points, but the seating systems needed to be tilted in space, not reclined. On 4/2/25 at 10:40 AM Staff U, Director of Nursing (DON), stated she would have to look at the facility's policy regarding positioning requirements and the use of reclining w/c's. The facility's Wheelchair Use of Policy from the [NAME] Healthcare Clinical Procedures for Long-Term Care revealed staff were to assist the resident to toilet and reposition frequently. The facility's Positioning the Resident Policy from the [NAME] Healthcare Clinical Procedures for Long-Term Care did not indicate the frequency for repositioning residents.

Based on observation, interview and record review the facility failed to adequately monitor skin issues and intervene with ordered treatments for 2 of 3 residents reviewed, (Residents #4 and #10). Staff failed to ensure that wound treatments were in place, and detailed skin assessments were completed for Res #4. The clinical record lacked weekly skin assessments for Resident #10. The facility reported a census of 45 residents. Findings included: 1. According to the Minimum Data Set (MDS) date 1/13/25, Resident #4 had a Brief Interview for Mental Status (BIMS) score of 11 (moderate cognitive deficit.) He was totally dependent on staff for toileting hygiene, lower body dressing, and transfers. The resident had Moisture Associated Skin Damage (MASD). The Care Plan last updated on 9/27/24, showed that Resident #4 had Activities of Daily Living (ADL) self-care performance deficits. The resident was being seen by an outside agency wound clinic and rounds would be completed weekly. Resident #4 required the assistance of 2 staff to the toilet and the use of the mechanical lift sit to stand for transfers. His diagnoses included diabetes mellitus, chronic kidney disease stage 3, edema, benign prostatic hyperplasia and diabetic neuropathy. The care plan lacked focus areas and interventions for skin breakdown and edema. On 4/1/25 at 9:31 AM, Resident #4 was in a wheel chair, in his room. He was wearing a pair of sweat pants that fit tightly around his lower extremities. He was not wearing shoes and his feet were swollen, with the right foot much larger than the left. The resident said that he'd had a lot of trouble with fluid retention and for a while it had gotten better. He said that he had some treatments to his legs, but he wasn't sure if there was a dressing on his right leg or not. The resident was waiting for staff to come in and transfer him to the recliner so he could put his feet up. At 9:56 AM, Staff EE, Certified Nurse Aide (CNA) and Staff Q, Licensed Practical Nurse (LPN) had transferred the resident to the toilet and back to the recliner where they prepared to complete the treatments on the right leg. The left leg has Kerlix (bandage roll of gauze) wrapped around it but the right leg did not. The resident had two, fluid filled blisters on the front of his right leg, the entire area was red with extensive dry, pealing skin throughout both lower extremities. There was a small soiled, undated pad stuck to an open sore on the inside of the right leg. Staff Q cleaned the open sore, applied a new, dated, non-adhesive pad, then wrapped the lower leg with Kerlix. Resident #4 commented that sometimes at night, he had to remind staff to wrap his leg. Progress Notes from the Wound Clinic (WC) dated 2/19/25, showed that Resident #4 had venous wounds on the right lower leg. The two, partial thickness wounds limited measurements due to exposed epidermis (outermost layer of skin) and dermis (below the epidermis.) The wound beds were macerated (occurs when skin is exposed to excessive moisture; soft, soggy and light color). Progress Notes from WC dated 3/12/25, showed an order to apply Plurogel to 3 open areas on right lower leg after cleansing with wound wash every 3 days. Apply non-adherent dressing to right lower leg to be changed daily and as needed. The Medication Administration Record and Treatment Administration Record (MAR/TAR) showed that the order entered on 3/13/25, included the Plurogel application and wound cleaning every 72 hours. The order entries lacked reference to the daily dressing changes. The Skin-Nurse Weekly Skin Observation Tool (SNWSO) showed the following: a. 3/12/25 at 12:01 PM Resident had flaky discolored skin on bilateral legs. Treatment on legs done per doctor's order. The form lacked measurements and detailed description. b. 3/19/25 at 11:04 AM Discoloration on bilateral legs, treatment completed. The form lacked measurements or description. c. 3/26/25 at 2:01 PM, Discoloration on bilateral legs, treatment completed. The form lacked measurements or description. A Nursing Note dated 3/24/25 at 1:38 AM, showed that the resident had edema to bilateral lower extremities, the skin was red with 2 fluid filled blisters to right shin, one measured 10 cm. around and the second blister was 7 cm. x 3 cm. The SNWSOT, dated 4/2/25 at 11:01 AM, lacked measurements, descriptions or mention of the new blisters. Discoloration on bilateral lower extremity. Order Audit Report for Resident #4 showed an order dated 8/1/24 at 1:33 PM, that staff were to include any measurements and progress note with description of skin issues every Wednesday for skin care and to notify the doctor of any new skin issues. On 4/2/25 at 10:50 AM, Staff J, Director of Nursing (DON) agreed that it would be difficult to determine progress or regression of skin condition if the assessments did not include measurements or detailed descriptions. A facility policy from a Nursing Manual dated 2010, titled Skin Care Policy, the needs of each resident would be assessed individually and developed into their plan of care to promote the prevention of skin trauma and prompt healing of the residents entering the facility with break down. Each resident would be assessed individually if a resident was at high risk for skin breakdown, result would be implemented into the plan of care. Nursing staff would measure the ulcers each week, documenting and evaluating a need to change treatment. With any skin breakdown the nursing staff would do an assessment no less than weekly. 49628 2. Resident #10's MDS assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13/15 indicating normal cognition. The document revealed diagnoses of cerebrovascular accident (stroke), hemiplegia (paralysis of 1 side of the body), and depression. The resident required substantial/maximal assistance for rolling in bed, and was dependent on staff for transfers. The document disclosed the resident was at risk for development of pressure ulcers and injuries, had a diabetic foot ulcer, and had pressure reducing devices for chair, bed, applications of ointments/medications other than to feet, and dressings to feet. Resident #10's Care Plan, dated 3/3/25, revealed the resident was at moderate risk for pressure ulcers. The document provided interventions for staff including pressure relieving cushion to the recliner, pressure relieving device to w/c, and an air mattress. The Electronic Medical Record (EMR) Clinical Physician Orders dated 12/18/25 had an order for completion of the Weekly Skin Observation Tool, including measurements and progress notes with description of skin issues, every evening shift every Wednesday for skin care and notify the physician of any new skin issues dated 11/6/24. The Assessments tab of the EMR on 4/2/25 revealed the last Skin Nurse - Weekly Skin Observation Tool was completed on 3/12/25 and was 14 days overdue with a due date of 3/19/25. The facility failed to complete the Skin Nurse - Weekly Skin Observation Tool as per physician orders to be completed weekly. On 4/2/25 at 10:35 AM when asked about the expectation of completing the Weekly Skin Observation Tool, Staff J, Director of Nursing (DON), and Staff U, DON, did not have a response, but Staff J was observed shaking her head. The facility's Physician Medication Orders Policy from the [NAME] Healthcare Clinical Procedures for Long-Term Care did not address following physician orders that were non medication involved.

Based on observation, interviews and record review the facility failed to provide interventions for pressure ulcer prevention for 1 of 3 residents reviewed, (Resident #1). Resident #1 had a pressure ulcer to the right heel and was found to be without his protective boots and without the ordered treatment dressing. The facility reported a census of 45 residents. Findings include: The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue). may be present on some parts of the wound bed. Often includes undermining and tunneling or eschar. Unstageable Ulcer: inability to see the wound bed. According to the Minimum Data Set (MDS) dated [DATE], Resident #1 had a Brief Interview for Mental Status (BIMS) score of 0 (severe cognitive deficit.) The resident was totally dependent on staff for toileting and transfers, and required substantial assistance with putting on and taking off footwear and lower body dressing. The resident had a stage 2 pressure injury and treatments included pressure ulcer care, application of ointments/medications and application of dressings to feet. The resident was on Hospice care. The Care Plan updated on 2/19/25, showed that Resident #1 had impairment to skin integrity related to fragile skin and a decline in his cognition and physical condition. He was admitted to Hospice services on 1/25/25. He had padded, protective boots that he was to wear as allowed. A wound specialist, Nurse Practitioner (NP) was seeing the resident for wound care. A Skin Nurse - Weekly Skin Observation Tool dated 1/6/25 at 1:34 PM, showed that a pressure ulcer was discovered on the right heel, measuring 5 centimeters (cm) x 4 cm. The right inner heel was black and mushy and painful. The summary from the NP wound specialist, dated 1/22/25 showed that the wound was a Stage II and staff were to ensure that Profo (protective) boot was on the right foot at all times. The Hospice Interdisciplinary Group (IDG) Comprehensive Assessment and Plan of Care Update Report showed that on 1/27/25 the right heel was a Stage IV wound. A treatment order, dated 3/10/25 at 8:28 PM, showed that staff were to clean the right heel with Dakins solution, apply small amount of Therahoney to the wound bed, and to cover with foam dressing every 3 days. On 3/31/25 at 9:15 AM, Resident #1 was in his wheel chair in the commons area, in front of the television. His head was hanging, and he was sleeping with a blanket in his lap. His feet rested on the foot pedal and he was wearing gripper socks on his feet. At 10:16 AM, and at 10:46 AM, the resident was in the same position in front of TV. At 11:20 AM, Staff BB, Certified Nurse Aide (CNA) pushed him down the hallway and said she was going to take him in for a bath. Staff BB and another CNA tried to transfer him with the use of the mechanical lift, Sit to Stand, but he was too agitated and they decided to try again later. At 11:48 AM, Resident #1 was at the table in the dining room and was wearing the protective boots on both feet. At 12:47 AM Staff BB and Staff Y CNA used the total mechanical lift with full body sling to transfer him to the bed, where they undressed him. Staff DD, Registered Nurse (RN) came in as they removed his socks and his right foot did not have a treatment dressing. They transferred him to the shower chair and wheeled him into the shower room. At 1:22 PM, after his bath was completed, the CNA's transferred Resident #1 back to the bed and Staff DD, measured the area of the wound on the right heel. She completed the treatment and covered it was a dated dressing. The open area was round, yellow and deep. On 3/31/25 at 2:51 PM, Staff DD, said that she recognized the resident did not have any dressing on his foot and that the CNA's would usually let the nurses know if it had come off so they could put on another one. Staff DD said she thought the depth of the wound was about 0.2 cm. but she didn't have anything to measure it with. On 4/3/25 at 11:30 AM the Administrator said that Resident #1 should have had his protective boots on while in the wheel chair. A facility policy titled: Pressure Ulcer/Injury, Prevention showed that staff would develop a care plan to eliminate or minimize risk factor including pressure relief measures. Residents would be positioned with appropriate surfaces to protect bony prominences. Repositioning would be at least every 2 hours or as designated in the plan of care. If a pressure ulcer was present, the Licensed Nurse was responsible to record condition of the skin, including stage, size, site, depth, color, drainage and odor as well as the treatment provided.

Based on observation, clinical record review, and staff interviews, the facility failed to protect a resident from a possible accident and injury by pushing the resident in a wheelchair without foot rests for 1 of 5 residents (Resident #12). The facility reported a census of 45 residents. Findings include: Resident #12's Minimum Data Set (MDS) dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated moderate cognitive impairment. The MDS included diagnoses of non-Alzheimer's Dementia, and Depression. It revealed the resident required partial or moderate assistance for sit to/from stand positions, and transfers to/from bed, wheelchair and toilet. It further indicated the resident utilized a manual wheelchair and required partial/moderate assistance for 50 ' with 2 turns, and partial/moderate assistance for 150 ' in a hallway. Resident #12's Care Plan revealed a focus area of Activities of Daily Living (ADLS) self care performance deficit with interventions included transfers with 1-2 staff assistance, able to self propel w/c. Observed on 3/31/25 at 9:40 AM Resident #12 self propel w/c down the hall towards the nursing station/living room area using bilateral arms and feet slightly off the floor, there were no foot rests. The resident stated she was going to the trailer court. Observed on 3/31/25 at 9:50 AM Staff GG, Certified Nursing Assistant (CNA)/Certified Medication Aide (CMA), push the resident from the end of the hallway to her bedroom without foot pedals; the distance was at least 50 ' . On 4/1/25 at 1:50 PM Staff GG stated if pushing a resident in a wheelchair the staff need to make sure feet are on foot pedals, clothing was not dragging, and Hoyer straps needed to be tucked in. On 4/1/25 at 2:38 PM Staff EE, CNA, stated foot pedals needed to be in place to push a resident in a wheelchair. On 4/1/25 at 9:12 AM Staff CC, CNA, stated residents needed to have foot pedals on their w/c ' s to be pushed by staff. On 4/2/25 at 10:47 AM Staff B, Physical Therapist Assistant (PTA)/Director of Rehabilitation (DOR), contract therapy, stated residents should have foot pedals when being pushed in their w/c ' s. On 4/2/25 at 10:41 AM Staff J, Director of Nursing (DON), expected that residents would have foot pedals when being pushed in their w/c ' s. The facility's Wheelchair Use of Policy from the [NAME] Healthcare Clinical Procedures for Long-Term Care revealed foot rests were to be lowered and the resident's feet placed on the foot rests prior to assisting the resident to the area of the facility desired.

Based on clinical record reviews, staff interviews, and policy review, the facility failed to identify target behaviors for psychotropic medication use for 2 of 2 residents reviewed (Residents #10, #18). The facility reported a census of 45 residents. Findings include: 1. Resident #10's MDS assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13/15 indicating normal cognition. The document revealed diagnoses of cerebrovascular accident (stroke), hemiplegia (paralysis of 1 side of the body), and depression. It included the resident had no episodes of little interest/pleasure in doing things, feeling down/depressed, social isolation, hallucinations, delusions, physical/verbal behavior towards others, or behaviors not directed at others. The document revealed the resident rejected care 1-3 days during the reporting period. The MDS revealed Resident #10 took antidepressant medication during the last 7 days of the assessment period. Review of Resident #10's Electronic Medical Record (EMR) Physician Orders dated 2/18/25 identified the resident was prescribed Fluoxetine HCI 40 mg 1time/day for mood related to Major Depressive Disorder. The Physician Orders failed to include target behaviors for antidepressant medication order. Resident #10's Care Plan revised 3/3/25 included antidepressant medication related to depression, mood and sleep (revision on 11/7/24). The goal identified remaining free from discomfort or adverse reactions related to antidepressant therapy. The Care Plan Interventions provided to administer medications as ordered, and monitor adverse reactions. The facility failed to identify person centered target behaviors in the Care Plan related to depression. 2. Resident #18's MDS dated [DATE] revealed it was in progress. The document revealed the resident had a BIMS of 10/15 indicating moderate cognitive impairment. The document indicated the resident had not related any concerns with little interest/pleasure in doing things, feeling down/helpless, hallucinations, delusions, verbal/physical behaviors towards others, wandering or rejection of care. Resident #10's EMR diagnoses included fracture of the right femur, depression, and hypertension (high blood pressure). The resident's EMR Clinical Physician Orders dated 4/1/25 identified the resident was prescribed Sertraline HIC 100 mg 1 time a day for depression. The Physician Orders failed to include individualized target behavior for depression, and the side effects of the antidepressant. Resident #18's Care Plan dated 3/26/25 included history of depression and taking antidepressant medications focus area (revised 3/31/25). The goal identified remaining free of signs/symptoms of depression, anxiety or sad mood. The Care Plan Interventions provided to administer medications as ordered, monitor any signs/symptoms of depression, and pharmacy review monthly. The facility failed to identify person centered target behaviors in the Care Plan related to depression, and side effects of taking antidepressant medications. On 4/2/25 at 10:46 AM Staff J, Director of Nursing (DON), and Staff U, DON, did not have a response related to the expectations of individualized target behaviors being identified on the Care Plans. The facility's Physicians Medication Orders Policy from the [NAME] Healthcare Clinical Procedures for Long-Term Care revealed identification of the appropriate problem for the medication, record instructions unique for the resident, and recording observation for effectiveness. The policy did not specifically identify target behaviors.

Based on observation, interview and record review the facility failed to ensure that staff followed Enhanced Barrier Precautions (EBP) while providing wound treatments for 1 of 1 resident reviewed (Resident #1). The facility reported a census of 45 residents. Findings include: According to the Minimum Data Set (MDS) date 2/14/25, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 0 (severe cognitive deficit.) The resident was totally dependent on staff for toileting and transfers, and required substantial assistance with putting on and taking off footwear and lower body dressing. The resident had a stage 2 pressure injury and treatments included pressure ulcer care, application of ointments/medications and application of dressings to feet. The resident was on Hospice care. The Care Plan updated on 2/19/25, showed that Resident #1 had impairment to skin integrity related to fragile skin and a decline in his cognition and physical condition. He was admitted to Hospice services on 1/25/25. He had padded, protective boots that he was to wear as allowed. A wound specialist, Nurse Practitioner (NP) was seeing the resident for wound care. On 3/31/25 at 12:51 PM, Staff BB, Certified Nurse Aide (CNA) and Staff Y, CNA, assisted Staff DD, Registered Nurse (RN) with a wound treatment dressing change to the right foot of Resident #1. The three staff members failed to wear gowns during the cares. On 4/3/25 at 6:55 AM, Resident #1 did not have EBP signs on his door to alert staff to wear full Personal Protective Equipment (PPE.) On 4/3/25 at 11:30 AM the Administrator said that they had just posted the signage on the door for Resident #1. She acknowledged that they failed to implement EBP while caring for the residents open wound. According to the undated facility policy titled: Enhanced Barrier Precautions (EBP), the facility would expand the use of PPE beyond situations in which exposure to blood and body fluids were anticipated and refer to the use of the gown and gloves during high-contact resident care activities that provide opportunities for transfer of pathogens to staff hands and clothing. EBP apply to: wounds and or indwelling medical devices.

Based on observation, interview and record review the facility failed to implement interventions to prevent pressure ulcers for 1 of 3 residents reviewed, (Resident #31). At the time of survey, Resident #31 was found to be sitting in the recliner in his room for long periods of time with no pressure-reducing device on the seat. The resident had two open sores on his buttocks. The facility reported a census of 47 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #31 had a Brief Interview for Mental Status (BIMS) score of 14 (intact cognitive ability). He required moderate assistance with toileting hygiene, lower body dressing, and toileting transfers. His diagnoses included; renal insufficiency, peripheral vascular disease, and hip fracture. Resident #31 did not have a pressure injury upon admission on 12/28/23, and staff were to provide a pressure reducing device for his chair and bed. The Care Plan last reviewed on 8/30/24, showed Resident #31 had insomnia and chronic fatigue. He did not participate in activities and preferred to stay in his room. The resident required 1-2 staff assistance with a walker for transfers and he was encouraged to use the call light. The care plan lacked any reference to skin conditions or interventions to prevent pressure sores. A Weekly Skin Observation Tool (WSOT) dated 1/21/25 at 9:29 PM, showed that Resident #31 had a reddened area on his bottom and staff were to apply cream. On 1/27/25 at 12:20 PM, Resident #31 was sitting in a recliner in his bedroom. His speech was soft and said that he had a sore on his bottom that was causing him some discomfort. He said that there was a cream that staff used, but they didn't apply it every day. Resident #31 said that he was not able to shift his weight in the chair without help, and at times, the call light response could take up to an hour. An inspection of the recliner seat revealed that he was sitting directly on the seat wearing a hospital gown that was open in the back and just a brief. There was no pressure-reducing device on the seat. On 1/28/25 at 9:15 AM, Resident #31 was wearing a hospital gown and sitting in the recliner in his room. The seat did not have a pressure-reducing device. On 1/28/25 at 11:00 AM, the resident was leaning to the right in his recliner, his body had slid down to where his head was resting on the arm of the chair. Staff K, Certified Nurse Aide (CNA) and Staff S, Certified Medication Aide (CMA) walked past his room and saw that he was sliding down. Staff K asked the resident if he needed help getting boosted back up in the chair. The resident nodded yes and she said that she would get a second person to help. Staff K and Staff S stood on each side and boosted him up in the recliner. They inspected the seat and saw that there wasn't any protective padding for pressure prevention, the aides acknowledged that he probably should have one under him. On 1/29/25 at 6:00 AM, Resident #31 was in the recliner sleeping. There was a urinal hanging on the walker next to his chair with urine in it. At 8:00 AM, Staff V, Certified Medication Aide (CMA) and Staff T, Certified Nurse Aide (CNA) went into the residents' room to get him ready for the day. Staff T put a gait belt around him and told him they would get him up to the toilet. Resident #31 had difficulty scooting his bottom to the edge of the chair to stand. His brief was soaked and the seat of the recliner was soiled with wet and brown stains. The chair did not have a protective pad or a pressure-reducing cushion. Staff V and Staff T used the gait belt to assist the resident to stand, directed him to pivot to the wheel chair and sit. He was wheeled to the bathroom, and pushed toward the wall where there was a handle bar for him to grab and pull himself to stand. Staff T removed his heavily soiled brief, and directed him to sit on the toilet. The resident indicated that he had pain on his bottom and she asked him if he wanted some cream applied and he said yes. When the resident was done on the toilet, the aide had him grab the handle bar to stand as she wiped his bottom. The residents' buttocks were red with darker blotched areas on the left side, with two open spots. The resident struggled to breath and had audible wheezing. The aide quickly wiped his bottom and applied a heavy cream and he indicated he needed to sit. He sat in the wheel chair. The CNA put an absorbent padding in the recliner, but no pressure reducing pad. Staff T said that the resident had become weaker and it was getting more difficult to transfer him. She directed him to move feet and gave much encouragement as he settled back into the wheel chair. On 1/29/25 at 11:00 AM, the resident was awake and sitting in his recliner with the foot feet extended. He had his legs bent at the knees and was frowning. When asked if he had pain on his bottom and he shook his head yes. On 1/29/25 at 2:46 PM, Staff P, Licensed Practical Nurse (LPN) had just come in for the 2:00 PM shift. When asked if she had gotten any information from the Aides or the off-going nurse that Resident #31 had some open spots on his bottom, she said that she did not. She agreed that a pressure-reducing matt in his recliner would probably be helpful. She said that the CNA's were expected to tell the nurses when there are new skin issues. A WSOT dated 1/29/25 at 7:17 PM, showed that the resident had two open areas on the left buttocks, both measured 0.5 centimeters (cm). The document lacked description in color or texture. On 1/30/25 at 1:20 PM, Resident #31 was in his recliner. He indicated that the staff put cream on his bottom today, but he still did not have a pressure reduction cushion in the chair. A Health Status Note dated 1/30/25 at 2:35 PM, showed that a wound care provider had been in to see the resident and directed staff to apply pressure relieve cushion to the recliner and wheel chair. A Braden Scale for Predicting Pressure Sore Risk (BSPPSR) dated 6/7/24 at 10:39 AM, showed that Resident #31 was at moderate risk for pressure ulcers. The following documentation was found in Nursing Notes: a. On 6/1/24 the resident had a fall with fracture to his hip. b. On 6/10/24 at 4:37 PM, the resident was notified of his wife's passing. c. On 6/28/24 at 1:54 PM, the resident was declining therapy services. d. On 7/30/24 at 1:02 PM WSOT showed that the resident had an open area on left buttocks that measured 1-centimeter (cm) x 1 cm. d. On 9/30/24 at 9:50, a new order for treatment to open area on buttocks. e. On 9/12/24 at 12:23 PM after orthodontist appointment the resident was noted to have increased weakness to right upper and lower extremities. f. On 9/12/24 at 5:32 PM, new medication added for Major Depressive Disorder. g. On 10/28/24 at 12:15 PM complaints of weakness and fatigue, refusing restorative therapy services, constipation and depression continued, increased antidepressant medication. h. On 11/21/24 at 12:32 PM, Care Conference and resident reported to have depressed mood. i. On 11/20/24 at 12:32 PM depression worsening. j. On 12/25/24 at 11:09 AM area is no longer open on buttocks, (A BSPPSR assessment dated [DATE] at 12:44 showed that Resident #31 was not at risk for pressure sores.) k. On 12/12/24 at 10:59 AM the resident had audible wheezing. l. On 1/30/25 at 11:14 AM, Care Conference, resident noted to have a decline in status and Hospice was contacted for evaluation. A review of the Weights & Vitals tab in the electronic chart showed that from 7/17/24 to 1/30/25, Resident #31 had a 14-pound weight loss. On 2/3/25 at 1:30 PM the nurse with the mobile wound clinic said she came into the facility on ce a week to treat skin breakdown. She did see Resident #31 and acknowledged that he had two small open areas on his bottom. She prescribed an air cushion to be used in his wheel chair and recliner and a cream. On 2/6/25 at 8:02 AM, Staff J, Director of Nursing (DON) said that she wouldn't necessarily expect a pressure reduction matt in the chair for Resident #31 because he had been up and around in his room. She acknowledged that he'd had a decline in status but it wasn't that he couldn't move around, he chose not to. She said that the Care Plan should have a focus area for skin breakdown and she was not aware that the MDS indicated that he would have pressure reduction mat in the chair and wheelchair. According to the undated Facility Assessment, between 60-70% of the residents were at risk for skin breakdown. The facility provided resident-specific preventive measure for the risk areas, based on an individualized assessment and in accordance with residents' treatment goals and preferences. An interdisciplinary approach was used to develop a resident centered care plan with input from the resident, nursing department, medical providers the therapy department the registered dietician and the social worker. The licensed nurses provided care and treatment to resident based on their medical needs. Facility policy titled: Skin Care Guidelines from Nursing Manual dated 2010, it was the policy of the facility that a resident who entered the facility without pressure sores would not develop pressure sores unless the individual clinical condition demonstrated that they were unavoidable. The needs of the resident would be assessed individually and developed into the plan of care to promote the prevention of skin trauma and prompt healing of the residents entering the facility with break down.

Based on observations, record review, facility investigative file review, resident and staff interviews and policy review, the facility failed to ensure 2 of 3 residents (Resident #11 and #96) reviewed were free of accidents/hazards with transfers. The facility reported a census of 47 residents. Findings include: 1) The quarterly Minimum Data Set (MDS) assessment tool with a reference date of 8/2/24, documented Resident #96 had a Brief Interview of Mental Status (BIMS) score of 9. A BIMS score of 9 suggested Resident #96 had mild cognitive impairment. Resident #96 did not exhibit behaviors during the review period nor did he reject care during the review period. He has impairments on both sides to bilateral upper and lower extremities and utilized a wheelchair. The MDS documented the following diagnoses: Parkinson's Disease, anemia, hip fracture, dementia, encephalopathy. The Care Plan focus area with an initiation date of 7/24/2023 and a revision date of 11/1/2023 documented Resident #96 was totally dependent on two staff for transferring with a hoyer lift. The following Progress Notes were documented for Resident #96: a) On 10/14/2024 at 8:10 AM the resident arrives to the dining hall. The Registered Nurse (RN) attempted to take his pulse and oxygen level with a pulse ox. Resident #96 refused to pull his fingers apart. Once able to get his fingers apart, discoloration and swelling noted to right thumb. After contacting his Primary Care Provider (PCP) an appointment was made for 1:30 PM at their office. Pain relief provided. b) On 10/14/2024 at 6:39 PM resident returned to the facility from his appointment with the PCP with orders to use ice to fractured right thumb for 10 minutes, three times a day (TID) along with pain control medication. A Weekly Skin Observation dated 10/14/2024 documented Resident #96's right thumb to be swollen and discoloration of multiple types. The facility provided an incident timeline dated 10/14/2024: a) On 10/13/2024 at 2:00 PM Staff F assumed responsibility of Resident #96. b) On 10/13/2024 at approximately 8:00 PM Staff F assisted the resident in EZ stand with 1 assist (against company policy of two assistance with mechanical lift) to bed. c) From 10/13/2024 at 8:00 PM until 10/14/2024 at 6:00 AM Staff F was responsible for Resident #96 with all cares. d) On 10/14/2024 at 6:00 AM shift report was completed with Staff F and Staff D. No report given about any injuries or incidents with Resident #96. e) On 10/14/2024 at 8:10 AM Resident #96 entered the dining room for breakfast, nurse attempted to get his oxygen saturation. Resident was unable to release his left hand from his right hand. Once he was able to release, the nurse noted a very swollen and purple bruising to right thumb on top and bottom of thumb. f) On 10/14/2024 at 8:15 AM Resident #96 stated that while using the machine last night, he was unable to get his hand to let go of the EZ stand, so staff took his hand off. g) On 10/14/2024 at 1:57 PM following his appointment with his PCP, fracture noted to right thumb. h) Investigation reveals: a. Staff F was responsible for Resident #96 from 10/13/2024 at 2:00 PM until 10/14/2024 at 6:00 AM. She did not follow policy and assisted resident #96 with an EZ stand transfer with 1 assistance resulting in an injury to the resident's right thumb. b. Staff F did not report any incidents or injury to the nurse or oncoming shift. c. After getting statements from all other staff that worked, no other staff assumed cares of Resident #96. Staff F provided the following verbal statement to the facility on [DATE]: she reported that she was working on Resident #96's hall on 10/13/2024 from 2:00 PM until 10/14/2024 at 6:00 AM. The EZ stand was used to transfer the resident. Staff reported no difficulties during transfers but did the transfer herself (1 assistance). She did not have a second person. Staff did not notice any concerns with the transfer, no swelling or bruising to his thumb. Staff F denied any noted concerns during her shifts with Resident #96. This statement was received via telephone call on 10/14/2024 at 12:47 PM. Staff D provided the following written statement to the facility on [DATE]: he went into Resident #96's room to get him ready for the day and out for breakfast. He did seem extra hard to realize (release) his hand from is nightgown. He did not notice his thumb until the nurse had said something about it. He had also got a skin tear on his left forearm. The statement was signed by Staff D. Staff G RN provided the following written statement to the facility on [DATE]: Resident #96 was brought to the dining hall around 8:00 AM. He refused to pull hands apart to check his oxygen level. Once she was able to get his hands apart, she noticed his right thumb was bruised and swollen with limited movement. She provided pain relief and notified his son, the DON and hospice staff. The statement was signed by Staff G. The facility provided an x-ray report with an order date of 10/14/2024 at 1:30 PM documented the following results: fracture at base of right thumb noted on x-rays. On 1/23/2025 at 9:14 AM Resident #5 stated they used two staff while using the hoyer this morning, they usually have two staff. She added they have used the lift with one staff, this happens during the day time. She added it does not happen a lot though. On 1/23/2025 at 9:30 AM Resident #35 stated there is generally two staff when they are using the EZ stand to assist him. At times they do only use one staff but it does not happen a lot. On 1/23/2025 at 2:59 PM Resident #36 stated they usually have 1-2 staff assist with the hoyer lift during transfers. He stated the majority of the time its 2 staff because he is so big. On 1/22/2025 at 4:54 PM Staff G stated on 10/14/2024 once they were able to pull his fingers apart to see what was going on she noticed some discoloration and swelling to his right thumb. She could tell with his facial expressions that he was in pain that day. His thumb also looked painful, so she gave him his as needed (PRN) morphine to help. As soon as she saw the injury she called the PCP and set up an appointment at the clinic to be seen. She worked on the 12th and his thumb was not like that. She asked Resident #96 if this happened the night before and he said yes, during the night. She also asked who did this to him and he gave different answers but she could not attest to who. Staff G stated she had heard that staff will use the mechanical lifts alone and if she saw it she would intervene. She stated they were to have two staff when using mechanical lifts on residents. On 1/22/2025 at 3:33PM Staff N CNA stated they are to have 2 staff present when using the EZ stand. When asked if that is happening at the facility she stated almost everyone uses the EZ stand with one staff unless it's for a specific resident on Hall 3. She indicated how many staff they use for the mechanical lifts all depends on how many staff they have that day. Staff N stated for the most part EZ stands are used with 1 staff. She added when they use the hoyer lift they are also mostly done with 1 staff. If the resident is hard to roll or required extensive help they will try to use two but that does not happen a lot because they are short staffed or busy. On 1/22/2025 at 5:11 PM Staff E Licensed Practical Nurse (LPN) stated when staff would use the mechanical lifts she would see staff using them alone without the second staff member. She would have to remind staff that the have to have a second person. If staff called for help and no one responded she would assist with the transfer. On 1/23/2025 at 9:24 AM Staff I CNA was asked if she had ever heard of or saw staff using an EZ stand with 1 staff, she indicated it happens. She added it does not happen often, maybe once in a blue moon. On 1/23/2025 at 10:55 AM Staff H previous Administrator stated if he remembered correctly a CNA was using a lift and he believed the Resident's thumb or hand got caught. He could not recall how it happened or if the CNA noticed if it got pinched. He remembered Resident #96's thumb was black and blue, swollen. Indicated the staff member involved was Staff F. He stated staff are always to have 2 present when using the mechanical lifts, it's their company policy. When asked if staff used the lifts with only 1 staff member he stated he was sure it happened when they could not find a second person. He added he was not going to say it did not happen but they always preached to have two staff for resident transfers. On 1/23/2025 at 11:07 AM Staff F stated on 10/13/2024 she worked 2:00 PM until 6:00 AM on 10/14/2024. She stated the facility called her in to the office, said something about Resident #96's thumb was swollen. She indicated when she left work that morning he was ok. The day they found an injury to his thumb she acknowledged she worked with him that night and morning. She transferred him to bed using the EZ stand. When asked if anyone was in the room with her during the transfer she stated no. She added they terminated her for improper use of equipment. Staff F stated staff normally would only have one staff for transfers using the mechanical lifts but then started telling everyone they needed two staff. She acknowledged that evening, she could not find anyone to help her so she did the transfer herself. She denied the resident had any pain during the transfer nor did he make any complaints. She indicated Resident #96 did not have issues with his hands not wanting to let go or hold on to the lift during the transfer. She added there were no issues when she transferred him that day. She added Resident #96 goes to bed after dinner, so she put him to bed between 6:00-6:30 PM. Resident #96 does not get up at night, they do check and change with him throughout the night. On 1/23/2025 at 1:04 PM Staff J Director of Nursing (DON) stated on 10/14/2024 she was notified by Staff G that while trying to use the [NAME]/oximeter on Resident #96 he would not put his hands apart. Once she was able to get his hands apart, she noticed it to be very bruised. He was given pain medication and the PCP was notified and wanted to see him. Through their investigation they learned only one staff had worked with the resident for 16 hours, the day prior. When they spoke with other staff members they did not have contact with him the night prior. That staff member was Staff F. The resident does have Parkinson's disease so he has a hard time getting his body to move with him. The resident told her staff took his hand off the lift. When she spoke to Resident #96 he stated it happened the night prior he was in the EZ stand and he could not get his hand to let go when he sat down. When asked what she meant by would not let go, she stated the resident in the EZ stand has to hold on to the grab bars to stand up and that day he could not let go after he was sat down in the chair, to release the lift. Resident #96 did not tell her what happened after he sat down, just that staff helped get his hands off the lift, but did not mention a name. He did not say if he had pain that night but did say he had pain that morning. She indicated Resident #96 was reliable at the time of the incident. Once they determined it was Staff F that had assisted him they called her in to terminate her for improper use of the lift and not reporting an injury. She admitted to using the EZ stand with Resident #96, alone that night prior. At the time of the incident Resident #96 was an assist of two because he required an EZ stand for transfers. She added any use of a mechanical lift requires 2 staff members. When asked if that is being followed at the facility she indicated to the best of her knowledge it is. On 2/4/2025 at 12:25 PM during a follow-up interview Staff J stated it is unacceptable to one staff when using the EZ stand. She added all mechanical lift to have two staff present when being used. On 1/23/2025 at 2:02 PM Staff D stated on the morning of 10/14/2024 Resident #96 was grippy that morning. He did not see any injuries until the nurse had said something. The resident was in the dining room when the injury was found. Staff D stated his thumb was 2-3 times bigger than his other thumb. When asked what he did to help get the resident ready for the day he stated he provided cares, put a new brief on him, got him dressed, put his teeth in, put on his socks and shoes, sprayed cologne, then put is hat and glasses on. He denied observation any injuries during morning cares. He accompanied Resident #96 to his appointment for an x-ray and did not display any pain. The clinic said he had a hairline fracture to the middle part of his thumb. The facility provided a document titled 8/28/2024 Nursing, that provided the following information: EZ stands are a two person assist in the State of Iowa, and hoyer lifts. Do not transfer a resident with an EZ stand with one staff member, especially Resident #96. Disciplinary actions will be made. The facility provided a document titled Nurse Aide Skills, Skills Checklist #9, Mechanical Residents Lifts. 1. Secure assistance needed (at minimum, have at least two people). 41785 2) According to the MDS dated [DATE], Resident #11 had a BIMS score of 15 (intact cognitive functioning.) She had limited functioning, and used a walker and a wheel chair for mobility. Resident #11 required partial assistance for sit to stand and toileting transfers. She was frequently incontinent of urine and occasionally incontinent of bowel. Her diagnoses included coronary artery disease, diabetes mellitus, arthritis, sepsis and anxiety disorder. The Care Plan for Resident #11 was last revised on 10/2/24, and staff were to monitor for cognition decline. She required the assistance of one staff with a wheelchair for long distance mobility. An Incident Report dated 9/5/24 at 11:15 PM, showed that 2 CNA's had transferred Resident #11 with the use of a mechanical lift, Sit To Stand (STS) to the bathroom and the resident slipped out of the sling and onto the floor. On 1/27/25 at 3:45 PM, Resident #11 was in her wheel chair in her room. She had supplemental oxygen via nasal cannula and struggled to breath as she spoke. When asked if she'd had any falls, the resident said that a while ago, she hadn't been feeling very well and was weak, so the staff used a Sit to Stand to transfer her to the bathroom. She said that she was so week she couldn't stand any longer, then slid from the machine onto the floor. On 1/28/25 at 9:46 AM, Staff L, CNA said that she was working when Resident #11 fell from the Sit to Stand, (STS) mechanical lift. She said that the resident needed to use the bathroom so she and Staff W, CNA got her hooked up and transferred her to the toilet but the resident put her arms up and slid to the floor. Normally, the resident would pivot transfer with one staff but she was weaker than normal and was having a hard time standing and was confused. The nurse was aware that the resident was weak and they weren't able to transfer her as usual so she told them to use STS. On 1/28/25 at 9:54 AM, Staff P, Licensed Practical Nurse (LPN) said that Staff L called her back to the room to help with Resident #11, and when she came into the room, the resident was on the floor with her back up against the recliner. She said the staff lowered the resident to the floor when she slid from the lift. The STS was next to the recliner and they used the total mechanical lift to get her off the floor. On 1/29/25 at 6:00 AM, Staff W, CNA said that she was with Resident #11 when she fell from the mechanical lift. She said that Staff L had been in with the resident and tried to get her up to the bathroom and the resident would normally transfer with just one assist but had gotten weaker. The two of them tried to get her up to pivot transfer to the wheel chair, which was just in front of the recliner but she couldn't stand. Staff W said that the recliner was inclined, tilted up, so the resident could get to standing position easier. The resident had a gait belt on, they were not able to get her into a standing position so they went to the nurse, Staff P, and explained they were having trouble transferring. The nurse went and tried, when they still couldn't get her up, so the nurse told them to go ahead and use the STS. They got her to the bathroom, but the resident was not standing up very well on the machine. When she was done on the toilet, they started to transfer her back to the recliner, and Staff W reached for the remote on the recliner to decrease the incline while Staff L had control of the STS. They did not have time to get the recliner down before the resident slid from the sling and onto the floor. Staff W said that the resident's arms had been parallel to the floor chicken winged. They could tell she was getting tired, her arms slid up and out of the sling. She was in front to the recliner, and as she came down, the recliner slide across the floor a little bit and the resident ended up on her bottom, on the floor. She did not remember what size of sling they used, there was usually one on the machine so they probably just used that. She said it was buckled, but she did not remember tightening the buckle. Staff W said that they aren't necessarily taught to tighten the buckle once the residents are standing, but it would make sense. On 1/29/25 at 6:15 AM Staff L, CNA, said that they had used to STS with Resident #11 one other time. The resident was very weak, she wasn't standing well enough and they were trying to hurry because she was wiggling, and chicken winged. She did not remember if they tightened the belt on the sling when she was standing. The nurses would let the CNA's know if/when a resident was safe for mechanical lift transfers. On 2/6/25 at 8:02 AM Staff J, Director of Nursing said that Resident #11 was usually one assist, but when she was ill, they would use the lift. If the resident was not bearing weight, she would ask to send her out for evaluation because that was out of her normal and they later found out she was septic with a urinary tract infection. According to the staff, they did tighten the belt. According to the User Manual for Stand Up Patient Lift, revised on 1/2010, Using the Sling; the Belt must be snug, but comfortable on the patient, otherwise the patient could slide out of the sling during transfer, possibly causing injury. Individuals that use the standing patient sling must be able to support the majority of their own weight, otherwise injury may occur.

Based on record review and staff interview, the facility failed to assure residents were free from significant medication errors for 1 of 22 residents reviewed, (Resident #30). The facility reported a census of 47 residents. Findings Include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #30 documented a diagnoses of Diabetes Mellitus (DM), renal insufficiency and hypertension. The MDS indicated the resident required the high risk drug class of insulin injections for DM management. The MDS showed a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderate cognitive impairment. The Care Plan for Resident #30 showed the following related to DM: a. Diabetes medication of glucose tabs, glipizide and insulin ordered by the physician. b. Monitor and document side effects and effectiveness. The Physician Orders for Resident #30 showed the following: a. Blood sugar check four times a day. Call the medical doctor (MD) if <70 or >250. b. NovoLOG Injection Solution 100 units/milliliter (ml). Inject 8 units subcutaneously (sq) before meals. c. Insulin Glargine Subcutaneous Solution 100 until/ml. Inject 34 units sq two times a day. d. Glucagon subcutaneous solution 1 mg per 2 ml. Inject 1 mg sq as needed for symptomatic hypoglycemia 1 gram intramuscular /sq as needed for blood sugar less than 60 and resident unconscious or unable to take oral. Recheck blood sugar in 15 minutes. May repeat if blood sugar is less than 60 mg/dl. Call MD when used. The January 2025 Medication Administration Record for Resident #30 showed the following medications were administered by Staff Q, Licensed Practical Nurse (LPN) on 1/3/25 during the morning medication administration: a. Novolog FlexPen Subcutaneous Solution Pen-injector 100 unit/ml. Injected 3 units subcutaneously. b. Insulin Glargine Subcutaneous Solution 100 until/ml. Injected 34 units subcutaneously. c. Glucagon subcutaneous solution 1 mg per 2 ml. Inject 1 mg sq given at 9:44 AM. The Weights and Vitals record for Resident #30 on 1/3/25 showed the following blood sugar results: a. 52 milligrams per deciliter mg/dl at 2:51 AM b. 122 mg/dl at 3:22 AM c. 69 mg/dl at 6:37 AM The Progress Note for Resident #30 dated 1/3/25 documented the following: At 9:38 AM, the Certified Nurse's Aide (CNA) called the nurse into the room and the patient was unresponsive but breathing. The resident was not answering any questions, checked blood sugar and it was 34 mg/dl. This nurse gave the patient 1 dose of glucagon and called the primary care physician (PCP) to get okay to send the patient to the emergency room (ER). 911 was called at 9:24 and they arrived and took the patient to ER. At 9:44 AM, the resident was sent to the ER. In an interview on 2/3/24 at 9:53 AM, Staff Q stated, I received a report from the night nurse that Resident #30's blood sugar check was low that night (1/3/25), she gave the resident snacks and the recheck was normal. He was fine. The blood sugar I took that morning was normal. No signs. Staff Q confirmed 69 mg/dl was the blood sugar she was referring to. Staff Q continued, after breakfast was served, the other nurse called out and told me the resident was not responding. When I got to his room the resident was moaning and groaning when we tried to talk with him but wouldn't respond with words. The breakfast tray was sitting beside him and not in front of him, he didn't touch it. The other nurse and the CNA stayed in the room while I left to get glucagon. After I gave that, I called the doctor immediately, then called for an ambulance. When we rechecked the blood sugar it was lower. Staff Q confirmed the blood sugar was 34 mg/dl. Staff Q reported Resident #30 received all the scheduled morning medications including long and short acting insulin after the blood sugar check of 69 mg/dl. When asked if there were high or low perimeters for blood sugar checks that required PCP notification. Staff Q replied, I didn't normally call if the resident was going to eat and it's like 90 mg/ml or higher, but the Administrator talked to me after this and told me that she doesn't normally give insulin unless the residents are above 100 ml/dl and eating. When asked if all residents had the same parameters that required PCP notification, Staff Q replied, no they are all different. Staff Q then retrieved a computer and checked the electronic health record. Staff Q verified the PCP should have been notified for blood sugars lower than 70 mg/dl. Staff Q stated, I should have called the primary physician. When asked if she should have held the insulin until after consulting with the physician, the nurse replied, yes. Staff Q stated, the Administrator went over that with me. Staff Q explained due to being a newer nurse, she wasn't used to handling abnormal blood sugar levels. Staff Q stated, I was in the wrong, I learned from it. When asked if the short acting insulin caused the blood sugar of 69 mg/dl to decline to 34 mg/dl. Staff Q replied yes, the short acting, Aspart (Novolog), would have caused that. The ER Record on 1/3/25 for Resident #30 recorded the resident was seen in ER with chief complaint as low blood sugar. The Physician's Note documented the following: He was found unresponsive this am. Noted to be hypoglycemic (low blood glucose) of 47 mg/dl. Transferred to the facility via emergency services. Intravenous dextrose given enroute. Upon arrival he was responsive and answered questions appropriately. During my examination he was unresponsive with hypoxia. He was given another dose of IV dextrose. He is currently responsive and eating lunch. Resident #30 subsequently admitted to the hospital for cellulitis and urinary tract infection. The Employee Counseling Form dated 1/3/25 for Staff Q LPN documented the following for the background and discussion information completed by the Administrator: Discussed insulin administration timing and using judgement with blood sugar checks. Talked about ensuring a resident is able to eat when the blood sugar is low to them. Also discussed parameters for calling the MD prior to administering insulin. The corrective actions to be taken by the employee documented Staff Q stated, I know I messed up. Staff Q stated to the Administrator that she understood and will be more mindful in the future. The American Diabetes Association, Insulin Basic Education, given with the employee counseling form to Staff Q LPN, indicated Novolog as a rapid-acting insulin that begins to work about 15 minutes after injection and peaks in about one to two hours after injections and lasts between two to four hours. The undated blood Glucose Monitoring policy failed to provide direction as to treatment of diabetes. In an interview on 2/3/24 at 12:48 PM, the Director of Nursing (DON) confirmed Staff Q was the only staff that received counseling and education related to the incident. In an interview on 2/5/25 at 2:15 PM, when asked if Staff Q in the morning of 1/3/25 should have contacted the physician, according to the physician's order, to call if blood sugar was less than 70 ml/dl before administering the insulin, the Administrator replied yes. When asked if the administration of insulin caused the resident to go unresponsive and resulted in the need for the ER visit, the Administrator stated, the insulin should have been held and the doctor notified of Resident #30's blood sugar. I gave the nurse education. She has been disciplined.

Based on clinical record reviews, observations, resident and staff interviews, and facility policy review, the facility failed to protect a vulnerable resident (Resident #22) from inappropriate sexual contact from another resident (Resident #9) while the staff sat at the nurses' station. Following the incident, Resident #9 continued to be allowed in Day Room with Resident #22. The staff reported that Resident #9 could walk independently throughout the facility and the facility did not always have staff in the common area near the nurses' station. In addition, the facility implemented an intervention to monitor Resident #9's location at all times but documented on it three times a day. During this time frame, Resident #9 had two documented instances of interaction with Resident #22. This failure resulted in Immediate Jeopardy to the health, safety, and security of Resident #22. The State Agency informed the facility of the Immediate Jeopardy (IJ) on 7/5/23 at 4:05 PM that started on 5/7/23. The facility removed the IJ on 7/6/23 through the following actions: a. Emailed every staff member the policies of dependent adult abuse and the training provided by National Voice for Quality Long-Term Care. The facility planned to attempt to contact each staff member via telephone to ensure that they received the information and ask if they had any questions. If the facility could not reach the staff members, they would speak to them in the facility as soon as possible. b. The facility contacted Resident #9's family about alternate placement. c. The facility contacted the Ombudsman about assistance with finding alternate placement. d. The facility started 30 minute checks with a proposed check sheet for the staff to verify his whereabouts at all times. The scope lowered from a J to a D at the time of the survey after ensuring the facility implemented education with their policy and procedure. Findings include: Resident #9's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate cognitive impairment. Resident #9's functional status listed him as independent with all activities of daily living (ADLs). The MDS included diagnoses of anxiety, depression, unspecified dementia, and other symptoms and signs of cognitive awareness. On 7/3/23 at 10:15 AM Resident #9 reported that he had some issues with other residents, and that he touched another Resident's breast. He added that he should not have did that, and explained that it did not happened again. Resident #9 said that he has not seen that resident since the incident happened. He added that it was an instinct thing. On 7/3/23 at 10:22 AM Resident #22's family member (R22 FM) explained that a male resident touched her family member's breast. R22 FM reported that the facility notified her, but she did not know what the facility was doing to prevent this type of incident from happening again. She did not know if the facility told her what they were doing. This was the first time that something like this ever happened. Resident #22 is aware of her surroundings and will talk, but this is very rare, and that she usually looked at you with a blank stare. On 7/3/23 at 2:11 PM witnessed Resident #9 out in the common area walking from his hallway and then around the nurses station with no staff present at this time. Observed him walking around the common area stopping at different areas, looking around, and watching TV. On 7/5/23 at 12:17 PM observed Resident #9 walking around the common area with Resident #22 sitting in a recliner in the common area, no staff observed in the area. The Behavior Note dated 11/6/22 at 11:46 AM while a Certified Nurse Aide (CNA) assisted Resident #9 with his bath, he asked to touch her breast. When she refused, Resident #9 started to massage his genitals. The CNA redirected him and he started to talk about his work and family. The Social Services Note dated 1/26/23 at 3:05 PM indicated that a Physical Therapist Assistant (PTA) witnessed Resident #9 with his hands on another female resident who sat on the couch. The staff intervened and place a pillow between the residents to set a boundary. The Social Worker visited with Resident #9 about respecting other people's personal space, he voiced understanding. The Social Worker spoke with Resident #9's daughter who supported the staff's decision to redirect him to the other couch to watch TV and not sit near the female resident. The Behavior Note dated 3/11/23 at 3:21 PM indicated that Resident #9 acted sexually inappropriate during his bath. He told the CNAs in the shower that he wanted to play with their breasts. The staff told Resident #9 that was inappropriate behavior, so he remained quiet the rest of his bath. The Behavior Note dated 5/7/23 at 2:56 PM reflected that as a CNA left the break room, they observed Resident #22 sleeping on the couch. Resident #9 stood behind Resident #22 groping her left breast aggressively with his other hand on her shoulder. The staff immediately removed Resident #9 from the area and asked him to return to his room. The Resident Care Coordinator (RCC) notified Resident #9's daughter and discussed his dementia and forgetfulness. The Incident/Fall Investigation dated 5/7/23 at 10:20 AM listed that Resident #9 touch Resident #22's breast while she slept. The form indicated that Resident #9 walked independent in the hall. The possible contributing factor for the incident detailed a lack of personal boundaries - Care Plan started. The Intervention put in place to prevent further incident reflected a provider visit on 5/8/23. The form included additional note at 3:58 PM that indicated the provider directed no changes or recommendations. The Evaluation of interventions within seven days list that the facility reached out to multiple providers for assistance. Resident #9 had no further incidents. The facility discussed alternate placement for Resident #9 with his family. The Staff Statement/Time of Falls/Incidents form completed by Staff W, Licensed Practical Nurse (LPN), on 5/8/23 dictated that while she sat at the desk on 5/7/23, Staff M, CNA, saw Resident #9 with his left hand on Resident #22's breast. Staff W informed Resident #9 that it was inappropriate to touch another resident and directed him to his room. Staff W kept Resident #22 close to the nurse or other staff for the rest of the day. When Staff W notified Resident #9's daughter, she mentioned that the physician recommended a memory care unit. The Social Services Note dated 5/8/23 at 12:45 PM indicated that the Social Worker visited with Resident #9 after learning of the incident from 5/7/23. When questioned about touching another resident, Resident #9 voiced that he touched a lady's breast. When inquired why he did that, he responded that he just liked breasts. The Social Worker explained that he did not have the right to touch anyone without their permission and he voiced understanding. The Social Worker encouraged Resident #9 to visit with a staff member regarding his sexual feeling or any other questions. The Social Worker contacted Resident #9's daughter who apologized for the incident and reported that she supported the facility if they needed to anything regarding the situation. The Social Worker contacted the inpatient geriatric psych unit, who explained that unless he demonstrated physical aggression or threatening comments to another resident, he would not meet their criteria. The Social contacted another behavioral health facility who reported that their unit as full but they would send the facility information to complete to add him to their waiting list. The Communication - with Physician Note dated 5/8/23 at 2:54 PM Resident #9's physician called with an update on his appointment. The physician reported that Resident #9 recognized his actions were wrong. The physician did not provide any new orders for Resident #9. The reply from the physician on 5/8/23 indicated that Resident #9 knew what he did and that it was wrong. Resident #9 did not want to take any medication or to discuss this with his family. Medically, there is nothing they could do. The situation would need handled per the facility's guidelines. The Social Services Note dated 5/16/23 at 1:20 PM reflected that the other behavioral health facility could not take Resident #9 as he did not have additional documented behaviors. As the staff could redirect him and he did not display additional inappropriate behaviors, he did not meet their criteria for admissions. The Health Status Note dated 5/18/23 at 6:26 PM indicated that facility sent a referral to an Advanced Registered Nurse Practitioner (ARNP) to initiate mental health services at the facility. The Behavior Note dated 5/24/23 at 5:52 PM detailed that the nurse observed Resident #9 ambulating to the couch in the day room twice near Resident #22. The nurse redirected Resident #9 to another couch across the room near Hall 6 to watch a movie. The Social Services Note dated 5/25/23 at 2:19 PM listed that the Social Worker, RCC, and Administrator spoke with Resident #9's family and Resident #9. The facility staff notified them that they would contact law enforcement, press charges, and initiate a 30-day involuntary discharge if Resident #9 displayed further sexual inappropriate behaviors. Resident #9's May 2023 Medication Administration Record (MAR) included an order dated 5/24/23 for the nurses and nursing staff to monitor resident's location at all times, then document any behaviors in the progress notes. Nursing Intervention every shift for monitoring behaviors. The MAR only had day, evening, and night shift to document Resident #9's location. The MAR listed yes on the 27, 28, 29, 31 on the night shift, and on the 31 day shift. Resident #9's Progress notes lacked documentation of the type of behaviors observed. The Telehealth Behavioral Health Progress Notes dated 6/7/23 at 10:00 AM reflected that Resident #9 visited with the ARNP. The Chief Complaint listed that Resident #9 lacked insight into the reason for his appointment. The Presenting Problem listed cognitive impairment. The note included that the resident cooperated with the ARNP during the visit with laughing and smiling at times. Resident #9 appeared only alert to person and laughed when he could not answer the questions. When the ARNP asked about his inappropriate touching of other residents, he responded that he would do that again and then laughed. According to the nursing home, Resident #9 touched other residents and wandered around the facility. The facility staff are concerned that he could need a locked unit, as he experienced impulsive behavior. The ARNP gave an order to start Namenda 5 Namenda 5 milligrams (MG) one tablet at bedtime for 7 days, then increase to 5 MG twice a day for dementia. The Physician Visit Note dated 6/7/23 at 11:20 AM reflected that Resident #9 had his initial visit with the ARNP. Resident #9 received new orders for Namenda 5 MG one tablet at bedtime for 7 days, then increase to 5 MG twice a day for dementia, and then follow-up on 6/30/23. The Health Status Note labeled Late Entry on 6/11/23 at 1:57 PM indicated that a CNA left a note with the RCC stating they saw Resident #9 walk behind the couch in the day room by Resident #22. He moved Resident #22's hand off the top of the cushion. As the CNA proceeds towards the couch, Resident #9 walked away. No behaviors noted. The Behavior Note dated 6/22/23at 4:30 PM detailed that the bath aide reported that while giving Resident #9 a bath, he began masturbating and asked her if she wanted to help. The bath aide attempted to redirect Resident #9, but he did not stop. After another CNA entered the room, Resident #9 stopped the behaviors before starting again after the CNA left the room. He did stop before getting out of the bath tub. The nurse notified the Social Worker, Director of Nursing (DON), ARNP, and the Administrator. The nurse added an intervention to have CNAs present during Resident #9's bath. The Health Status Note dated 6/27/23 at 8:30 AM reflected that Resident #9 met with the ARNP via telehealth on 6/7/23 and visited with the ADON about starting him on Provera to reduce his sexual drive. The Assistant Director of Nursing (ADON) faxed Resident #9's primary care provider (PCP) regarding the recommendation. The Health Status Note dated 6/27/23 at 3:15 PM indicated that Resident #9's PCP reported that Provera was a medication that they would manage. They added that if the ARNP would not order it, they could try referring Resident #9 to psychiatry. The ADON emailed the ARNP regarding the PCP's response. The Physician Visit dated 6/30/23 at 10:00 AM detailed that the RCC assisted the ARNP via telehealth for Resident #9's visit. The ARNP gave new orders to start sertraline 25 MG for 4 days, then increase to 50 MG daily to decrease sexual drive. The Social Services Note dated 6/30/23 at 3:05 PM reflected that the Social Worker witnessed Resident #9 leaning over the couch as Resident #22 sat on it. The Social Worker asked Resident #9 to go to the other side of the day room to watch TV. Resident #9 responded that he did not have to and asked why did they think he had to? The Social Worker explained to respect Resident #22's personal space. Resident #9 replied that he could, but he was not going to. The Social Worker then left Resident #9 to speak with the RCC and he left the area. Resident #9's June 2023 MAR included an order dated 5/24/23 for the nurses and nursing staff to monitor resident's location at all times, then document any behaviors in the progress notes. Nursing Intervention every shift for monitoring behaviors. The MAR only had day, evening, and night shift to document Resident #9's location. The MAR listed yes for the following days: a. Day shift - 1, 17, 19, 22, 26, 27, 28, and 29. b. Evening shift - 14, on the 17 directed to see the Progress Notes. c. Night Shift - 5, 6, 10, 11, and the 17 directed to see the Progress Notes. Resident #9's Progress notes lacked documentation of the type of behaviors observed. On 7/3/23 at 10:33 AM observed Resident #22 exit her bathroom and walk to the recliner with staff in the day room. Resident #22 sat and looked at the TV with a blank stare. On 7/5/23 at 10:20 AM Staff J, CNA, reported that she watched out for two other residents as they wander and have alarms. She received some training when she started at the facility about abuse, with videos and pamphlets. If she saw a resident inappropriately touch another resident she would tell them to stop and report it. On 7/5/23 at 10:30 AM the Social Worker explained that she learned about the incident after it happened. She only contacted Resident #9's FM regarding the incident. She talked to the Ombudsman about the incident, as she wanted to make sure the facility did the appropriate things. The Social Worker added that they monitored Resident #9 and redirected him as necessary. They would look back into the medication changes that occurred after the incident. On 7/5/23 at 10:33 AM Staff K, Certified Medication Aide (CMA), explained that she monitored three residents for wandering. Resident #9 is one of the residents she watched for wandering, but did not specifically watch Resident #9 for inappropriate behaviors. She only worked during one of the incidents involving Resident #9. As she left the breakroom, a CNA called for her and the nurse due to Resident #9's inappropriate touching of another resident's breasts. Staff K denied being at the facility when Resident #9 moved Resident #22's hands off the couch while he stood behind her. On 7/5/23 at 11:56 AM Staff L, CNA, explained that they watched one resident related to wandering. Staff L reported that the facility did not have anyone that had sexual behaviors at that time. Staff L revealed that if she saw an incident, she would stop the situation, and then report it to the nurse. On 7/5/23 at 12:05 PM Staff M reported that after clocking out in the breakroom as she went on break, she came out of the breakroom. She saw Resident #9 leaning over the edge of the couch and had one hand bracing himself on the back of the couch with the other hand rubbing Resident #22's breast vigorously. In a louder voice, she told him to stop. The two staff who sat at the nurses' station charting, came over to help with the situation. Staff M added that she worked at the facility for six months and heard that Resident #9 previously touched Resident #22, but she did not witness it. She had Resident #9 go back to his room after the incident and the staff put Resident #22 in her wheelchair by the nurses' station. This allowed her to be monitored for the rest of the shift. Staff are supposed to watch Resident #9 and redirect when necessary, but they only chart on it once a shift. There is an as needed (PRN) section to chart on but she never used this section. Staff M added that the common area around the nurses' station did not always have staff around it. Staff M stated the facility did not provide education after the incident, they only said there was an incident and to watch Resident #9. On 7/5/23 at 2:27 PM the Social Worked explained a PTA placed a pillow in between Resident #9 and Resident #22 on 1/26/23, but did not know why. On 7/5/23 at 2:30 PM the DON revealed that she did not know anything about the incident on 1/26/23 until she looked it up in the electronic health record (EHR). The DON added that she heard a nurse stated that Resident #9 kept taking Resident #22's shoe and tying the shoe. The DON explained that the nurse reported that they put a pillow between the two residents so staff could see if he reached over to touch Resident #22. The Abuse Prevention, Identification, Investigation, and Reporting Policy revised March 2019 directed that all residents have the right to be free from verbal abuse, sexual abuse, mental abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members, legal guardians, friends, or other individuals. On 7/5/23 at 2:05 PM Staff N, [NAME] President of Clinical Services, explained that on 5/8/23 a CNA told her that she had a statement from the incident on 5/7/23. Staff N reported this was her first time dealing with a situation like this. She went back and learned that not all notifications were completed that first day. Staff N indicated that a psych consult was put in as intervention, but the CNA's could not access that form. Resident #9 saw the physician on 5/8/23 and she notified Resident #22's FM. Staff N added that the facility documented in the EHR for 24 hours and kept an eye on Resident #9 but they did not document the behavior task.

Based on facility document review, clinical record review, and staff interviews the facility failed to protect residents from accidents and injuries by not providing a newly hired Temporary Nurse Aide (TNA)/Certified Nurse Aide (CNA) enough education to know which residents could go outside unsupervised and/or if a resident could get up after a fall before a nurse assessed them. After the TNA left the resident outside unsupervised and without a means to call for help, the resident fell hitting her head that resulted in a hematoma (a collection of blood outside of a blood vessel). Following the incident, the facility failed to provide formal education to all the staff of which residents could be outside unsupervised. In addition, the facility did not have a list available of residents who could or could not leave the facility unattended for 1 of 1 resident reviewed (Resident #10). The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of June 17, 2023 on July 11, 2023 at 5:10 P.M. The Facility Staff removed the Immediacy on July 11, 2023 through the following actions: a. All staff will read the education and complete the required signature to indicate the read the education. Any questions staff may have on the topic will be answered at that time. The education will also be added to new hires orientation. The education provided directed the following: i. Independent residents going outside: 1. No resident can be outside unsupervised unless they are completely independent, as deemed by the nurse. 2. The nurse must give permission for a resident to be outside. 3. Staff will give the resident a walkie for communication and document the time in and out of the facility in the sign-out book. ii. If you are aware of a fall/incident: 1. Stay with the resident and call for assistance (or send another staff member for assistance). 2. Do not attempt to move or transfer a resident that fell until the nurse has assessed them and gives permission for a position change, if possible. This information will be used for all current staff and education with orientation/new hires. b. The sign relating to supervision for residents when outside will be hung at both the timeclock and the nurse's station so all staff are aware. The sign instructed the following: i. These are the only residents allowed outside unsupervised: 1. Resident #20 and Resident #21 ii. You must: 1. Get permission from the charge nurse before taking them outside. 2. Give them a walkie to communicate with staff. 3. Use the sign out book to document time the resident is out and time in the facility. The scope lowered from a J to D at the time of the survey after ensuring the facility implemented education and their policy and procedures. Finding include: Resident #10's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview of Mental Status (BIMS) of 4, indicating severe cognitive impairment. Resident #10 required limited assistance of one person with locomotion on and off the unit. The MDS included diagnoses of Alzheimer's, type 2 diabetes, age related osteoporosis without current pathological fracture (weakened bones without injury related breaks), and unspecified dementia. The Care Plan Focus related to Falls revised 7/26/22 indicated that Resident #10 had a potential for falls related to a history of falls and weakness with a diagnosis of scoliosis (abnormal curve in the spine) and dementia. Resident #10 has experienced an actual fall. The Interventions directed the following: a. Created 6/8/23: Signs in bathroom to remind staff to stay with her. b. Created 5/20/23: Use two person assist with transfers when she has increased weakness c. Revised 6/8/23: Sign on bathroom door to remind to get assistance. d. Created 9/2/22: Door shut when Resident #10 is not in her room. e. Created 7/21/22: Give simple one step directions when ambulating or transferring. f. Created 7/21/22: Keep call light within reach and remind Resident #10 to use it. The Care Plan Focus related to activities of daily living (ADLs) revised 7/21/22 reflected that Resident #10 had a self-care deficit due to weakness with a diagnosis of scoliosis and dementia. The Interventions directed the following: a. Created 7/21/22: Mobility - Assist of one with front wheeled walker (FWW) and a manual wheelchair for long distances. b. Created 7/21/22: Transfers - Assist of one with FWW The Incident Note dated 6/17/23 at 11:00 PM written by Staff C, Registered Nurse (RN) indicated that at 8:30 PM the staff called her to the front parking lot. When she arrived to the front parking lot she discovered Resident #10 lying on her right side with her wheelchair tipped over. Staff C's assessment revealed that Resident #10 had a 1.5 centimeter (cm) by (x) 3.2 cm hematoma to her right upper outer forehead and she said it hurt along with her shoulder. Resident #10 said that she usually had pain in her shoulder. Staff E called and reported the fall to the on-call provider who gave an order for as needed (PRN) Tylenol 325 milligrams (MG) 1-2 tablets by mouth every four hours. The Incident Report dated 6/17/23 at 8:30 PM indicated that Resident #10 fell outside. Precautions already in place indicated that she required staff assistance with transfers. The immediate intervention initiated directed for Resident #10 to not be outside unsupervised and anti-rollback brakes applied to her wheelchair. The report indicated that the nurse started neurological checks (checks use to determine any brain injury). The Incident/Fall Investigation dated 6/17/23 at 8:30 PM on a Saturday reflected that staff found Resident #10 lying on her right side with her wheelchair tipped over. It appeared that Resident #10 went off the curb. The Staff Statement/Timeline of Falls/Incidents dated 6/18/23 signed by Staff I, TNA, indicated that at 8:00 PM while she was in the lobby Resident #10 asked to go outside. Staff I took her outside a little after 8:00 PM and put Resident #10 by the side of the chair when she left her. While in a room putting another resident to bed, she heard Staff H, Certified Nurse Aide (CNA), say something. At 8:30 PM Staff H brought Resident #10 back in the facility and told her that she fell . Staff I's Progressive Discipline Note marked as Coaching signed 6/20/23 documented a description of Violation as she left a resident solo outside. The resident is a one assist in the bathroom and requires supervision in the public area. Staff I did not verify Resident #10's skill level with the nurse. The Resolution of Violation or Action Taken indicated Staff I received education that only independent residents can be outside on their own and residents with memory loss must be attended every 15 minutes checks. The form labeled Nursing Meeting on 6/21/23 for all staff instructed that if a resident expressed that they wanted to go outside, the staff must ask a nurse if it is okay for them to be outside by themselves. Then notify another staff member when taking a resident outside. On 7/11/23 at 10:03 AM Staff C, RN, explained that the facility had residents that sat outside by themselves. Staff C stated Staff I, TNA/CNA, let Resident #10 outside unsupervised when she shouldn't. Staff C added that Staff I did not ask if Resident #10 could be outside at all. The found Resident #10 in the parking lot on the ground with her wheelchair tipped over, she only received a hematoma on her head. Resident #10 would not be a resident that would be allowed to go outside by herself. Staff I did not know and did not check if Resident #10 could be outside, Staff I let her out the front door and left her unsupervised. On 7/11/23 at 1:22 PM Staff U, Certified Medication Assistant (CMA), explained that a CNA who did not know Resident #10 should not go outside, but she could not remember her name, possibly Staff I. Resident #10 was not supposed to be outside unless she had somebody with her, especially that late at night. Staff U added that all residents could go outside but the facility did not have a list with the residents who could go outside by themselves. Staff U reported that staff can take any resident outside as long as they check on them every 15 minutes. On 7/11/23 at 2:23 PM Staff M, CNA, reported that she decided which residents could and could not go outside by her common sense. She did not take residents outside unless the resident asked. When she took a resident outside, she checked on them every hour. Staff M stated the facility did not have a paper that says who can go outside unsupervised and how long they can be outside. On 7/11/23 at 2:35 PM Staff V, CNA, stated she had worked at the facility for almost a year. Staff V reported that she would ask the charge nurse, the Assistant Director of Nursing (ADON), or the Director of Nursing (DON) before taking a resident outside. Staff V added that they had some residents that go outside quite a bit. She would still ask the nurses if those residents could go outside. The facility did not have a list of residents who could or could not go outside. In addition, the facility did not have a list of residents that needed or did not need supervision while outside. She would check on residents who went outside every 15 to 30 minutes. On 7/11/23 at 2:52 PM Staff I, Certified Nurse Assistant (CNA), reported at the time of Resident #10's incident she did not have her CNA certificate. When Resident #10 asked to go outside, Staff I explained that she took her outside. Staff I stated she sat outside with Resident #10 for one or two minutes. Staff I expressed that about 5 or 10 minutes after she took Resident #10 outside, someone attempted to enter the facility from the outside. The man who attempted to enter the facility explained that a resident fell on the ground outside in the parking lot. Resident #10 had a large bump on her forehead after the fall. Before Resident #10's fall, no one told her which residents could and could not go outside unsupervised. Staff I denied that the facility had a current list of residents who can and cannot go outside unsupervised. Since Resident #10's fall, she checked every five minutes on any resident that she took outside. Staff I reported that the facility did not have a way for the resident to call to let the staff know they wanted to come inside. Staff I stated after Resident #10's incident the facility provided education that some residents have a foggy memory and not to trust what the residents stated. Staff I stated Resident #10 asked to go outside a lot. On 7/11/23 at 3:10 PM Staff H, CNA, reported that he did not know when Resident #10 went outside. A new employee, Staff I, took Resident #10 outside. Staff H stated it is common for Resident #10 to request employees to take her outside. Resident #10 should not be outside and should not be left alone outside. He stated saw a male figure running from the apartments, waving at him. Staff H explained that the male figure from across the street reported a person lying on the ground with a wheelchair tipped over. Staff H ran outside and found Resident #10 on the ground, she held her hearing aid and glasses in her hand. He paged for Staff C over the walkie talkie to come outside right the, Staff C asked why? At that time, he told Staff C that he found a resident on the ground. Staff C then asked which resident? He told Staff C that it didn't matter which resident, she just needed to come outside right then. When Staff C came outside, she only had a blood pressure cuff. Staff H stated it took Staff C between 3 and 5 minutes to get outside after paged. Staff H stated Staff C came out with only a blood pressure cuff and then she did not assess Resident #10. They put a gait belt on Resident #10, stood her up, and put her in her wheelchair. Then he wheeled her into the lobby. Staff C did not do any vitals or an assessment. On 7/11/23 at 5:10 PM the DON explained that Resident #10 should not have been outside unsupervised. The DON reported that the CNA responsible was a minor. The DON added that only one staff member made the mistake, not all the staff, and the incident did not involve all the residents. They disciplined and educated Staff I, then educated all the staff in the meeting on 6/21/23. Review of a document provided by DON titled, Nursing Meeting dated 6/21/23 reflected that if a resident expressed that they wanted to go outside, the staff must ask a nurse if it is okay for the resident to be outside by themselves, then notify another staff member when taking them outside. On 7/12/23 at 8:12 AM a review of a document provided by the Administrator titled, New Hire Orientation and Education lacked education related to supervision of a resident when outside of the facility. On 7/12/23 at 8:15 AM the Administrator stated the new hire orientation packet did not have training for supervision of a resident when outside the facility. The Administrator stated he would bring the orientation packet in when had added the training on resident supervision to the new hire orientation packet.

Based on clinical record review, observation, staff interview, physician interview, and facility record review, the facility failed to thoroughly assess and initiate interventions for residents with pressure sores for 4 out of 4 residents reviewed for pressure sores (Resident #5, #3, #7, #4). The facility failed to assess Resident #5's blackened toe after first identifying the skin concern on 11/4/20 at time of admit, failed to notify the physician of the skin area, failed to obtain a treatment or consultation, and failed to intervene to prevent deterioration of the toes. The failure resulted in harm to the resident when on 11/9/20, the resident found to have several blackened toes that required hospitalization , amputation, and contributed to her death. This resulted in an immediate jeopardy situation for the facility. The facility reported a census of 44 residents. Findings include: The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue). may be present on some parts of the wound bed. Often includes undermining and tunneling or eschar. Unstageable Ulcer: inability to see the wound bed. Other staging considerations include: Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration. Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. These changes often precede skin color changes and 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. 1. The admission MDS assessment dated [DATE] for Resident #5 identified a Brief Interview for Mental Status (BIMS) score of 13. A BIMS score of 13 indicated intact cognition. The MDS revealed the resident required the extensive physical assistance of 2 persons for bed mobility, transfers, dressing, and personal hygiene. The MDS documented [DIAGNOSES REDACTED]. The MDS recorded the presence of 2 stage II pressure ulcers and 2 unstageable pressure ulcers due to slough or eschar; all 4 pressure sores present upon admission to the facility. The MDS coded skin and ulcer/injury treatments that included application of dressings to the feet. The Care Area Assessment (CAA) Summary marked ADL (Activities of Daily Living) and pressure ulcer as triggered and care planning decisions made on 11/11/19. The CAA (care area assessment) Worksheets dated 11/9/19 included the following documentation: a. The resident required assist of 2 with gait belt and front wheel walker with attached right arm brace related to cast to RUE (Right Upper Extremity) following fracture to arm with multiple breaks from fall at home when the resident attempted to go to the restroom independently. The resident noted to have weakness and pain to feet related to pressure areas prior to admission. b. The resident admitted to the facility with pressure areas to the coccyx and multiple areas to left foot toes with 2 stage II areas and 2 unstageable areas related to slough tissue. Per the resident the areas present at home for a long time, she tried to heal them with home health services, she did not wear shoes, and her feet always cold because she could not turn the heat up in her house very high. Bilateral feet observed to be light purple in color; feet elevated and sock and blankets in place. The resident stated she had the area to her coccyx for a while due to incontinence and not able to get to the restroom when needed. The Discharge Return Not Anticipated (DRNA) MDS dated [DATE] identified Resident #5 admitted to the facility on [DATE] and discharged to the hospital acutely on 11/9/19. The care plan focus area initiated 11/5/19 identified impaired skin integrity related to bladder and bowel incontinence and impaired mobility. The goal included the areas to the toes and coccyx would heal without signs/symptoms of infection by target date of 11/17/19. The interventions listed: a. assess open areas/skin condition when doing treatment, documenting progress at least weekly. b. keep skin clean and dry as possible. c. monitor for signs/symptoms of infection, i.e. redness, warmth, pain, swelling, drainage, and increased temperature. d. monitor intake of meals and record. e. monitor skin condition with daily dressing and weekly bathing. f. offer and assist to restroom upon rising, before and/or after meals, and bedtime. g. peri-care (incontinence care) twice a day and as needed after incontinent episodes. h. PRD (Pressure Reduction Distribution) to bed and wheelchair. i. report any reddened or open areas. j. treatments to areas per physician order. The Care Plan Review dated 11/7/19 documented treatments done for wounds and a copy given to Resident #5's family member. The facility Discharge Summary dated 11/11/19 documented the resident with lower right leg in poor condition and some wounds on sacrum and right toes; [MEDICAL CONDITION] to right hand. The summary failed to document under Course of Treatment any treatments to the left toes or coccyx. The historical hospital medical records prior to Resident #5's admit to the facility 11/4/19 lacked documentation pertaining to any wounds or treatments for wounds on the resident's coccyx or left toes. The Nursing Admission Screening/History dated 11/4/19 at 5:01 p.m. recorded a full head-to-toe nursing assessment completed on Resident #5. The Assessment Tab of the electronic record printed 7/29/20 reflected this initial nursing assessment completed by Staff T, Licensed Practical Nurse (LPN). The clinical record lacked any indication a Registered Nurse (RN) completed or participated in the initial nursing assessment. The assessment documented the resident resided in room [ROOM NUMBER]-1; fell and broke her wrist at home; alert and oriented to person, place, time, and situation; and both right and left legs normal color, normal temperature, and she could bear weight on legs. The assessment recorded the skin assessment done by Staff D, LPN; and pain rated an 8 out of 10 (zero no pain and ten the worst pain imagined). The resident reported pain located mostly in her bottom but some pain in her right arm. The Skin Nurse Weekly Skin Observation Tool dated 11/4/19 at 2:28 p.m., written by Staff D, documented the following 5 pressure sores present at admit: a. left foot 3rd digit, stage II pressure that measured 1.2 centimeters (cm) by 1.2 cm. b. left foot 4th digit, unstageable pressure that measured 1.3 cm by 0.8 cm. c. left foot 5th digit, unstageable pressure that measured 0.5 cm by 0.4 cm. d. left foot top of 2nd digit, area noted as pressure but not staged that measured 0.4 cm by 0.3 cm. e. sacrum, stage II pressure that measured 0.6 cm by 0.3 cm by 0.3 cm depth. Staff D documented the left foot 3rd digit deep purple/black on approximately 2/3rd of the toe. The foot cherry red, cool to the touch, blanched fair. Slough present on the 4th and 5th digits with foam between the resident's toes when she arrived to the facility. The resident's family member stated he cared for the areas at home like that and did not treat them. The skin surrounding the sacrum very red with wound base meaty red, wound edges very macerated. Staff D recorded she faxed out to the doctor to request a new treatment. On 7/30/20 at 12:05 p.m., the Director of Nursing (DON) stated the facility kept all skin assessments either in the electronic record or on paper. The DON confirmed if a resident discharged then all skin assessments documented on paper should be in the closed hard chart record. The DON not aware of any other areas in the facility where skin assessments documented or stored. The clinical record lacked documentation of any other full nursing assessments pertaining to the wounds located on the sacrum and left toes. The Braden Scale for Predicting Pressure Sore Risk dated 11/5/19 at 7:57 a.m. documented a score of 17 that indicated the resident at risk. The Order Summary Report signed 11/6/19 contained all the active physician's orders [REDACTED]. The report lacked orders for treatments to any of the resident's 5 pressure sores located on her sacrum and left toes. The orders lacked any orders pertaining to compression stockings/hose. The November 2019 Medication Administration Record (MAR) and Treatment Administration Record (TAR) lacked documentation of any pressure sore treatments. The MAR and TAR lacked documentation pertaining to compression stockings/hose. The clinical record contained daily Skilled Charting nursing assessments from 11/5/19 thru 11/9/19. The Skilled Charting form contained a section to document a complete head-to-toe physical assessment of a resident and included these sub-sections: vital signs; Level of Consciousness/Orientation/Cognition; ADLs/Functional Status; Mood and Behavior; Bladder; Bowel; Skin/Wound; Respiratory; Cardiovascular; Neurological/Sensory/Communication; Pain; Medications/Orders; and Skilled Services. The Assessments Tab of the electronic record printed 7/29/20 reflected who wrote each assessment. The Skilled Charting nursing assessment dated [DATE] at 1:47 p.m. written by Staff G, RN. Staff G documented under Skin/Wound Care the resident with treatable wounds on left toes and coccyx and no treatment order at that time. The nurse wrote the area assessed and sent for treatment order. The Cardiovascular section recorded peripheral pulses palpable with mild [MEDICAL CONDITION] to bilateral lower extremities (BLE), bilateral feet dark red and cooler to touch, left hand red and cooler to touch, and unable to obtain accurate O2 (oxygen) saturation reading. The Pain section recorded the resident rated her pain at a 5 out of 10, location of pain left blank, [MEDICATION NAME] (pain medication) given after therapy and while doing treatment per request, and when asked if having pain at breakfast the resident said no. The Skilled Charting nursing assessment dated [DATE] at 2:43 p.m. written by Staff G. Staff G documented under Skin/Wound Care the exact same information as 11/5/19 assessment; the resident with treatable wounds on left toes and coccyx, no treatment order at that time, the area assessed, and sent for treatment order. The Cardiovascular section documented the exact same information as the 11/5/19 at 1:47 p.m. assessment; peripheral pulses palpable with mild [MEDICAL CONDITION] to BLE, bilateral feet dark red and cooler to touch, left hand red and cooler to touch, and unable to obtain accurate O2 sat. The Pain section recorded a pain rating of 5, the location left blank, and noted [MEDICATION NAME] given per request at lunch time. The Skilled Charting nursing assessment dated [DATE] at 12:49 p.m. written by Staff K, LPN. Staff K documented under Skin/Wound Care the resident with treatable wounds and no other information recorded. The Cardiovascular section documented peripheral pulses palpable, mild [MEDICAL CONDITION] to BLE, and bilateral feet dark red and cooler to touch. The Pain section recorded the resident verbalized pain but no rating, location, or notes recorded. The Skilled Charting nursing assessment dated [DATE] at 1:36 p.m. written by Staff K. Staff K documented nothing under Skin/Wound Care as the section left blank. The Cardiovascular section recorded the exact information as the 11/7/19 at 12:49 p.m. assessment; peripheral pulses palpable, mild [MEDICAL CONDITION] to BLE, and bilateral feet dark red and cooler to touch. The Pain section recorded the resident verbalized pain but no rating, location, or notes recorded. The Skilled Charting nursing assessment dated [DATE] at 1:19 p.m. written by Staff L, LPN. Staff L documented under Skin/Wound Care the resident with treatable wounds, location left blank, and unable to assess wounds due to cast placement. The Cardiovascular section documented peripheral pulses palpable, mild 1+ [MEDICAL CONDITION] (mild pitting, slight indentation, no perceptible swelling of the leg) present, and the resident remained up in wheelchair much of the shift and offered the use of recliner but declined. The Pain section recorded the resident denied pain or discomfort that shift. The Medications section recorded the resident continued antibiotic for skin/wound management with no adverse effects. The Pain Level Summary recorded only numerical numbers for pain rated on a 0 to 10 scale and no other characteristics of pain or its location: a. 11/4/2019 at 5:10 p.m. - 10 b. 11/4/2019 at 6:24 p.m. - 10 c. 11/4/2019 at 10:41 p.m. - 8 d. 11/5/2019 at 12:30 a.m. - 3 e. 11/5/2019 at 5:32 a.m. - 7 f. 11/5/2019 at 10:10 a.m. - 0 g. 11/5/2019 at 10:30 a.m. - 5 h. 11/5/2019 at 2:35 p.m. - 3 i. 11/5/2019 at 4:25 p.m. - 7 j. 11/5/2019 at 6:18 p.m. - 5 k. 11/6/2019 at 1:23 a.m. - 5 l. 11/6/2019 at 4:32 a.m. - 0 m. 11/6/2019 at 5:20 a.m. - 5 n. 11/6/2019 at 7:56 a.m. - 4 o. 11/6/2019 at 12:11 p.m. - 6 p. 11/6/2019 at 1:55 p.m. - 4 q. 11/6/2019 at 5:10 p.m. - 5 r. 11/6/2019 at 9:09 p.m. - 3 s. 11/7/2019 at 5:11 p.m. - 8 t. 11/7/2019 at 7:05 p.m. - 6 u. 11/7/2019 at 8:49 p.m. - 10 v. 11/7/2019 at 11:06 p.m. - 9 w. 11/8/2019 at 5:28 p.m. - 8 x. 11/8/2019 at 8:08 p.m. - 6 y. 11/9/2019 at 3:30 a.m. - 8 z. 11/9/2019 at 5:16 a.m. - 3 The clinical record only contained correlating, partial pain assessments on the dates highlighted in bold above. The Progress Notes only described the location of the pain on the following dates; otherwise, the clinical record lacked thorough pain assessment information: a. 11/4/19 at 5:10 p.m. noted in the initial nursing assessment pain located mostly in her bottom and some in right arm b. 11/5/19 at 4:25 p.m. noted complaints of right wrist pain c. 11/5/19 at 11:25 p.m. noted complaints of right wrist pain with [MEDICATION NAME] given with some relief and no further pain d. 11/6/19 at 5:20 a.m. noted arm pain e. 11/6/19 at 5:10 p.m. noted arm pain f. 11/7/19 at 5:11 p.m. noted right arm pain g. 11/7/19 at 8:49 p.m. noted right arm and buttock pain h. 11/8/19 at 5:28 p.m. noted right arm and coccyx pain i. 11/9/19 at 6:58 a.m. noted complaints of positional pain while in bed throughout the night The Progress Notes lacked documentation of an initial admit note to record the resident's arrival to the facility and status/circumstances of her arrival on 11/4/19. The Progress Notes contained the following documentation: a. On 11/5/19 at 5:32 a.m., [MEDICATION NAME] medication given for increased pain. b. On 11/5/19 at 5:46 a.m. Staff R, LPN, wrote a skilled note. Staff R documented the resident skilled for right arm fracture with surgical repair and complaints of pain rated 7 out of 10 that shift. The resident's skin with several existing skin issues noted, including pressure ulcer to coccyx, toe discoloration with foam in place, and bruising noted to left wrist at that time. Staff R recorded the resident's cast in place to right arm with no complaints of numbness or swelling. The entry lacked indication of which toes affected or status of the sores. c. On 11/5/19 at 1:54 p.m. Staff G, RN, wrote a Health Status Note. Staff G recorded she spoke to the resident's primary physician office about allergies [REDACTED]. d. On 11/5/19 at 11:25 p.m. Staff O, LPN, wrote a Skilled Note. Staff O documented the resident complained of pain once and [MEDICATION NAME] given. Staff O recorded the resident with bruising to left hand/wrist area, pressure ulcer to coccyx, and pressure areas to left toes. The entry lacked indication of which toes affected or status of the sores. e. On 11/6/19 at 4:08 a.m., Staff R wrote a Skilled Notes. Staff R documented the resident experienced pain with pain medication given. Staff R recorded the resident continued with bruising to left wrist, pressure ulcer to coccyx, and discoloration to toes. The entry lacked indication of which toes affected or status of the sores. f. On 11/7/19 at 12:04 a.m., Staff O wrote a Skilled Note. Staff O documented the resident experienced pain once and [MEDICATION NAME] given. Staff O recorded the resident continued with bruising to left hand/wrist area, pressure ulcer to coccyx, and pressure areas to left toes. The entry lacked indication of which toes affected or status of the sores. g. On 11/7/19 at 7:15 a.m. Staff H, LPN, wrote a Skilled Note. Staff H recorded the resident with pressure ulcer to coccyx and pressure areas to toes. The entry lacked indication of which toes affected or status of the sores. h. On 11/7/19 at 12:47 p.m. Staff K, LPN, wrote a Health Status Note. Staff K recorded the resident went out for a physician visit to see her hand surgeon. At 4:02 p.m. Staff O documented the resident returned with order to keep the cast clean and dry, try to elevate up in air, and give [MEDICATION NAME] 5 mg (milligrams)/325 mg (narcotic pain medication combined with [MEDICATION NAME]) 1 to 2 tabs every 6 hours as needed for pain. i. On 11/7/19 at 7:03 p.m., Staff O documented a fax received from the resident's hand surgeon ordering Keflex antibiotic medication 500 mg capsule four times a day for 10 days for lacerations under the cast. j. On 11/7/19 at 11:44 p.m., Staff O wrote a Skilled Note. Staff O documented the resident experienced pain with [MEDICATION NAME] given. Staff O recorded the resident continued with bruising to left hand/wrist area, pressure ulcer to coccyx, and pressure areas to left toes. The entry lacked indication of which toes affected or status of the sores. k. On 11/8/19 at 6:48 a.m., Staff H wrote a Skilled Note. Staff H documented the resident complained of pain at the beginning of the shift rated a 9 out of 10 and Tylenol given with [MEDICATION NAME], which was effective. Staff H recorded the resident continued with pressure areas to coccyx and to left toes. The entry lacked indication of which toes affected or status of the sores. l. On 11/8/19 at 11:25 p.m., Staff O wrote a Skilled Note. Staff O documented the resident complained of pain rated at an 8 with [MEDICATION NAME] given and some relief voiced. Staff O recorded the resident continued with bruising to the left hand/wrist area, pressure ulcer to coccyx, and pressure areas to left toes. The entry lacked indication of which toes affected or status of the sores. m. On 11/9/19 at 6:58 a.m., Staff H wrote a Skilled Note. Staff H documented the resident complained of positional pain while in bed throughout the night, [MEDICATION NAME] given, and the resident stated relief. Staff H recorded the resident continued with pressure areas to coccyx and left toes. The entry lacked indication of which toes affected or status of the sores. n. On 11/9/19 at 1:52 p.m. Staff L, LPN, wrote a Health Status Note. Staff L documented the resident sat in her recliner with her family member standing at the foot of the recliner with her sock off the left foot. The family member upset about the appearance of the toes on the foot stating the toes not that way when the resident in the hospital, now much worse. The family member took pictures of the foot. Staff L wrote she reassured the family member they monitored the toes and would leave the compression hose off the right leg and the family member voiced they wanted the socks on but they didn't need to be so tight nor did her shoes need to be on. Staff L wrote she attempted to educate the family member the reasoning and use of compression stockings and assured them the resident could go without shoes except when transferring. Staff L recorded she called Staff D, LPN/Skin Nurse, to update on the situation. The entry lacked documentation of a full skin assessment, description of what the toes looked like, measurement of the wounds, location of the wounds, or notification to the physician. o. On 11/9/19 at 2:10 p.m., Staff L documented the family member reported they called the physician and the physician wanted to speak to the nurse. The entry recorded the nurse updated the physician on the appearance of the toes and the physician wanted the resident sent to the ER (emergency room ) for evaluation of the area. At 2:20 p.m., the resident left the facility and transported to the ER. p. On 11/9/19 at 9:12 p.m. the entry recorded the resident admitted to the hospital [MEDICAL CONDITION] (infection in the blood) due to [MEDICAL CONDITION] (inflammation of the skin) with necrosis (death of body tissue) of toes and problems with the cast (right arm). q. On 11/20/19 at 4:34 p.m., a Social Service entry recorded the resident's wheelchair picked up from ICU (Intensive Care Unit). Review of the clinical record revealed the record lacked documentation the resident's primary physician notified of the resident's 5 pressure sores as recorded on the initial skin assessment or the notation of a deep purple/black toe discoloration. The resident's family member sent a text message with a picture of the left foot to the physician on-call for the primary care physician on Saturday, 11/9/19 at 2:14 p.m. The family member wrote to the physician they wanted the doctor to see that the facility did not provide care of the foot all week since Monday (11/4/19). Review of the pictures taken by Resident #5's family member, dated 11/9/19 on the pictures, revealed the left foot with wounds. The 2nd toe with a scabbed, darkened area on the top of the toe; the 3rd toe mostly deep purplish and black in color; the 4th toe all black, appeared swollen; and the 5th toe not visible due to soiled gauze wrapped around the toe and in-between the 2nd and 3rd toes that appeared stuck in place without tape. The pictures revealed the left foot with redness darker in color on the top of the foot. The ED (Emergency Department) Provider Notes dated 11/9/19 at 3:58 p.m. documented the resident presented with foot pain, skin breakdown of 3rd and 4th digits on left foot blackening, and redness and swelling of bilateral feet. The Clinical Impression and Disposition dated 11/9/19 at 7:35 p.m. diagnosed [MEDICAL CONDITION] due to [MEDICAL CONDITION]; toe necrosis; problem with fiberglass cast; and acute [MEDICAL CONDITION] with [MEDICAL CONDITION] (low blood oxygen levels). The Hospitalist Discharge Summary dated 11/26/19 at 2:13 p.m. recorded the following: a. Hospital Course - the patient (Resident #5) presented to the hospital with left foot pain and blackish discoloration in her toes. Vascular surgery consulted. The patient started on [MEDICATION NAME] drip (blood thinning medication). Patient had left SFA (Superficial Femoral Artery), popliteal artery atherectomy (procedure that utilizes a catheter with a sharp blade on the end to remove plaque from a blood vessel) and angioplasty (procedure to open narrowed or blocked blood vessels). Patient had stent placed to left popliteal artery. Podiatry consulted and she had a transmetatarsal amputation (surgery to remove part of foot) left foot on 11/15/19. The patient developed C.Diff ([MEDICAL CONDITION] - type of infection) during hospitalization . The patient started on [MEDICATION NAME] orally (antibiotic medication). Diarrhea improved. Tissue culture from her foot [MEDICAL CONDITION] ([MEDICAL CONDITION]-Resistant Staphylococcus Aureus) and Proteus (types of bacteria). Patient was on [MEDICATION NAME] and [MEDICATION NAME] (two additional types of antibiotic medications). Infectious Disease consulted and following during hospitalization . Patient developed respiratory distress during hospitalization attributed to [MEDICAL CONDITIONS] (fluid in lungs) and possible aspiration pneumonia. Patient intubated on 11/22/19 and started on tube feeds. The patient passed away on 11/26/19 at 7:58 a.m. b. The primary cause of death documented as shock, [MEDICAL CONDITION], [MEDICAL CONDITIONS], and pneumonia. The secondary causes of death documented as left toes gangrene status [REDACTED].difficile. The Certificate of Death dated 11/26/19 at 7:58 a.m. documented the immediate cause of death shock due to or as a consequence of [MEDICAL CONDITION] due to or as a consequence of [MEDICAL CONDITIONS] with underlying cause of pneumonia and other significant condition of left toes gangrene status [REDACTED]. Physician Interview On 8/4/20 at 10:30 a.m., the nurse for Resident #5's primary care physician reviewed the clinic's medical records for Resident #5. The clinic representative stated the clinic received a fax on 11/4/19 regarding a message about the resident's vitamin B12 injection, and a call from the facility pharmacy regarding clarification of [MEDICATION NAME] (narcotic pain medication) and [MEDICATION NAME] medication. The clinic representative reported on 11/5/19 the clinic received a fax related to the [MEDICATION NAME] being too strong for the resident but nothing about a black toe. The clinic representative reported on 11/6/19 the facility faxed the resident's immunization records. The clinic representative stated they did not scan every fax if they did not have to address anything, but otherwise they scanned the faxes into the record if orders written. The clinic representative reported they received a call on 11/9/19 from the resident's family member about Resident #5's toes. On 8/24/20 at 1:23 p.m., Resident #5's primary care physician reported he never examined the resident while the resident resided at the facility and he did not see the resident's toes. The physician stated in his opinion, a black toe is considered something critical requiring a call to the physician rather than a fax. The physician responded it would depend on the strength of the resident's ted hose whether or not the hose are contraindicated to wear on an extremity with a wound present. The physician responded the facility called with any headaches, small bruises, or falls without injury, so he would not know why they would not call to report a black toe as it would indicate a blood flow issue. On 8/13/20 at 4:08 p.m., the podiatrist who performed the amputation for Resident #5 responded he remembered the resident vividly and reviewed the resident ' s medical records. The podiatrist responded to a question about if the resident ' s outcome could have changed if staff notified the physician of the deep purple/black discoloration at the time of admit 11/4/19. The podiatrist stated the 3rd and 4th toes completely black and the 5th starting to get black when he evaluated the resident and no way the symptoms reported as seen on 11/9/19 would have happened overnight. The podiatrist commented maybe 1 toe but not all 3. The podiatrist stated what should have happened was as soon as the nurse documented she observed deep purple/black discoloration she should have called the resident ' s primary physician. The podiatrist stated if the primary physician had contacted him at that point, the podiatrist would have gotten the resident seen that day. Family Interview On 8/4/20 at 11:24 a.m., Resident #5's family member reported the resident seen at the wound clinic prior to admit to the facility 11/4/19 for a chronic, coccyx ulcer located at the top of her rectum. The family member denied the wound center seeing the resident for pressure sores on her toes. The family member stated the hospital gave them a discharge paper that directed to keep eye on the baby toe and watch for gangrene. The family member said they gave the paper and the orders from the hospital to the facility. The family member said they noticed a pink spot on the resident's baby toe. The family member stated they wanted the hospital doctor to do something but they never took any blood work and did anything about it. The family member reported the resident wore compression socks on her feet at home ordered by their family doctor related to the resident's heart issues. The family member said the facility held a big meeting with them the day before they observed the resident's feet on 11/8/19. The family member reported the resident going in and out of therapy and supposed to keep her foot elevated so they did not swell but the facility not doing that and not keeping the arm with a cast elevated in the air. The family member said the resident sat in a chair, kept the arm down, and the arm swelled up as not kept in the sling. The family member voiced the facility did not provide care for their mother. The family member recalled the resident's pinky toe had just the one spot that got bigger by the end of stay. The family member identified the resident on narcotic pain medication and so made no noise of pain complaints when asked why she wore compression hose. The family member reported the family physician mainly recommended wearing the hose a long time before the hospitalization in October 2019. The family member said they asked the facility everyday if they were checking the resident's foot. The family member stated they could not believe what they saw when they took off the socks/compression hose on 11/9/19. The family member stated the resident reported to them the staff did not remove her compression hose since she admitted to the facility and told them the night before the facility put her to bed in her socks and shoes. The family member stated they voiced disbelief to the resident that the facility did not remove the hose during her 5-day stay, but upon removing the socks, they could not believe what they found. The family member recalled taking off the right compression hose first, everything okay, then they took off the left compression hose sock and the resident stated ow, ow. The family member stated the resident reported the foot had been hurting but she did not say anything. The family member reported the area on the foot reddish in color when they last saw it at the hospital and then the whole toes black; no way it just happened. The family member reported they called the on-call physician for the family doctor on 11/9/19 and sent pictures to notify the doctor of the concern and the doctor ordered the resident sent to the ER for evaluation. The family member forwarded a text message of a screen shot of the message and picture sent to the doctor on 11/9/19. The family member commented the resident admitted to the facility just for therapy and then to go back home; the facility should have kept an eye on the resident's foot. The family member reported the hospital cut off the resident's toes as diagnosed with [REDACTED]. The family member said the resident passed away after four different antibiotic treatments. The family member again stated it looked nothing like that when the resident admitted to the facility and she only had one spot with spacers between the toes. In a follow-up interview on 8/4/20 at 1:27 p.m., Resident #5's family member reported the resident wore the type of compression hose with an enclosed toe area so there was no opening to view the toes. < (TRUNCATED)

Based on chart review and interviews the facility failed to ensure that all residents recieve sufficient fluid intake to maintain proper hydration and health for 1 of 9 residents reviewed (Resident #4). The facility admitted to the facility 12/30/19 with gastric tube feeding orders that did not meet his nutritional & fluid needs. The facility failed to follow up with the dietician to ensure the resident received adequate nutritional and fluid needs. The facility failed to ensure staff was consistent with water flushes and di not have a policy for them. On 1/24/20 the resident admitted to the hospital severely dehydrated with an [MEDICATION NAME] level of 2.2 (low) A low [MEDICATION NAME] can identify malnutrion. The facility reported a census of 44 residents. Findings include: According to the Minimum Data Set ((MDS) dated [DATE], Resident # 4 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the MDS the resident required the use of a Hoyer lift for transferring, assistance of two staff with dressing, bathing and toileting. He did not receive any food or fluids orally and had a feeding tube. The care plan for Resident #4 dated 1/14/20 addressed risk areas that included altered nutrition related to enteral feedings and aspiration. The care plan identified the resident with self-care deficits with impaired physical mobility, impaired communication and the care plan directed staff to assess the residents' non-verbal behaviors such as restlessness and facial expressions. The care plan revealed the resident chose not to wear his dentures and staff were instructed to provide frequent oral care and oral inspection. Staff were directed to monitor and access the calories, fluid and protein needs of Resident #4 and to monitor for signs and symptoms of dehydration such as dry mouth, skin, eyes, and decreased urinary output. A physician's orders [REDACTED]. The orders included: Bolus tube feedings [MEDICATION NAME] 1.5-290cc followed by 50cc flush five times a day. Clean gastrostomy tube (g tube) every day, daily weights, oxygen as needed (PRN) to keep saturations above 90% check when appears symptomatic. Sacral wound cleanse with soap and water apply [MEDICATION NAME] ag (a sterile dressing with silver used to cover acute and chronic wounds) followed by dressing every day. Suction orally PRN as needed secretions and congestion. Up 2 times a day for therapies and back to bed for pressure relief to sacrum. Up in chair no longer than 2 hours at a time. Daily weights related to fluid retention. A review of the transfer records from the Madonna Center signed by the referring physician and dated 12/30/19, revealed several orders that staff did not transcribe into the residents record: 1) Provide oral hygiene every 2 hours. 2) [MEDICATION NAME] (anti-fungal) suspension to be given 4x a day orally for oral cares to prevent thrush. The omission was discovered and entered into the electronic chart on 1/10/20. 3) Vital signs every 3 hours. A review of the medical chart revealed several as needed orders (PRN) that were seldom used: 1) [MEDICATION NAME] Nebulizer every two hours as needed for shortness of breath, this was not used at all. 2) [MEDICATION NAME] liquid 100millegrams per 5 milliliter as needed for secretions was only used three times during the residents stay. 3) Suction every 6 hours as needed for increased secretions. The electronic chart contained three references to staff suctioning the resident up until 1/23/20: on 1/8/20, 1/11/20, and 1/19/20. One nursing note on 1/22 indicated that the resident had refused suctioning. The baseline care plan dated January 2, 2020 lacked instruction regarding daily weights, the need for suctioning of secretions, the use of pressure reduction adaptive equipment to assist with healing of sacral wound, supplemental oxygen use or percutaneous endoscopic gastrostomy (PEG) tube daily cleaning. The resident admitted to the facility on [DATE] and the care plans did not address oral cares until 1/14/20 and did not address suctioning needs at all. According to the admission nutritional assessment dated [DATE] the recommendations for nutrition and fluid were as follows: Resident is difficult to understand, current feeding provides: 2175 calories, 90 grams of protein, 1160 cubic centimeter (cc) free water plus flushes after of 50 cc and with medication of approximately 450 cc for total fluid of 1600 cc average per day. Nutritional needs with pressure areas; 2400-2600 calories, 88-105 gram protein and 2000-2300 cc fluid. Will follow weights and any plans for oral intakes and consider a feeding increase to 320 cc [MEDICATION NAME] 1.5, 5 times daily with 60 cc before and after each feeding and 30 cc before and after each med pass. Would provide 2400 calories, 100 grams protein. In a telephone interview on 8/5/20 at 1:10 PM, the dietician stated that she remembered giving the recommendations for tube feedings for Resident #4. She said that she followed up with the facility in an email to request an increase in food and fluids if oral intake was not going to be possible. She said that many times when a resident comes to a facility with a feeding tube they may quickly move toward oral feedings, however, if that isn't in the plan, the tube feedings may need to be increased to meet the needs of the resident. The dietician said that she expected the facility would have a plan if/when they would trial oral intake and assess if the resident was healthy enough to start an oral trial. If that was not possible then the tube feedings would have to be increased. A review of the email sent to the facility on [DATE] from the dietician to Staff D revealed that the dietician communicated to the facility that the resident's feedings did not meet his nutritional needs with pressure areas. She indicated that if oral intake was not established soon, they should fax out for an increase from [MEDICATION NAME] 1.5 290 cc 5x daily to 320 cc 5x daily and increase flushes to 60 cc water before and after each feeding and with the standard medication pass. Resident #4 admitted to the hospital on [DATE] with [MEDICAL CONDITION], dehydration, aspiration pneumonia, [MEDICAL CONDITION] and acute kidney injury. A review of the hospital laboratory records dated 1/24/20 revealed that the residents BUN was 84 (8-25 normal range). The residents baseline on 12/28/19 was 38.2. Creatinine was 1.6 (0.6-1.4 normal range). The residents baseline range on 12/28/19 was 1.02. Sodium 153 (136-144 normal range). The residents baseline range on 12/28/19 was 133 and chloride 120 (normal range 98-108). The residents baseline on 12/28/19 was 103. A hospital history and physical dated 1/24/20 revealed an [MEDICATION NAME] level of 2.2 (low). [MEDICATION NAME] is a protein found in the blood. A low [MEDICATION NAME] can identify malnutrition. A hospital consultation dated 1/24/20 revealed the reason for the consultation as: Acute kidney injury with [MEDICAL CONDITIONS] and dehydration. The impression included: acute kidney injury with free water deficit and severe dehydration In an interview with the DON on 8/4/20 at 8:45 AM, the DON looked at the follow up email from the dietician with the recommendations to increase food and fluids if he was unable to transition to oral intake. She said the note would have gone directly to the Resident Care Coordinator (RCC) that person had been responsible to monitor and follow up. In a telephone interview on 8/3/20 3:00PM, Staff D LPN (licensed practical nurse) said she remembered Resident #4, specifically that he required suctioning, that he had some paralysis, and that he was a big guy. She said she was the RCC at that time and her responsibilities included doing some skin assessments and checking to see whatever else the nurses needed; if they needed advice on anything. When asked if she was solely responsible for skin assessments she said no, it was usually the nurses that would do the skin assessments but she would do them sometimes. She said that she did not remember the wound that Resident #4 had on his sacrum. When asked if there was anything else about Resident #4 that she remembered she said that the resident did not function at the level that the referring facility described. She said the resident's daughter told them he would sit on the side of the bed and play cards but he was far from that description. However, she said she believed that Pioneer had the resources and training to care for him. On 8/3/20 2:10, Staff C RN, recalled the resident because he was the husband of another resident that resided at the facility for a long time. She did remember that she completed the suctioning on him a couple of times when he experienced difficulty clearing phlegm. She remembered applying treatments to his bottom and said that at that time, it was Staff D that would do the measuring of the wounds and the nurses would let Staff D know if they thought any areas got worse. Staff C said since they did not have a clinical coordinator at the time of the survey, she would take any concerns to the DON and she would call the doctor with any resident concerns that needed the attention of the doctor. On 8/4/20 12:40 Staff E, occupational therapist (OT), said she remembered the resident because he was at a different level of functioning than what they expected. She said the resident's daughter described some of the things he could do and they wondered if he'd had another stroke that caused more damage before he came to the facility. Staff E said she hadn't been concerned that the resident wasn't getting repositioned and she believed the staff tried different techniques to keep him off of the pressure sore area. On 8/4/20 at 12:46 p.m. Staff F, speech therapist, said he remembered Resident #4. He said he'd had some concerns that staff did not provide oral cares so he addressed this with nursing. He said the residents tongue looked like he developed thrush and he had saliva that was solidified behind his teeth. Staff F said that it had been early on in the residents stay and that once he addressed it, the oral hygiene improved. He said that initially, the resident had been resistive to cares. On 8/4/20 at 3:10 PM, Staff H said he remembered Resident #4, specifically that he completely depended on staff, post stroke. Staff H said that he worked nights and at that time and the resident would occasionally talk to him whereas during the day he didnt respond. Staff H remembered doing some treatments to the resident's sacrum area and thought it was a [MEDICATION NAME] treatment. He did not remember having any concerns that the ulcer got worse. He said the resident would scratch himself often and had long finger nails, and he clipped them a couple of times. Staff H recalled the night before the resident went to the hospital because he had been in the room for almost an hour suctioning secretions. Staff H said that a CNA told him that the resident was struggling to breathe so they went in and did the suctioning. When asked if he remembered ever seeing signs or symptoms that the resident may have been dehydrated and he said he did not remember having any concerns in that area. On 8/5/20 at 2:15 PM LPN Staff O said that she would stictly go by whatever the physician orders [REDACTED]. She was not aware of any facility policies or standards on how much water to give with medications. Staff O said one of the residents has a 150cc flush after feedings and she thought it was 15-30cc before, with and after medications. She added that she would always go by the physician order [REDACTED]. In an interview with LPN Staff Q on 8/5/20 at 2:20PM, she said she would use 90cc before and after medication for a resident with a PEG tube, but would do whatever the order is in the electronic record. In an interview on 8/6/20 at 11:55 AM DON acknowledged the missed items on the transfer orders from Madonna Rehabilitation Center. She said that it was the responsibility of the patient care coordinator to enter transfer orders. The person that was in this position was terminated the end of June and since that time, the DON had been entering orders. She stated that the expectation is that all physician orders [REDACTED]. In an email communication with the administrator on 8/11/20 at 4:28 she indicated that the facility did not have any policies on suctioning procedure or on oral cares for residents who have feeding tubes.