Every finding on record at Providence Healthcare

Based on observation, record review, staff interviews, and review of the facility policy titled Freedom of Abuse - Abuse Prevention Fast Alert and the Certified Nursing Assistant (CNA) job description, the facility failed to assess and provide wound care in a timely manner to one resident (R) (R9) reviewed for wound care. On 2/21/2026, actual harm occurred when CNA BB neglected to provide (R9) adequate incontinent care, resulting in R9 developing a blister on the left upper thigh. R9 required a debridement to remove necrotic tissue on 3/5/2026. The sample size was 9.Findings include: Review of the policy titled Freedom of Abuse Abuse Prevention Fast Alert dated 1/2025 revealed. Policy: The purpose of this written Freedom of Abuse, Neglect, and Exploitation; Abuse Prevention Standard is to outline the preventive and action steps taken to reduce the potential for abuse, mistreatment, and neglect of residents. Neglect: Failure of a facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of the job description titled CNA/STNA dated 11/2023. Position Summary: Under the direction of a licensed nurse, the CNA/STNA delivers efficient and effective nursing care while achieving positive clinical outcomes and patient/family satisfaction. CNA/STNA performs various patient care activities and related non-professional services essential to caring for personal needs and comfort for patients. Responsibilities: Reports changes in the patient's condition, patient/family concerns, or complaints to the charge nurse and/or supervisor. An observation on 3/19/2026 at 10:10 am with the Wound Care Nurse (WCN) R9 was sitting up in bed finishing morning care. The resident permitted the surveyor to observe the area on her left upper thigh. An observation of R9 left upper thigh open to air (no dressing) the area was shiny pink granular in appearance, the size of a half dollar. Review of the admission Record for R9 revealed she was admitted to the facility on [DATE], and a diagnosis of, but not limited to, disorder of the skin and subcutaneous tissue and lymphedema. Review of the resident's most recent Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed that a Brief Interview for Mental Status (BIMS) was assessed as 15, which indicated cognitively intact. Section M was assessed as at risk for developing pressure ulcers with no unhealed pressure ulcers at the time of the assessment. Review of the care plan dated 6/6/2024 revealed R9 has the potential for pressure ulcer development and/or skin integrity issues related to immobility and diagnosis of lymphedema. Intervention to be implemented included Observe/document/report as needed any changes in skin status: appearance, color, wound healing, signs and symptoms of infection, wound size (length X width X depth), stage. Review of the Skin Wound Note dated 3/2/2026 revealed: New open area noted to the left Posterior thigh, Resident stated she is now having pain while sitting on the bedpan. Area noted 0.7 centimeters (cm) x 0.3 cm x 0.2 cm. The physician and nurse practitioner were notified, and treatment was in place. Review of the __ Nurse Practitioner (NP) progress note dated 3/5/2026 revealed: Chief Complaint: Open Wound. History Of Present Illness: The patient was seen today for a new wound care consult for evaluation and management of a right thigh wound that has been present for approximately two weeks per nursing report. Wound measurement 3.5 cm x 4.0 cm x 0.2 cm. Medically indicated sharp excisional debridement was performed to remove necrotic tissue and decrease bacterial burden. Sharp debridement was used to remove nonviable devitalized soft tissue. Debridement was carried to viable tissue as evidenced by bleeding. An interview on 3/18/2026 at 2:45 pm with R9 stated on 2/21/2026 on the night shift she was on the bed pan for approximately an hour and half. She stated CNA BB came and assisted her with getting cleaned up. The resident stated she informed CNA BB that she did not feel as though she was cleaned good. She stated the CNA BB did not check to see if she was cleaned but left the room. She stated the next morning, 2/22/2026, when CNA EE arrived at work and came to her room, she informed her of what happened and that her left upper thigh was burning. She stated that when CNA EE checked her, she informed her that the linen was soiled with feces and there was a blister on her (R9) left upper thigh. The resident stated she sent a text to the Administrator and informed her that CNA BB did not provide adequate incontinent care, and she had developed a blister that was burning. In an interview on 3/20/2026 at 10:19 am with CNA EE stated that when she arrived at work last month (February 2026), she did not recall the exact date, on the 7 am-3 pm shift. She stated that during her initial round, R9 informed her that the CNA BB from the previous shift (7 pm-7 am) did not clean her well, and she was itchy. The CNA stated she provided incontinent care and found that the pad underneath R9 had feces on it and was wet with urine. She stated the resident also had a blister on the left upper thigh. She stated she informed R9 that the area on her thigh had a blister. The CNA stated she did not report that R9 had developed a blister on the left upper thigh to the charge nurse or Director of Nursing.

Based on record review, interviews, and review of the facility policy titled Freedom Of Abuse Abuse Prevention Fast Alert the facility failed to ensure an allegations of neglect was reported to the State Survey Agency (SSA) within the required time frame for one Resident (R) (R9) of nine sampled residents. Resident (R9) verbally and via text reported to the facility that one Certified Nursing Assistant (CNA) BB neglected to provide her (R9) adequate incontinent care. As a result, R9 developed a blister on the left upper thigh. Due to the delay in care the blister progressed to an open wound.Findings include: Review of the policy titled Freedom Of Abuse Abuse Prevention Fast Alert dated 1/2025. Policy: The purpose of this written Freedom of Abuse, Neglect, and Exploitation; Abuse Prevention Standard is to outline the preventive and action steps taken to reduce the potential for abuse, mistreatment, and neglect of residents. Reporting/Investigation/Response Policy: Any complaint, allegation, observation, or suspicion of resident neglect, whether physical or verbal. mental or sexual. involuntary, or voluntary, is to be communicated to the Abuse Coordinator, thoroughly reported, investigated, and documented uniformly as detailed below. Reporting-All employees are required to immediately notify the administrator or nursing supervisory staff who is on duty of any complaint, allegation, observation, or suspicion of resident neglect so that the investigation can be undertaken promptly. Investigation: All alleged violations involving mistreatment, sexually inappropriate behaviors, and abuse or neglect will be thoroughly investigated by the facility under the direction of the Administrator and in accordance with state and federal law. Review of the admission Record for R9 revealed she was admitted to the facility on [DATE], and a diagnosis of, but not limited to, disorder of the skin and subcutaneous tissue and lymphedema. Review of the resident's most recent Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed that a Brief Interview for Mental Status (BIMS) was assessed as 15, which indicated cognitively intact. Section M was assessed as at risk for developing pressure ulcers with no unhealed pressure ulcers. Review of the Skin Wound Note dated 3/2/2026 revealed: New open area noted to the left Posterior thigh, Resident stated she is now having pain while sitting on the bedpan. Area noted 0.7 centimeters (cm) x 0.3 cm x 0.2cm. The physician and nurse practitioner were notified, and treatment was in place. An interview on 3/18/2026 at 2:45 pm with R9 stated on 2/21/2026 on the night shift, she pressed the call light for a CNA to assist her with incontinent care after using the bedpan. She stated that after about thirty minutes, a Licensed Practical Nurse AA entered the room and asked what she needed. The resident stated she needed the CNA to assist her with getting cleaned up. She stated that thirty minutes later, CNA DD entered the room and asked what she needed. The resident informed the CNA DD that she had been on the bedpan for a while and was starting to hurt. She stated the CNA DD left the room, and about twenty minutes later, CNA BB came and assisted her with getting cleaned up. The resident stated she informed CNA BB that she did not feel as though she was clean. She stated the CNA BB did not check to see if she was cleaned, but left the room. She stated the next morning, 2/22/2026, when CNA EE arrived at work and came to her room, she informed her of what happened and that her left upper thigh was burning. She stated that when CNA EE checked her, she informed her that the linen was soiled with feces and there was a blister on her (R9) left upper thigh. The resident stated she sent a text to the Administrator and informed her of what had happened. The resident stated she reported the incident to the SSA because nothing was ever done. A telephone interview on 3/20/2026 at 10:52 am with Administrator CC stated that on 2/23/2026, she received a text from R9. She stated the text read: Good morning, CNA BB left feces on me, and I have developed a blister on the back of my left thigh at the crease. The area is burning. I hope we can get this under control. The Administrator stated she texted R9 back and told R9 she would get the nurse to come in and assess the area. The Administrator stated that the allegation of neglect was not reported to the SSA. The Administrator stated she is aware that the allegation of neglect should have been reported. An interview on 3/20/2026 at 11:32 am with Administrator FF stated that the allegation of neglect would be reported immediately to the SSA. She also stated CNA BB will be suspended pending the investigation. Refer to F-Tag 600.

Based on observation, record review, interviews, and review of the facility policy titled RAI Care Planning Management the facility failed to implement the care plan interventions for a newly develop pressure ulcer for one (1) Resident (R) (R9) out of nine (9) care plans reviewed. Findings include: Review of the policy titled RAI Care Planning Management, revised date of 8/2017. Standard: It is the practice of this facility to conduct a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacity. If modifications, deletions, or additions are necessary, changes should be made at the time of occurrence. Review of the admission Record for R9 revealed she was admitted to the facility on [DATE], and a diagnosis of, but not limited to, disorder of the skin and subcutaneous tissue and lymphedema. Review of the resident's most recent Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed that a Brief Interview for Mental Status (BIMS) was assessed as 15, which indicated cognitively intact. Section M was assessed as at risk for developing pressure ulcers with no unhealed pressure ulcers at the time of the assessment. Review of the care plan dated 6/6/2024 revealed R9 has the potential for pressure ulcer development and/or skin integrity issues related to immobility and diagnosis of lymphedema. Intervention to be implemented included Observe/document/report as needed any changes in skin status: appearance, color, wound healing, signs and symptoms of infection, wound size (length X width X depth), stage. Review of the __ Nurse Practitioner (NP) wound report dated 3/5/2026 revealed: Chief Complaint: Open Wound. History of Present Illness: The patient was seen today for a new wound care consult for evaluation and management of a right thigh wound that has been present for approximately two weeks, per nursing report. Wound measurement 3.5 centimeters (cm x 4.0 cm x 0.2 cm. An interview and observation on 3/19/2026 at 10:00 am of R9's left upper thigh with the Wound Care Nurse HH. The resident and WCN confirmed that the area that the wound care NP is treating is the left upper thigh. An interview on 3/24/2026 at 1:04 pm with the MDS-Coordinator GG, stated that in the past, she would receive a weekly wound sheet from the WCN. She stated she has not received one from the WCN in a month or so. She stated the facility's procedure is that the Director Of Nursing is now responsible for emailing the weekly wound report. The MDS-Coordinator reviewed her emails, stating that the last report that she received was on 3/2/2026, and R9 was not part of that wound report. She also stated any new wound occurrence would be discussed in the am management meeting, and the care plan is updated in real time. The MDS Coordinator stated she recently became aware that R9 had a wound on the upper left thigh. She confirmed that the care plan was not updated for the wound on the upper left thigh. Refer to F-Tag 600.

Based on record review, staff interview, review of the facility policy titled Freedom Of Abuse Abuse Prevention Fast Alert the facility failed to ensure Georgia Criminal History Check System (GCHEXS) Fingerprint check was conducted for one (1) Certified Nursing Assistant (CNA) of ten employee files selected for review. The facility census was eighty residents.Review of the policy titled Freedom of Abuse Abuse Prevention Fast Alert dated 1/2025. revealed Pre-Employment Screening: When a potential new employee is considered for hire, take the following steps to ensure the applicant is suitable for hire. 3. Criminal Background Checks are required; all employment candidates are required to authorize the facility to conduct a background check for conviction of crimes. The Human Resource Manager's job description was requested but not provided. During a record review of the employee files with the Human Resources Manager (HRM), there was no documentation that a fingerprint records check was conducted on CNA BB. An interview on 3/24/2026 at 2:15 p.m. with the HRM stated that she is responsible for background checks, fingerprint checks, reference checks, and maintaining the employees' files. She confirmed that CNA BB did not have a GCHEXS fingerprint check conducted. The HRM stated she has started an audit of employees' files to ensure that GCHEXS fingerprint checks were conducted for the required employees. Refer to F-Tag 600.

Based on observations, staff interviews, record reviews, and review of the facility policies titled Management of Laundry and Infection Control Manual, the facility failed to ensure that laundry staff followed infection control processes while performing laundry services and failed to ensure the laundry room was maintained in a sanitary condition. In addition, the facility failed to ensure that Enhanced Barrier Precautions (EBP) were followed for one of two residents with a gastrostomy tube (G-Tube) [a tube surgically inserted through the abdomen into the stomach used to deliver nutrition, fluids, and medications]. These deficient practices had the potential to place residents at risk of infections due to cross-contamination. The census was 73 residents. Findings include:Review of the facility policy titled, Management of Laundry, dated 1/2016, revealed the Description of Steps in the Laundry Process section included, Pck-up or Collection of Soiled Linen. B. Transferring Soiled Linen: . all soiled linen must be covered during transportation while being stored on unit or floors. A soiled linen container should be lined with an impervious (waterproof) liner. At designated times, laundry workers are to collect soiled linens from each soiled linen room using a large bin with lid marked - For Soiled Linen Use Only. Laundry workers must always wear the proper protective equipment (PPE) when handling soiled linen. 2). Sorting soiled linen: The laundry room must have a process in place to effectively sort soiled linen without cross contaminating clean linen. As soiled linens are sorted into proper wash classifications, employees must wear the proper personal protective equipment (PPE), which includes gloves and a protective apron.Review of facility policy titled, Infection Control Manual, revised date 9/2023, revealed the section titled Two-Tier Transmission Based precautions: Airborne Precautions included, Enhanced Barrier Precautions expand the use of PPE [personal protection equipment] and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfers of MDROs [Multi-Drug Resistant Organism] to staff hands and clothing. Examples of high-contact resident care activities requiring gown and glove use for EBP include: . Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator.1. During observation and interview of the laundry room on 7/22/2025 at 9:40 am, with the District Manager (DM), observation revealed a blanket on the floor in front of an exterior door. The DM confirmed the blanket and stated it was placed there because of heavy rain, and he was unsure how long the door had been leaking. Continued observation and interview on 7/22/2025 at 10:58 am, with the DM revealed that during the observation of Laundry Aide NN separating and washing laundry, the aide's apron was loose, and soiled laundry came in contact with her uniform. Further observation revealed that Laundry Aide NN went into the clean laundry area to wash hands while wearing a protective apron. The DM confirmed the findings. In an interview on 7/22/2025 at 11:05 am, Laundry Aide NN revealed that the protective gown should be fitted. An observation and interview on 7/22/2025 at 11:11 am of the clean linen storage area revealed a towel with dark black stains coming out of a hole in the wall. Further observation revealed that an uncovered basket of clean laundry was against the towel. Laundry Aide NN stated she was unsure how long the towel had been there. She stated that she had not notified the Maintenance Director about the hole in the wall and stated she would need to rewash the laundry in the basket.In an interview on 7/22/2025 at 11:15 am, the Maintenance Director revealed that he was unaware of the hole in the wall and stated he would place a cap over the hole.During an observation and interview on 7/23/2025 at 1:25 pm, in the laundry room, it was observed that a bag of laundry had been placed on top of the soiled linen bin, and not under the bin cover. The DM stated that the staff had hurriedly placed the bag of laundry on top of the bin cover and covered the bag. 2. Review of R1's admission Record revealed diagnoses including, but not limited to, malignant neoplasm of the tongue and anemia. Review of the Annual Minimal Data Set (MDS) assessment for R1, dated 5/12/2025, revealed that Section K (Swallowing/Nutritional Status) documented that R1 had a feeding tube while a resident. Review of the Care Plan Report for R1 revealed a Focus area, revised date 2/6/2025, of the resident was at risk for changes in skin integrity and had a G-tube. Interventions included enhanced barrier precautions in place, dated 5/21/2025. Further review revealed a Focus area, created 2/3/2025 and revised 7/15/2025, of the resident was at risk for impaired immunity related to currently receiving chemotherapy secondary to tongue cancer. Interventions included that the resident was at risk for contracting infections due to impaired immune status, and keeping the environment clean and people with infection away. Observations on 7/21/2025 at 11:09 am and 7/22/2025 at 10:14 am revealed there was no EBP signage or PPE supplies at R1's doorway or in the room. Observation revealed EBP signage on other resident doors in the facility. Observation on 7/23/2025 at 5:09 pm revealed Licensed Practical Nurse (LPN) FF administering bolus tube feeding to R1, wearing gloves and not wearing a gown. In an interview on 7/24/2025 at 10:35 am, LPN FF confirmed she did not wear a gown while administering tube feeding to R1. She stated that R1 should be on EBP and was unsure where the cart of PPE supplies for R1 was. She further stated residents with indwelling devices should be on EBP. In an interview on 7/24/2025 at 11:11 am, the Director of Nursing (DON) stated that residents with catheters, wounds, and feeding tubes were to be on EBP. The DON further stated the expectation was for the nurse to place a sign on the door and a cart outside the room, and stated that the Wound Care Nurse usually handled EBP.

Based on staff interviews, record review, and review of the facility policy titled, Infection Control Manual, the facility failed to ensure three of five sampled residents (R) (R1, R29, and R13) for vaccinations had a completed consent, declination and/or proof of education for the pneumococcal and/or influenza vaccine. This deficient practice had the potential to place R1, R29, and R13 at risk of unmet needs. Findings include:Review of the facility policy titled, Infection Control Manual, revised date 9/2023, revealed the Immunizations: Standing Orders, section included, . 3. Counsel resident and/or family/responsible party on the benefits and adverse effects of each vaccine prior to administration of the vaccines. 4. Complete the Pneumococcal and Influenza Vaccine-Information and Consent with the resident or family at the time of admission and each time offered. Place in the medical record.1. Review of the admission Record for R1 revealed admission on [DATE]. Review of the Immunization Record for R1 revealed the resident received Prevnar 23 in 2020, at age [AGE]. Review of the clinical record revealed no consent, declination, or education for the pneumococcal vaccine. 2. Review of the Admissions Record for R29 revealed admission on [DATE]. Review of the Immunization Record for R29 revealed the resident received Prevnar 13 on 10/2/2020, at age [AGE], and there were no historical dates for the influenza vaccination. Review of the clinical record revealed no consents, declinations, or education for the influenza or pneumococcal vaccines. 3. Review of the admission Record for R13 revealed admission on [DATE]. Review of the Immunization Record for R13 revealed R13 was administered an influenza vaccine on 11/21/2024 by the Assistant Director of Nursing (ADON) at the facility. Review of the clinical record revealed no consent, declination, or education for the influenza vaccine.In an interview on 7/23/2025 at 1:56 pm, the Director of Nursing (DON) stated that nurses document vaccine administration in the medical record. The DON stated that on admission, consent and education was provided to the residents or resident representative for vaccines. The DON further stated that the influenza vaccine was given to residents during flu season. The DON stated there was no further documentation for the resident's vaccines.

Based on observations, staff interviews, and review of the facility's policy titled Incontinence Management, the facility failed to ensure a urinary catheter privacy bag was provided for one of one resident (R) R2 with a urinary catheter. This failure had the potential to diminish the resident's quality of life.Findings include:Review of the facility's policies titled Incontinence Management dated January 2025 documented Other Options Catheterizations: Not Appropriate for Rehabilitation; If the resident is not appropriate for a Program, the care plan will identify other interventions to maintain skin integrity, prevent urinary tract infection and provide dignity for the resident.Review of the facility's Electronic Medical Records (EMR) revealed R2 was re-admitted to the facility on [DATE] with a diagnosis that included but not limited to neuromuscular dysfunction of bladder and presence of urogenital implants.Review of the Significant Change Minimum Data Set (MDS) dated [DATE] documented Section C (Cognition) Brief Interview of Mental Status (BIMS) of 14, which indicated R2 had intact cognition and Section H (Bowel and Bladder) R2 had a urinary catheter.Review of care plan dated 7/8/2025 documented included but not limited to Focus: R2 has an indwelling suprapubic catheter in place related to neuromuscular dysfunction of bladder. Goal: R2 will be/remain free from catheter-related trauma through the review date. Intervention: Check tubing for kinks, enhanced barrier precautions in place, provide catheter care as indicated, suprapubic catheter 18 French per 10 milliliters (FR / 10mL) Balloon to drainage bag. Use strap/securement device to stabilize tubing (as requested/needed).Review of Physician's Orders dated 7/10/2025 documented included but not limited to Suprapubic Catheter _16___FR / __10__mL Balloon to Drainage Bag. Use trap/Securement Device to stabilize tubing (as requested/needed). Label Bag with Date. For: ____neurogenic bladder_____ (Specify Reason/diagnosis [Dx]) every day shift every 30 day(s) for catheter maintenance.Observation on 7/21/2025 at 11:54 am, 4:50 pm, and 7/22/2025 at 10:04 am revealed R2 in his room, lying in bed with an uncovered urinary catheter bag hanging on the bed rail that could be viewed by residents, staff, and visitors ambulating in the hallway.Interview on 7/22/2025 at 10:18 am with Licensed Practical Nurse (LPN) DD confirmed R2's urinary catheter bag was not covered, and it was visible from the hallway. She stated it should be covered with a privacy bag to provide privacy for R2. She further stated that when the urinary catheter bag was not covered, it would cause low self-worth and embarrassment for R2.Interview on 7/22/2025 at 10:49 am with Certified Nursing Assistant (CNA) EE confirmed R2's urinary catheter bag was not covered, and it was visible from the hallway. She stated it should be covered with a privacy bag because it was a dignity issue and also to provide privacy for the resident. She further stated that when the urinary catheter bag was not covered, it could cause R2 to be uncomfortable. She stated the bag had not been covered for about one week because she thought the facility was out of privacy bags.Interview on 7/23/2025 at 12:30 pm with the Director of Nursing (DON) revealed that her expectations were for urinary catheter bags to be covered at all times except when they were being emptied. She stated that when the foley bags were not covered, it was a dignity issue and it could affect the resident emotionally and psychologically.

Based on observations, staff interviews, and review of the facility's policies titled Medication Administration, the facility failed to remove expired medications from one of four medication carts and failed to remove expired medication and medical supplies from one of two medication rooms. The facility's census was 73.Findings include:Review of the facility's policy titled Medication Administration dated January 2025 documented Medications are to be stored appropriately as per manufacturer instructions. All expired medications or medications to be destroyed are to be taken off the medication cart and properly destroyed by the Environmental Protection Pharmacy guidelines.1. Observation on 7/22/2025 at 5:10 pm during review of the 400 Hall medication cart revealed there was one bottle of melatonin 1 mg tablets with an expiration date of 3/2025.Interview on 7/22/2025 at 5:11 pm with Licensed Practical Nurse (LPN) BB, who confirmed the bottle of melatonin 1 mg tablets was expired and should not be on the medication cart. She stated that if the residents received this expired medication, they would get sick, and the medication would not be effective for the residents.Interview on 7/22/2025 at 5:12 pm with Unit Manager (UM) AA, confirmed the bottle of melatonin 1 mg tablets had an expiration date of 3/2025 and should not be on the medication cart. She stated that no expired medications should be on the medication cart. She further stated her expectations were for the nurses to remove expired medications from the carts, and the expired medications were not administered to the residents. The UM stated that if the expired medication was administered to the residents, it would not be good for the residents and it would not be effective.Interview on 7/22/2025 at 5:14 pm with LPN DD, confirmed the bottle of melatonin 1 mg tablets was in the medication cart and had an expiration date of 3/2025. She stated that if the residents received the medication, there could be negative outcomes, and the medication would not be effective. 2. Observation on 7/22/2025 at 5:18 pm of the Back Hall medication room revealed one bottle of aspirin 325 mg tablets with an expiration date of 9/2024, three packets of oxygen masks with expiration dates of 12/2016, and one packet of oxygen tubing with expiration dates of 2/2023. Unpackaged gauze rolls and one open pack of gauze were on the surface of a cupboard in the medication room.Interview on 7/22/2025 at 5:20 pm with LPN CC confirmed there was one bottle of aspirin 325 mg tablets with an expiration date of 9/2024, three packets of oxygen masks with expiration dates of 12/2016, and one packet of oxygen tubing with expiration dates of 2/2023 in the medication room. LPN CC stated that the nurses should do a daily audit and were responsible for removing expired medications and expired medical supplies from the medication room. She further stated that if the expired medication were administered to the residents, they could get sick. She also stated that if the expired medical supplies were used on the residents, they may not be useful due to the expiration. Interview on 7/22/2025 at 5:22 pm with LPN DD revealed that if the residents received the expired medication, it could cause the residents' conditions to worsen, and the medication should not be in the medication room.Interview on 7/22/2025 at 5:25 pm with UM AA confirmed there was one bottle of aspirin 325 mg tablets with an expiration date of 9/2024, three packets of oxygen masks with expiration dates of 12/2016, and one packet of oxygen tubing with expiration dates of 2/2023 in the medication room. She stated her expectations were for the nurses to remove the expired medications and medical supplies from the medication rooms. The UM further stated that it was a collaborative effort with the nurses to remove the expired items. If this effort was not made, the residents would receive the expired medications and become sick. Interview on 7/23/2025 at 12:35 pm with the Director of Nursing (DON) revealed that her expectations were for expired medications and medical supplies to be removed immediately from the medication carts and rooms. She stated that the nurses were responsible for removing expired medications. If residents received expired medications, they could experience negative side effects, and the medication would also be ineffective for them.

Based on observations, resident representative (RR) interview, and staff interviews, the facility failed to provide a sanitary and comfortable environment for one of 53 sampled residents (R) (R58). This deficient practice had the potential to place R58 at risk of living in an uncomfortable environment. Findings include:Review of the medical record for R58 revealed an admission date of 8/2/2023. Diagnoses included, but not limited to, cerebrovascular accident.Review of R58's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) of 6 (indicating severe cognitive impairment). Section GG (Functional Abilities and Goals) documented R58 required assistance with all ADLs. In a concurrent observation and interview on 7/21/2025 at 1:15 pm, observation R58 lying in bed watching television and eating lunch, with the RR at the bedside. In an interview, the RR stated the sewage smell in the resident's bathroom was an ongoing problem and was bad. The RR stated the resident's daughter had reported it to the nurses. The RR further stated that some days it was so bad, it was difficult to stay in the room. In an interview on 7/22/2025 at 11:08 am, the Director of Nursing (DON) revealed that she was aware of the odor in R58's room. She stated she was told the bathroom smelled bad because it was rarely used and the toilet was not flushed often. In a concurrent observation and interview on 7/22/2025 at 11:12 am, the Corporate Maintenance confirmed the smell in R58's bathroom. He stated that the P-trap on the sink was designed to hold water, and if no one used the sink in a long time, the water would evaporate, which would cause a smell. In an interview on 7/22/2025 at 11:22 am, the Administrator stated she had not received a complaint regarding the smell in R58's room. She stated that when she had smelled an odor in the hall, she always assumed it was the resident with a colostomy bag.

Based on observations, staff interviews, and review of facility policies titled Procedure for Washing Pots and Pans, and Proper Temperatures For Meal Preparation and Service, and review of the EcoLab Product Specification document for the Multi-Quat Sanitizer, the facility failed to demonstrate the proper usage of the three-compartment sink to sanitize dishware to prevent contamination, failed to allow dishware items to air dry, and failed to ensure all food items on the steam table were held above 135 degrees Fahrenheit (F) to prevent bacteria growth. These deficient practices had the potential to place residents consuming an oral diet at risk of contracting a foodborne illness. The facility census was 69 with 68 residents receiving an oral diet. Findings include: 1. A review of the undated facility policy titled Procedure for Washing Pots and Pans, revealed the Procedure section line 3: The third sink sanitizes the items by: a. Use of a chemical sanitizer added to water filling the sink with water; or b. Filling the sink with water kept at 180 degrees F and submerging the items for at least one minute. 4. Place pots and pans on the drain sink to air dry. A review of the EcoLab Product Specification document for the Multi-Quat Sanitizer stated to expose all surfaces to the sanitizing solution for not less than 1 minute. Observation on 2/24/2024 at 10:50 am of the Dietary Manager (DM) washing dishware using the three-compartment sink revealed that the sanitizing sink had not been set up for usage. The DM began to set up the sanitizing sink and was having difficulties getting the sink to fill with sanitizing solution. Continued observation of the DM revealed that she washed the dishware in soapy water, rinsed it, and placed it in the sanitizing sink that continued to not fill with sanitizing solution. The DM took the plastic hose in the sink that was dispersing the sanitizing solution and splashed it over the dishware. The DM then handed the dishware items to the dietary cook to use, the items were not placed to air dry. Further observation revealed that the facility was using EcoLab brand quaternary sanitizing solution. During an interview on 2/24/2024 at 10:50 am, the DM confirmed that the dishware was not properly sanitized in the sanitizing solution. The DM confirmed that the facility uses a quaternary sanitizing solution and dishware should be submerged in the solution for at least 60 seconds. The DM was not able to state why the proper procedure was not used and confirmed that she gave the dishware items to the cook to use without air drying. 2. A review of the undated facility policy titled Proper Temperatures for Meal Preparation and Service, revealed the minimum acceptable temperature for meat is 135 degrees F. Steam table temperatures were completed on 2/24/2024 at 12:35 pm with Dietary Cook AA using the facility's calibrated thermometer. Continued observation revealed the ground liver had a temperature of 131 degrees F. During an interview on 2/24/2024 at 12:35 pm, Dietary Cook AA confirmed that after stirring the pan containing ground liver four times the temperature of the meat was 131 degrees F. The Dietary Cook revealed that food items on the steam table should be at least 135 degrees F and the ground liver needed to be re-heated.

Based on observation, staff interview, record review, and review of facility policy titled Skin Management Standards, the facility failed to provide wound treatment per the physician's order and failed to wash/sanitize hands and change gloves during wound treatment for one resident (R) (R67) of three residents reviewed for pressure ulcers. This deficient practice had the potential to place R67 at risk for medical complications and infection. Findings include: A review of the undated facility policy titled Skin Management Standards, revealed the procedure for dressing change: 1. Check the doctors' orders for the type and frequency of dressing and any special instructions required for performing the procedure, including pre-medication for the resident's comfort. 6. Wash/ Sanitize hands, put on clean gloves, remove soiled dressing, and discard immediately in a plastic bag. 7. Remove gloves, and place them in a plastic bag. 8. Wash/ sanitize hands. 9. Put on a pair of clean gloves. 10. Clean the wound from the center of the wound in a circular motion . 11. Discard gloves. 12. Wash/ sanitize hands. 13. Put on a pair of clean gloves. 14. If ordered, apply medication and topical treatment to the wound. A review of the Minimum Data Set (MDS) Significant Change assessment dated [DATE] revealed R67 was not able to complete the Brief Interview for Mental Status (BIMS) score assessment, and had diagnoses including neurological condition, paraplegia, and malnutrition. The resident had one stage 4 pressure ulcer that was not present on admission. A review of the current February 2024 Physician's Orders revealed the following orders: 1. Sacrum: Clean sacrum with Dakin's, apply crushed Flagyl 500 milligrams (mg) (a medication used to treat infections) to the wound bed, then apply Dakins 0.5% (a topical antiseptic used to clean infected wounds and ulcers) moistened gauze to wound bed/undermining, super absorbent, cover dry protective dressing such as superabsorbent adhesive - every day shift for Treatment Plan for Sacrum and as needed for misplaced or soiled dressing. 2. Clean Left Elbow, cleanse wound, pat dry, apply Flagyl directly to the wound bed then apply Dakin's 0.5% moistened gauze to the wound bed, cover with dry protective dressing such as rolled gauze secured with tape or composite. Change Daily/PRN (as needed). Flagyl Oral Tablet 500 mg - Apply to Left Elbow topically every day shift for Treatment to Left Elbow. 3. Left Elbow Medial, cleanse the wound with NS (normal saline) or Dakin's, pat dry, apply Santyl (an ointment used to remove damaged tissue from chronic skin ulcers) nickel thick to the wound bed, cover with calcium alginate for drainage management, then cover with dry protective dressing such as rolled gauze secured with tape or composite, every day shift for Treatment For medial Elbow and as needed for misplaced or soiled dressing. Physician Documentation dated 11/28/2023 revealed pressure ulcers to the sacrum, coccyx, heels, and hips - unavoidable. During observation of wound care on 2/25/2024 at 6:25 am, Licensed Practical Nurse (LPN) BB started treatment to the sacrum. The dressing dated 2/24/2024 was removed. The sacrum wound was cleaned with Dakin's, and crushed the Flagyl was placed on the Dakin's soaked gauze which was then placed on the wound bed. LPN BB did not change gloves or sanitize hands after cleaning the wound and before applying the medication. The Dakin's soaked gauze was not placed into the undermining of the wound. LPN BB completed the treatment, changed gloves, sanitized hands, and moved to the next wound. LPN BB cleaned the left elbow, applied Flagyl to the wound bed, and applied Dakins' soaked gauze and a dry protective dressing. She then cleaned the medial left elbow with Dakin's, applied Santyl to the wound bed, and covered it with calcium alginate and a dry protective dressing. The treatments to the left elbow and medial left elbow was performed according to the physician's order. However, LPN BB failed to change gloves and sanitize hands after cleaning each wound and between each wound treatment. An interview with the LPN BB on 2/25/2024 at 7:30 am revealed that she normally sanitizes hands and changes gloves after cleaning and before placing medication and also, she would normally place the Dakin's soaked gauze into the undermining with a cotton swab. She stated she was nervous.

Based on observations, interviews, and review of the facility's infection control policy titled, Pandemic Pathogen Plan (Coronavirus), and Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to ensure that all staff were wearing face masks appropriately when the COVID-19 county transmission level for the facility was high. This had the potential to affect all 67 residents in the facility. Findings included: A review of the facility's policy titled, Pandemic Pathogen Plan (Coronavirus), dated 03/2020, revealed in part the following: Person to person appears like other respiratory viruses, mainly due to respiratory droplets produced when an infected person coughs or sneezes. These droplet land in the mouths, nose and/or eyes of people who are nearby or possibly inhaled into their lungs. A review of the CDC COVID Data Tracker, indicated that at the time of the survey entrance, 08/29/2022, the facility was located in a county with high community transmission of COVID-19. A review of the CDC guidelines, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic updated 02/02/2022, indicated, Source control and physical distancing (when physical distancing is feasible and will not interfere with provision of care) are recommended for everyone in a healthcare setting. This is particularly important for individuals, regardless of their vaccination status, who live or work in counties with substantial to high community transmission or who have: - Are not up to date with all recommended COVID-19 vaccine doses; or - Have suspected or confirmed [CONDITION(S)]-CoV-2 infection or other respiratory infection (e.g., those with runny nose, cough, sneeze); or - Had close contact (patients and visitors) or a higher-risk exposure (HCP) with someone with [CONDITION(S)]-CoV-2 infection for 10 days after their exposure, including those residing or working in areas of a healthcare facility experiencing [CONDITION(S)]-CoV-2 transmission (i.e., outbreak); or - Have moderate to severe immunocompromise; or - Have otherwise had source control and physical distancing recommended by public health authorities. An observation on 08/29/2022 at 12:20 PM revealed Dietary Aide (DA) HHH was sitting in the dining room without a face mask. There were three residents observed sitting in the dining room less than six feet from the staff member at that time. DA HHH stated she had her mask in her pocket and did not have a reason for not wearing it. DA HHH stated the facility policy was to always wear a face mask while in the nursing home. An observation on 08/29/2022 at 12:10 PM revealed Certified Nursing Assistant (CNA) III sitting behind the front nurses' station without a mask on. CNA III stated the facility policy was to wear a mask whenever there was anyone around her, and she did not wear one because there was no one around. CNA III later confirmed a nurse had been sitting next to her at the nurses' station immediately prior to this surveyor approaching her. An observation on 08/29/2022 at 11:46 AM revealed the Administrator sitting at her desk in her office. The DON was standing behind her chair, leaning over the Administrator's desk. The DON's face mask was pulled down under her chin. An observation on 08/29/2022 at 2:13 PM revealed the DON leaning across the front hall nurses' station, talking to a staff member. The DON's face mask was pulled down under her chin. The DON stated the mask had slipped under her chin. She stated the facility's policy was to have the mask always covering the nose and mouth in the facility. An observation on 08/29/2022 at 2:36 PM revealed Licensed Practical Nurse OO sitting behind the back hall nurses' station with a surgical mask under her nose. LPN OO stated she did not pinch the nose piece and the mask slid down. LPN OO stated the facility's policy was to wear a face mask always covering the nose while in the facility. An observation on 08/29/2022 at 1:30 PM revealed DA KKK emptying tray carts and handing trays to the dishwasher through the service window in the dining room. There were staff members within six feet of him. DA KKK did not have a mask on. DA KKK stated he removed his mask because his nose itched. DA KKK stated the facility policy was to wear a mask at all times that covered the nose and mouth. An observation on 08/29/2022 at 1:32 PM revealed Cook LLL walking down the main hallway pushing a food cart and not wearing a face mask. Cook LLL walked past residents, proceeded to the front lobby area, and picked up a mask. Cook LLL stated there were no masks in the kitchen and someone needed to get the kitchen staff a box of masks. An interview was conducted on 08/29/2022 at 2:36 PM with LPN CC, who was the infection preventionist. LPN CC stated the facility's last outbreak for COVID-19 was between 06/25/2022 and 07/26/2022, and the positive COVID-19 cases were employees. LPN CC stated the facility policy was to wear masks covering the nose and mouth at all times while in the facility. LPN CC stated the residents were encouraged to wear masks, and staff was trained on proper mask wearing and usage at least monthly and whenever there was an outbreak. An interview was conducted on 09/01/2022 at 2:20 PM with the DON. The DON stated face masks were to be worn at all times and should cover the nose and mouth completely. The DON stated that if the mask was ill fitted, staff should get a mask that fit properly. The DON stated there was no excuse for not wearing the mask properly. An interview was conducted on 08/30/2022 at 12:19 PM with the Administrator. The Administrator stated face masks were to be worn covering the nose and mouth and should be worn at all times. The Administrator stated that not wearing masks properly could cause a COVID-19 outbreak and may have been the cause of the most recent outbreak. The Administrator stated she would conduct additional training. An interview was conducted on 08/29/2022 at 2:36 PM with LPN CC, who was the infection preventionist. LPN CC stated the facility's last outbreak for COVID-19 was between 06/25/2022 and 07/26/2022, and the positive COVID-19 cases were employees. LPN CC stated the facility policy was to wear masks covering the nose and mouth at all times while in the facility. LPN CC stated the residents were encouraged to wear masks, and staff was trained on proper mask wearing and usage at least monthly and whenever there was an outbreak. An interview was conducted on 09/01/2022 at 2:20 PM with the DON. The DON stated face masks were to be worn at all times and should cover the nose and mouth completely. The DON stated that if the mask was ill fitted, staff should get a mask that fit properly. The DON stated there was no excuse for not wearing the mask properly. An interview was conducted on 08/30/2022 at 12:19 PM with the Administrator. The Administrator stated face masks were to be worn covering the nose and mouth and should be worn at all times. The Administrator stated that not wearing masks properly could cause a COVID-19 outbreak and may have been the cause of the most recent outbreak. The Administrator stated she would conduct additional training.

Based on observations, record review, interviews, and policy review, the facility failed to ensure staff followed physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] #35, #51, and #65) of four sampled residents reviewed for physician orders. Findings included: A review of the facility's policy, titled, Physician Services indicated It is the standard of this facility that all medications and treatment protocols are ordered by the resident's attending physician or designee. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. A review of an Admission Record revealed the facility admitted R#51 on 05/06/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a quarterly Minimum Data Set (MDS) assessment, dated 08/02/2022, revealed R#51 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15. Per the MDS, R#51 had verbal behaviors for 1-3 days and rejected care for 1-3 days during the review period. A review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order directed staff to administer [MEDICATION(S)] (used to treat nerve pain and depression) 25 milligrams (mg) 1 tablet at bedtime. The order was signed by Nurse Practitioner DD. A progress note, dated 08/03/2022 at 11:00 AM, noted the new order for [MEDICATION(S)] and identified that there were possible drug interactions between the [MEDICATION(S)] and some other medications prescribed for R#51. A review of a pharmacy invoice revealed the pharmacy sent 30 tablets of [MEDICATION(S)] 25 mg on 08/04/2022. A review of R#51's Medication Administration Record (MAR) for August 2022 revealed one 25 mg tablet of [MEDICATION(S)] was documented as administered at bedtime from 08/04/2022 through 08/11/2022. A review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #51 at bedtime. The order was signed by Nurse Practitioner DD. A review of the August 2022 MAR revealed the medication was signed as given from 08/12/2022 to 08/26/2022. A review of the August 2022 MAR revealed R#51 refused [MEDICATION(S)] on 08/27/2022. An 08/28/2022 entry on the August 2022 MAR revealed the [MEDICATION(S)] was not administered to R#51. The 08/28/2022 entry referred the reader to a nurse's note and was signed by Licensed Practical Nurse (LPN) BB. A review of an associated nursing progress note dated 08/28/2022 at 7:45 PM and signed by LPN BB indicated the increased dosing of [MEDICATION(S)] to one 50 mg tablet daily at bedtime was ordered on 08/12/2022, but staff were still waiting on the pharmacy to send 50 mg tablets, leaving staff with no 50 mg tablets and a limited and/or non-existent supply of 25 mg [MEDICATION(S)] tablets remaining from the 08/03/2022 order. An 08/29/2022 entry on the August 2022 MAR referred the reader to a nurse's note and was signed by LPN EE. However, a review of nursing progress notes for 08/29/2022 failed to reveal a note related to [MEDICATION(S)] documented by LPN EE. On 08/31/2022 at 8:25 AM, an observation of the medication cart on the 100 Hall was made with LPN FF. LPN FF looked through R#51's medications, including back-up medications, and stated there was no [MEDICATION(S)] on the cart for R#51. On 08/31/2022 at 2:30 PM, Consulting Pharmacist GG stated the 50 mg dosing of [MEDICATION(S)] was never sent to the facility by the pharmacy due to a warning that the [MEDICATION(S)] could cause an undesired interaction with other medications prescribed for R#51. Consulting Pharmacist GG stated a fax was sent to the facility on [DATE] asking staff to clarify the order for 50 mg of [MEDICATION(S)] with the prescriber. An interview was conducted with Unit Manager CC on 08/31/2022 at 2:34 PM. Unit Manager CC stated Nurse Practitioner DD entered the orders for [MEDICATION(S)] herself in the computer on 08/03/2022 and 08/12/2022. Unit Manager CC stated a drug interaction warning showed up at that time and Nurse Practitioner DD had to indicate via electronic signature that she wanted the medication to be given. The unit manager stated when the nurse practitioner ordered the medication on 08/03/2022 and noted the warning, Nurse Practitioner DD ordered an electrocardiogram (EKG; measured electrical activity of the heart to detect cardiac problems) for R#51 (due to the potential for heart rhythm-related issues associated with the warning), which was conducted on 08/03/2022. On 08/31/2022, an interview was conducted with LPN FF, who initialed an 08/21/2022 MAR entry indicating she administered 50 mg of [MEDICATION(S)] to R#51, even though the pharmacy had not sent 50 mg tablets of [MEDICATION(S)]. LPN FF stated she could not recall the [MEDICATION(S)] order or how many tablets she administered. During an interview on 08/31/2022 at 4:30 PM, Unit Manager CC stated a copy of the document faxed by the pharmacy on 08/12/2022 could not be located, noting she planned to call the pharmacy to request they re-fax the document. Unit Manager CC stated Nurse Practitioner DD was aware of the drug interaction warning and noted that R#51 did not want to take the medication due to drowsiness (a potential side effect of the medication). Per Unit Manager CC, Nurse Practitioner DD stated R#51 needed the medication due to behaviors. A review of a fax resent to the facility by the pharmacy on 08/31/2022 noted the fax was originally sent on 08/12/2022 and identified that the [MEDICATION(S)] 50 mg ordered for R#51 had the potential for significant drug interactions. Via the faxed message, the pharmacy asked the facility to verify with the prescriber that medication therapy should proceed, noting the pharmacy could not send the 50 mg [MEDICATION(S)] tablets until this was addressed. There was no documentation that the [MEDICATION(S)] dosing was clarified with Nurse Practitioner DD or a physician. On 09/01/2022, an interview was conducted with Nurse Practitioner DD, who stated she entered orders on 08/03/2022 for R#51 to be administered [MEDICATION(S)] 25 mg every night and then entered orders on 08/12/2022 for staff to administer [MEDICATION(S)] 50 mg nightly to R#51. The nurse practitioner stated she was aware of the medication interaction warning and, on 08/03/2022, she ordered an EKG and the EKG was normal. Nurse Practitioner DD further stated R#51 wanted ordered pain medications increased and that R#51 had behaviors, so she was trying to find a medication to help with both issues. Nurse Practitioner DD stated Unit Manager CC notified her the day prior, on 08/31/2022, that the pharmacy did not fill the 50 mg [MEDICATION(S)] order due to possible drug interactions. Nurse Practitioner DD stated she told Unit Manager CC to send the 08/03/2022 EKG report to the pharmacy and tell them she was following the resident very closely. A review of R#51's August 2022 MAR revealed LPN BB signed off that [MEDICATION(S)] 50 mg was given on 08/23/2022 and 08/24/2022. LPN BB was called for an interview on 09/01/2022 at 12:10 PM. However, a message was received that the mailbox was full and the caller was unable to leave a message for LPN BB to return the call. A review of R#51's August 2022 MAR revealed LPN EE signed to indicate she administered [MEDICATION(S)] 50 mg on 08/25/2022. On 09/01/2022 at 12:44 PM, Nurse EE stated in an interview she could not recall the specifics of R#51's [MEDICATION(S)] order or how many [MEDICATION(S)] tablets she gave to the resident. On 09/01/2022 at 2:33 PM, an interview was conducted with the Administrator and the Regional Vice President. The Administrator stated there was no way to know what dose of [MEDICATION(S)] R#51 received (after the 50 mg tablets were not delivered by the pharmacy), stating the scenario represented a medication error. The Administrator stated the missed fax from the pharmacy was also a problem. The Regional Vice President stated staff needed to check the fax machine for received documents, including on the weekends. The Regional Vice President also stated the nurse administering medications should have called the pharmacy regarding R#51's [MEDICATION(S)] when the order changed from 25 mg daily to 50 mg daily and the 50 mg dose was not on the medication cart. During an interview on 09/01/2022 at 4:40 PM, the Director of Nursing (DON) stated nursing staff should have matched the medication in the cart against the order on the bubble pack of medication and against the order on the MAR for R#51, noting if the order and the dose of the medication on the bubble pack did not match, the nurse should have clarified the order. The DON further stated nursing staff had apparently failed to read R#51's new [MEDICATION(S)] order. 2. A review of R#65's Admission Record revealed R#65 was admitted with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A review of R#65's significant change (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating moderately impaired cognition. A review of R#65's physician orders, dated 07/25/2022, revealed a treatment order directing staff to apply [MEDICATION(S)] ([MEDICATION(S)]-iodine; used to help prevent infection in minor cuts, scrapes, and [CONDITION(S)]) to the left heel every two days during the dayshift to treat a deep tissue pressure injury (DTPI). A review of R#65's medication administration record (MAR), dated 08/01/2022 through 8/31/2022, revealed nine of 16 ordered [MEDICATION(S)] treatments were not documented as completed. During an interview on 08/31/2022 at 11:51 AM, Licensed Practical Nurse (LPN) RR (wound care nurse) stated the treatment orders for R#65 were to apply [MEDICATION(S)] to the left heel every two days. She stated that, after treatments were completed, she documented them on the MAR. She stated a check mark and initials on the MAR meant a treatment was completed. She stated the empty space on R#65's MAR meant the treatment was not checked off as completed. LPN RR stated the only day of the month in August of 2022 when she did not work (Monday through Friday) occurred on 08/19/2022. She noted she sometimes worked the medication cart, during which times she only conducted treatments scheduled on her hall. She stated she worked the medication cart for several days through the month. During an interview on 09/01/2022 at 12:50 PM, Director of Nursing (DON) KK stated she expected wound care to be completed per physician orders. She stated if a treatment was completed, staff initials would be placed in a corresponding space on the MAR. She stated if the treatment record was blank, the care was not provided. DON KK stated R#65's treatments were not administered in accordance with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 09/01/2022 at 12:59 PM, Administrator stated she expected wound care to be done as prescribed by the physician. She stated the empty spaces on the MAR indicated staff had not done the treatment or had not checked the treatment as completed. She stated if the treatment was completed, she would expect it to be documented. During an interview on 09/01/2022 at 5:40 PM, LPN SS stated if there were residents with wounds on the hall, the wound care nurse conducted wound treatments. She stated if there was not a treatment nurse, the nurse on the floor would be responsible to do the wound care. Per LPN SS, she could not recall if she conducted R#65's wound care on 08/19/2022. She stated if she had done the wound care, it would be documented on the MAR. 3. A review of an Admission Record for R#35 revealed the facility admitted the resident with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R#35's quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 10, indicating moderately impaired cognition. The MDS indicated R#35 had a stage 3 pressure ulcer and was at risk for developing additional pressure ulcers. A review of the care plan for R#35 indicated a comprehensive care plan had been developed on 08/09/2022 with a sacral wound focus area. Interventions directed staff to provide [CONDITION(S)] care as indicated, provide a diet as ordered, notify the physician as needed, refer to the Registered Dietician as needed, provide supplement as ordered, observe wound for signs and symptoms of delayed healing during care, refer to wound consultant as indicated, provide suprapubic catheter care as indicated, and provide treatments as ordered. A review of R#35's physician Order Summary Report revealed the following orders: -Clean sacral wound with wound cleanser and Dakin's solution 1/2 strength (25%). Apply Dakin's Solution Half Strength (25%) to moistened gauze to wound bed, cover with sacral foam dressing daily, dated 05/03/2022. -Skin prep left heel one time a day every three days. Order written 04/25/2022. A review of a July 2022 medication administration record (MAR) for R#35 indicated sacral wound care was ordered daily but was not initialed in the MAR as completed for 15 of 31 days in the month. Though wound care to the left heel was ordered once every three days, it was not initialed as completed on four of 11 ordered days for the month. A review of the August 2022 MAR for R#35 indicated sacral wound care was ordered daily until 08/31/2022 but was not initialed on the MAR as completed on 17 of 31 days for the month. Wound care to the left heel was ordered once every three days but was not initialed as completed for 5 out of 10 ordered days for the month. Observation on 08/29/2022 at 9:21 AM revealed R#35 was in bed, had a low air loss mattress in place, and had a [CONDITION(S)] and suprapubic catheter in place. Observation on 08/30/2022 at 8:38 AM revealed R#35 was in bed with a low air loss mattress in place. R#35 stated he/she received wound care once or twice a week but not daily. R#35 stated he/she was seen at the wound clinic once a month and noted he/she thought the wound on the sacrum was healing. During an interview on 08/30/2022 at 2:19 PM, Licensed Practical Nurse (LPN) RR (wound care nurse) stated R#35 was seen by the wound care clinic once a month. LPN RR stated all wound measurements were completed by staff from an outside wound care company who came to the facility weekly except for R#35, who went to the clinic monthly. LPN RR stated the wound measurements were completed for R#35 at the outside wound care clinic visits. LPN RR stated that all wound care was provided by her except on the days she was not working or was pulled to work the floor as a charge nurse. LPN RR confirmed there were 15 undocumented wound care treatments for R#35's sacral wound and four undocumented wound care treatments to the left heel for the month of July 2022 and 17 days of undocumented wound care treatments to the sacral wound and 5 undocumented left heel wound treatments documented for the month of August 2022. LPN RR stated any nurse who completed a treatment was to initial the electronic MAR to indicate the treatment was completed. LPN RR stated, If it wasn't documented, it was not done. LPN RR stated she took full responsibility for not signing the MAR when she completed R#35's treatment and noted that a blank (uninitialed) area on the MAR meant the treatment was not done. LPN RR stated that in the month of August 2022, she did not always work as the treatment nurse because she was pulled from the treatments to work as a charge nurse on the floor six days in August 2022. LPN RR stated that when she worked as a treatment nurse, either she or the Director of Nursing (DON) notified staff that each nurse had to provide wound care for their assigned residents. During an interview on 08/30/2022 at 8:58 AM, LPN OO stated the treatment nurse was responsible to provide wound care but if the treatment nurse was not working, each nurse was responsible for wound care for their residents. During an interview on 08/30/2022 at 9:10 AM, LPN PP stated each nurse was responsible to provide wound care and treatments to their residents if the treatment nurse was not working. LPN PP stated the DON usually notified staff if they needed to do their own treatments. LPN PP stated that a blank spot on the MAR indicated that a treatment was not done, or a medication was not given. LPN PP stated, If you didn't document it, it was not done. During an interview on 09/01/2022 at 2:20 PM, the DON stated wound care was provided by the treatment nurse and, if the treatment nurse was pulled to work the floor as a charge nurse, the floor nurses were responsible for the wound care for their residents. The DON confirmed she was not aware that there were many missed wound care treatments for R#35 until the survey. During an interview on 08/30/2022 at 12:19 PM, the Administrator stated nurses were expected to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 09/01/2022 at 10:02 AM, the facility Medical Director stated he expected staff to follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medical Director stated he was not made aware of missed treatments for R#35.

Based on observations, interviews, record review, and review of facility policy titled, RAI [Resident Assessment Instrument]/Care Planning Management, the facility failed to develop person-centered, comprehensive care plans for four (Resident [R] #13, R#35, R#57 and R#60) of 24 residents whose care plans were reviewed. Specifically, the facility: - Failed to develop a care plan that addressed behavioral management for R#13. - Failed to develop a care plan that addressed R#35's pressure ulcer care. - Failed to develop a care plan with resident-specific interventions addressing R#57's nutritional needs and [CONDITION(S)] care. - Failed to develop a care plan for R#60 that accurately addressed behavioral symptoms that were pertinent to the resident. Findings included: Review of a facility policy titled, RAI [Resident Assessment Instrument]/Care Planning Management, dated July 2022, revealed, Problems will be identified and written in an interdisciplinary CAA [Care Area Assessment] integrated format. A discharge plan will be included in the care plan at admission. Goals will be resident specific, measurable and realistic. Interventions will be action verb directed and specific to each resident. 1. Review of an Admission Record revealed R#13 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an admission Minimum Data Set (MDS) dated [DATE] revealed R#13 had a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. The MDS indicated R#13 had physical and verbal behavioral symptoms directed toward others on one to three days during the seven-day assessment period. Review of an Order Summary Report revealed R#13 had physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - Behaviors: Monitor for restlessness, hitting, biting, kicking, spitting, cussing, delusions, hallucinations, [CONDITION(S)], aggression, refusing care, ordered 08/03/2022. - [MEDICATION(S)] solution (an antipsychotic medication) 100 milligrams per milliliter (mg/mL). The directions were to inject 0.5 ml intramuscularly every 30 days for violent behavior and dementia with behavioral disturbance, ordered 07/20/2022. - [MEDICATION(S)] (an anti-anxiety drug) 0.5 mg twice a day for agitation, ordered 06/22/2022. - [MEDICATION(S)] (an antipsychotic medication) 15 mg at bedtime for dementia with behavioral disturbance, ordered 08/03/2022. - [MEDICATION(S)] (an antidepressant medication) 100 mg daily, ordered 06/17/2022. Review of a Care Plan, dated 06/22/2022, revealed R#13 had behavior problems. Interventions included: - Resident will use plastic silverware. - Administer medications as ordered, monitor/document side effects. - Anticipate and meet resident needs. - Provide opportunity for positive interaction, attention; stop and talk when passing by, explain all procedures to the resident before starting. - Intervene as necessary to protect the rights and safety of others. - Resident placed on 1 on 1. Observation on 08/29/2022 at 9:43 AM revealed R#13 sitting on the edge of the bed in his/her room. The resident did not have a roommate. The resident was alert and stated he/she had lived at the facility for six years. The resident mumbled when speaking and did not make eye contact. Observation on 08/30/2022 at 8:52 AM revealed R#13 sleeping in a chair in his/her room. Observation on 08/31/2022 at 10:17 AM revealed R#13 sitting on the edge of his/her bed. The resident was leaning back against the wall and was sleeping. There was a fall mat by the bed. During an interview on 09/01/2022 at 10:11 AM, the MDS Nurse confirmed a care plan regarding behaviors was developed for R#13 but the interventions in place were not resident-specific. The MDS Nurse stated the care plan should include the use of the specific medications and the signs and symptoms of [MEDICATION(S)] use, like extrapyramidal symptoms (EPS), oversedation, sleepiness, increased falling, disorientation, and mental changes. The MDS Nurse confirmed the resident was no longer on 1-on-1 supervision and that this intervention would be removed from the care plan. The MDS Nurse stated the safe way to approach R#13 varied, depending on the time of day and the staff member, and just talking to the resident did not always work. 2. Review of an Admission Record revealed R#35 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a quarterly Minimum Data Set (MDS) dated the 07/13/2022 revealed R#35 had a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. The MDS indicated R#35 had a stage 3 pressure ulcer and was at risk for developing pressure ulcers. Review of an Order Summary Report revealed R#35 had physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - Clean sacral wound with wound cleanser and Dakin's solution 1/2 strength. The directions were to apply Dakin's solution half strength-moistened gauze to the wound bed and cover with a sacral foam dressing, ordered 05/03/2022. - Skin prep to the left heel one time a day every three days, ordered 04/25/2022. Review of a Care Plan, dated 08/09/2022, revealed R#35 had a sacral wound. Interventions included to provide the diet as ordered, notify the physician as needed, refer to the RD, supplement as ordered, observe wound for signs and symptoms of delayed healing during care, refer to a wound consultant as indicated, suprapubic catheter care as indicated, and treatments as ordered. Observation on 08/29/2022 at 9:21 AM revealed R#35 in bed on a low air-loss mattress. The resident was noted to have a [CONDITION(S)] and suprapubic catheter. Observation and interview on 08/30/2022 at 8:38 AM revealed R#35 in bed. R#35 stated he/she received wound care once or twice a week but not daily. R#35 stated he/she went to the wound clinic once a month and thought the wound on the sacrum was healing. Observation on 08/31/2022 at 10:25 AM revealed LPN RR providing wound care to R#35. LPN RR used proper clean technique to provide wound care to the sacral wound. LPN RR did not provide wound care to the left heel at this time. During an interview on 09/01/2022 at 10:11 AM, the MDS Nurse confirmed the interventions on the care plan for sacral wound care were not resident-specific for R#35. The MDS Nurse acknowledged that R#35 was to receive wound care daily for a sacral wound and had monthly appointments at the wound care clinic. The MDS Nurse stated R#35's care plan interventions should have included notification of the physician if the wound started draining or started to have an odor. The MDS Nurse stated the care plan should also have included the type of wound care to be provided, the frequency of the care, and when to measure the wound. The MDS Nurse confirmed R#35 did not receive any nutritional supplements. 3. Review of an Admission Record revealed R#57 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed R#57 had modified independence in cognitive skills for daily decision-making and required only supervision and set-up assistance with eating. According to the MDS, the resident received [CONDITION(S)] care. Review of an Order Summary Report revealed R#57 had physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - Regular diet, mechanical soft food with chopped meat texture. - Suction as needed. - [CONDITION(S)] ([CONDITION(S)]) care every shift and as needed (PRN) with a #6 Shiley flex (a flexible [CONDITION(S)] tube without a cuff to maintain position and an inner canula to be reused after cleaning). Review of Care Plan, dated 06/30/2022, revealed R#57 had a [CONDITION(S)]. Interventions included to ensure the [CONDITION(S)] ties were secured; monitor/document for restlessness, agitation, confusion, increased heart rate, level of consciousness, mental status, and lethargy; provide good oral care daily and as need; provide paper and pencil if needed; and suction as necessary. Review of a Care Plan, dated 08/09/2022, revealed R#57 was at risk for alteration in nutritional status. Interventions included providing the diet as ordered, completing laboratory services (labs) as ordered, notifying the physician as needed, referring to the Registered Dietitian (RD), supplements as ordered, and weighing the resident monthly and as needed. Observation on 08/29/2022 at 9:52 AM revealed R#57 was in his/her room, sitting in a wheelchair, eating breakfast. The tray consisted of scrambled eggs, chopped sausage, cream of wheat, and a biscuit. The resident had a [CONDITION(S)] in place with a cap, which allowed the resident to answer questions easily. Observation on 08/31/2022 at 2:03 PM revealed Licensed Practical Nurse (LPN) PP in R#57's room providing [CONDITION(S)] care to the resident. LPN PP followed proper sterile technique throughout the procedure, during which the LPN cleaned and dried the [CONDITION(S)] cap placed it back over the resident's [CONDITION(S)]. During an interview with LPN PP at this time, LPN PP stated the resident could speak easily with the cap in place on the [CONDITION(S)] tube. LPN PP stated the resident did not use a paper and pencil or communication board to communicate because the resident was able to speak. During an interview on 09/01/2022 at 10:11 AM, the MDS Nurse confirmed the care plans regarding R#57's nutritional status and [CONDITION(S)] care were not resident-specific. The MDS Nurse acknowledged being aware that R#57 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS Nurse stated the care plan interventions should have included notification of the physician with concerns such as coughing while eating, refusing meals, weight loss, and other concerns specific to the resident. The MDS Nurse confirmed Resident #57 did not receive any special supplements and that the interventions regarding [CONDITION(S)] care should include the type of [CONDITION(S)] used, how to clean it, and the size of the [CONDITION(S)] tube. 4. Review of an Admission Record revealed the facility admitted R#60 on 08/02/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an admission Minimum Data Set (MDS) dated [DATE] revealed R#60 had a Brief Interview for Mental Status (BIMS) score of 4, indicating severe cognitive impairment. The MDS indicated R#60 did not exhibit any behavioral symptoms. Review of an Order Summary Report revealed R#60 had physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - [MEDICATION(S)] (an antipsychotic medication used to treat [CONDITION(S)], [CONDITION(S)] disorder, and [CONDITION(S)]) 10 milligrams (mg) daily for behaviors. - [MEDICATION(S)] 7.5 mg at bedtime for depression. Review of a Care Plan, dated 08/03/2022, revealed R#60 used [CONDITION(S)] medications related to behaviors. Interventions included: - Administer medications as ordered. Monitor for side effects and effectiveness every shift. - Behaviors: Monitor for itching, picking at skin, restlessness, hitting, increase in complaints, biting, kicking, spitting, cussing, racial slurs, elopement, stealing, delusions, hallucinations, [CONDITION(S)], aggression, refusing care. Observation and interview on 08/29/2022 at 9:48 AM, revealed R#60 in bed. The resident responded to questions appropriately and stated he/she had pain in the groin area and was not sleeping well. Observation on 08/31/2022 at 9:00 AM, revealed R#60 ambulating in the hallway with staff assistance. During an interview on 09/01/2022 at 10:11 AM, the MDS Nurse confirmed a care plan regarding behavior monitoring was developed for R#60 but the interventions and behavior monitoring in place were not resident-specific. The MDS Nurse acknowledged being unaware of what behavioral symptoms R#60 exhibited but confirmed the resident did not have any aggressive behaviors; did not exit-seek; did not hit, kick, or spit; and did not exhibit any verbal behaviors. The MDS Nurse stated the interventions were selected from a computer-generated library of possible interventions, and that the MDS Nurse should have talked to staff to identify R#60's behaviors. The MDS Nurse confirmed the interventions on R#60's care plan were not appropriate. During an interview on 09/01/2022 at 12:22 PM, Licensed Practical Nurse (LPN) PP revealed R#60 did not have physically or verbally aggressive behaviors. LPN PP stated the resident liked to ambulate in the halls to look around but did not exit-seek. LPN PP stated the resident was pleasant but sometimes resistive to care. During an interview on 09/01/2022 at 2:20 PM, the Director of Nursing (DON) stated R#60 liked to walk around and was sometimes resistive to care. The DON indicated the purpose of care planning was to tell staff what they needed to know be able to care for the resident, to evaluate the plan, and to adjust the care plan as needed. During an interview on 08/30/2022 at 12:19 PM, the Administrator stated care plans directed the residents' care and explained to staff what the residents' needs were. The Administrator stated the care plans should paint a picture of each resident.

Based on interviews, record review, facility policy titled Freedom of Abuse, Neglect and Exploitation; Abuse Prevention: Fast Alerts, the facility failed to ensure staff immediately reported an allegation of staff-to-resident abuse to the Administrator for one (Resident [R] #13) of one sampled resident reviewed for abuse. The facility further failed to ensure the allegation of staff-to-resident abuse was reported to the State Survey Agency (SSA) for R#13. Findings included: Review of a facility policy titled, Freedom of Abuse, Neglect and Exploitation; Abuse Prevention: Fast Alerts, dated January 2022, revealed, Reporting/Investigation/Response Policy. Any complaint, allegation, observation or suspicion of resident abuse, mistreatment or neglect, whether physical, verbal, mental or sexual, involuntary, or voluntary, is to be communicated to the Abuse Coordinator, thoroughly reported, investigated, and documented in a uniform manner as detailed below. Reporting - All employees are required to immediately notify the administrative or nursing supervisory staff that is on duty of any complaint, allegation, observation or suspicion of resident abuse, mistreatment, or neglect so that the resident's needs can be attended to immediately and investigation can be undertaken promptly. The policy also indicated, The intent of the regulation is that as soon as the facility is aware of a situation that meets the reporting requirements, they must immediately notify the administrator, and other officials in accordance with State law, including the State Survey Agency. Review of an Admission Record revealed R#13 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an admission Minimum Data Set (MDS) dated [DATE] revealed R#13 had a Brief Interview for Mental Status (BIMS) score of 3, indicating the resident had severe cognitive impairment. The MDS indicated R#13 exhibited physical, verbal, and other behavioral symptoms directed toward others on one to three days during the seven-day assessment period. Review of an incident report, dated 07/17/2022 at 11:00 PM, revealed Licensed Practical Nurse (LPN) RRR approached R#13 with medications, and the resident refused to take them. The LPN informed the resident of the importance of taking the medications. Per the report, the resident then stood up over the nurse and stated, I'm not taking no medication from no fat [expletive] nurse. LPN RRR returned to the medication cart, and R#13 came and stood behind the nurse. LPN RRR instructed the resident to go to his/her room. Per the report, the resident proceeded to grab LPN RRR and began striking the nurse with his/her hands. The nurse screamed for help, and another resident and staff began to separate the resident from the nurse. The report indicated 911 was activated, and other appropriate parties were made aware. According to the report, R#13 had dementia, was often combative and resistive to care, and frequently refused to take medications, which made it very difficult to keep the resident stable and the behaviors controlled. Review of the police incident report, dated 07/17/2022, revealed an officer was dispatched to the facility and upon arrival, spoke with LPN RRR, who informed the office that one of the residents hit her. LPN RRR reported that R#13 used a closed fist to hit the nurse in the chest and back, then the other nurses were able to get R#13 off of her and call the police. The report indicated upon speaking with the resident, R#13 alleged that he/she wanted to use the bathroom and the nurse hit him/her. R#13 reported that LPN RRR punched him/her several times. The report indicated LPN RRR was evaluated by emergency medical services (EMS), and R#13 was transported by EMS to the hospital for further evaluation. During an interview on 08/31/2022 at 10:07 AM, R#35 stated he/she witnessed the entire incident between R#13 and LPN RRR. R#35 stated he/she was in bed and the incident occurred outside the door to his/her room. According to R#35, R#13 approached LPN RRR and asked about his/her medicine. R#35 stated the nurse instructed R#13 to go back to his/her room and stated she would bring the resident's medication, but R#13 stated, I want my [expletive] medicine now. The nurse again instructed R#13 to return to his/her room and R#13 began to hit the nurse in her face and chest. R#35 stated the nurse started to scream for help, put her hands up to protect herself, and eventually pushed R#13 away. R#35 stated R#13 had a closed fist and hit the nurse at least three times, but maybe more. R#35 stated, it all happened so fast. Per R#35, two staff members responded and walked R#13 back to his/her room. R#35 indicated he/she spoke with the police officer who came to the facility and informed the officer that R#13 started the altercation when R#13 hit LPN RRR. R#35 stated LPN RRR was nice to R#13 throughout the entire incident. Review of a quarterly MDS dated [DATE] revealed R#35 had a BIMS score of 10, indicating moderate cognitive impairment. During an interview on 08/31/2022 at 10:17 AM in R#13's room, R#13 denied remembering an incident with a nurse. During a telephone interview on 08/31/2022 at 11:11 AM, Certified Nursing Assistant (CNA) VV stated she was eating in the dining room, so did not see the altercation, but heard hollering at the time of the incident. CNA VV stated after the incident, she saw LPN RRR cheeks were red. CNA VV stated abuse and suspected abuse should be reported to the Administrator, but she did not report anything related to this incident because she thought LPN RRR would. On 08/31/2022 at 11:09 AM and 4:55 PM, a telephone interview was attempted with LPN RRR. On both occasions, there was no answer. The surveyor left a voice mail message requesting a return call, but no return call was received. During an interview on 09/01/2022 at 2:20 PM, the Director of Nursing stated the Administrator was the abuse coordinator and that abuse should be investigated and reported to the State Agency within two hours. During an interview on 08/30/2022 at 12:19 PM, the Administrator stated allegations of abuse should be reported to the State Agency within two hours after the allegation was received. During a follow-up interview on 08/30/2022 at 12:53 PM, the Administrator stated she should have reported the allegation of abuse voiced by R#13. The Administrator offered no reason as to why the allegation was not reported to the State Agency.

Based on interviews, record review, the facility failed to promote and facilitate resident self-determination for one (Resident [R] #51) of four sampled residents reviewed for pain management. Specifically, the facility failed to ensure nursing staff honored R#51's choice regarding acceptance or refusal of specific medications. Findings included: A review of the Admission Record revealed R#51 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a quarterly Minimum Data Set (MDS), dated [DATE], revealed R#51 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The MDS indicated the resident received pain medications on an as-needed (PRN) basis and had frequent pain at an intensity level of 7 out of 10 (with zero being no pain and 10 being unbearable pain). According to the MDS, the resident received an opioid (narcotic pain medication) on seven days during the seven-day assessment period. Review of a Care Plan, dated 05/09/2022, revealed R#51 was at risk for pain. A planned intervention was to administer pain medication as ordered. Further review of the care plan revealed an entry dated 06/22/2022, which indicated R#51 refused care and was verbally abusive toward staff. Additionally, a care plan entry dated 08/20/2022 noted that two staff members were to provide all care. Review of the August 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a Progress Note, dated 08/29/2022 at 6:28 AM, revealed Licensed Practical Nurse (LPN) BB noted that R#51 argued about his/her medications when it was time to take them after having repeatedly requested the medications. Per the note, R#51 stated he/she did not want a sleeping pill and just wanted the pain medication. The note revealed all of the medications had been prepared and placed into two medication cups. The note indicated LPN BB advised the resident to discuss with the physician, any medications about which the resident had questions. The note revealed the resident eventually took the medications. During an interview on 08/30/2022 at 7:25 PM, LPN BB stated on the evening of 08/28/2022, she prepared medications for R#51 and had to wait for a Certified Nursing Assistant (CNA) to go in the room with her. LPN BB stated the resident had made false accusations against the staff, so two staff members had to go in the room during care. LPN BB stated when the CNA was available, she went in to give R#51 the medications. R#51 wanted to argue and only wanted to take the pain pill. LPN BB stated the pills were all mixed together and she could not remember which one was the pain pill, so told R#51 it was all or nothing. LPN BB stated the resident did take the medications later, but she could not recall what time they were given. LPN BB stated she was passing medications on the 100, 200 and 300 Halls and did not take the time to go back to verify which pill was the pain pill. During an interview with the Administrator and the Regional Vice President on 09/01/2022 at 2:33 PM, the Administrator stated the resident had the right to refuse medications. The Regional Vice President stated the nurse should have identified the pain medication to give the resident and educated the resident on the potential results of not taking the other medications. During an interview on 09/01/2022 at 4:40 PM, the Director of Nursing (DON) stated the nurse should have pulled the bubble pack (medication packet with doses of medication separated into individual bubbles) off the cart to identify the pain medication. The nurse could have given the resident the pain medication and then documented that the resident refused the other medications.

Based on observations, record review, and interviews, the facility failed to change an indwelling urinary catheter at the frequency specified by the physician for one (Resident [R] #62) of three sampled residents reviewed for urinary catheters. Findings included: Review of an Admission Record revealed the facility admitted R#62 on 06/24/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed R#62 was severely impaired in cognitive skills for daily decision-making per a staff assessment of mental status. The MDS indicated the resident had an indwelling urinary catheter. Review of the July 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the August 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 08/31/2022 at 11:10 AM, LPN CCC stated there was no #17 French catheter available on 07/22/2022, so she did not change R #62's catheter. The LPN stated there was a smaller size and a larger size, but not a size 17. The LPN asserted she told some of the staff working that night and the supervisor the next morning before she left that the catheter was not available but could not recall the names of the staff she told. LPN CCC stated she documented the information in the computer, in the area where the nurses documented information for shift report. During an interview on 08/31/2022 at 1:48 AM, Unit Manager CC stated the nurses used a communication board in the computer system to document their shift reports. The Unit Manager checked the communication board in the computer and stated there were no notes from LPN CCC on 07/22/2022 or 07/23/2022 to indicate there was not a #17 French catheter available to change the resident's catheter. During an interview on 08/31/2022 at 12:57 PM, LPN DDD, who worked 7:00 AM to 7:00 PM on 07/23/2022, stated she did not recall anyone reporting a problem to her regarding not having the correct size catheter to change the catheter for R#62. During an observation on 08/31/2022 at 12:45 PM with Certified Nursing Assistant EEE, the resident's urinary catheter was noted to be a #18 French. During an interview on 09/01/2022 at 9:07 AM, Weekend Supervisor FFF stated LPN CCC did not say anything about not having the correct size catheter to change R#62's catheter on the morning of 7/23/2022. During an interview on 09/01/2022 at 9:25 AM, Physician GGG stated he could not recall why he ordered for R#62's catheter to be changed every 30 days. He stated he did not write this order for all of his patients with an indwelling urinary catheter but if he ordered the catheter to be changed every 30 days, it should have been changed. During an interview on 09/01/2022 at 2:23 PM, the Administrator stated there was no such thing as a #17 French Foley catheter and that the nurse should have called the physician to clarify the size of the catheter and changed the catheter. During an interview on 09/01/2022 at 4:35 PM, the Director of Nursing stated the nurse should have called the doctor and clarified the order for R#62's catheter and changed the catheter.

Based on observations, interviews, and record review, the facility failed to ensure prompt efforts were made to resolve residents' grievances and the results of those efforts were communicated to the resident for two (Resident [R] #51 and R#55) of five sampled residents reviewed for grievances related to missing personal property. Specifically, the facility: - Failed to ensure R#51's verbal complaint of missing clothing was documented as a grievance, efforts were promptly made to locate the clothing, and the resident was kept informed of efforts to resolve the grievance. - Failed to ensure R#55's grievance related to missing money was thoroughly investigated. Findings included: 1. Review of an Admission Record revealed R#51 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed R#51 had a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. During an interview on 08/29/2022 at 11:08 AM, R#51 stated R#57 was formerly his roommate and had taken his pants with footballs on them and a family reunion shirt that had family names on it. R#51 stated this occurred two to three weeks ago and R#57 now resided in another room. R#51 stated he/she had reported the missing clothing to staff, but the items had not been returned. During an interview on 08/30/2022 at 1:09 PM, R#51's Family Member VVV stated about three weeks ago, R#51's roommate took a black family reunion shirt with family names on it, a brown pair of pants with footballs on them, and a green and white striped pair of pants. Family Member VVV stated the clothing was brought in so that R#51 would have something to wear when he/she went out of the facility to the doctor. Review of the facility's Grievance Log dated June through August 2022 revealed no written grievances related to R#51's report of missing clothing. During an interview on 08/30/2022 at 3:13 PM, Social Services Director (SSD) TT stated several weeks ago, she received a complaint that R#51 reported that R#57 was wearing clothing that belonged to R#51. SSD TT stated she had never seen R#51 in anything but a hospital gown and had not seen any clothing for R#51. SSD TT indicated one day when she was not working, an employee spoke with her out in the community and told her R#51 stated R#57 took clothing that belonged to R#51. SSD TT stated she was not able to recall the name of the employee who provided the information. SSD TT stated when she returned to work, she did not have a grievance form, did not think about the issue, and took no action regarding the clothing. SSD TT stated there were grievance forms outside her office door to allow the staff to fill out grievances for the residents. During an observation and interview on 08/30/2022 at 3:24 PM, SSD TT obtained permission from R#51 to look for the missing clothing in the resident's room. The missing clothing was not located in R#51's room. SSD TT proceeded to R#57's room, where she found a pair of brown fleece pants with footballs on them and a black shirt with names on it, including the last name of R#51. There was no name tag inside the pants or shirt to verify to whom the clothing belonged. SSD TT checked the facility's unclaimed clothing in the laundry but did not find a pair of green and white striped pants. SSD TT stated she would verify that the shirt and pants belonged to R#51 and then make sure the resident's name was written in the clothing. 2. Review of an Admission Record revealed R#55 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an annual Minimum Data Set, dated dated [DATE], revealed R#55 had a Brief Interview for Mental Status score of 15, which indicated the resident was cognitively intact. The MDS indicated the resident required extensive assistance with bed mobility and was totally dependent for transfer. During an interview on 08/29/2022 at 8:35 AM, R#55 stated $160.00 cash had been taken from the lockbox in his/her room, which was provided by the facility. The resident stated he/she had reported the missing money to the facility but had not received any response. Review of a Complaint Form, dated 02/28/2022, revealed R#55 reported $160.00 had been taken from a locked box in the resident's room. The resident reported the money had been placed in the lock box, and the key was accidently left inserted in the lock while the resident left the room to visit with family. The resident did not check the contents of the box until the next day, when he/she discovered the money was gone. The section of the form designated for documentation of the steps taken to investigate, summary of pertinent findings or conclusions, and corrective action taken indicated the police were notified and came to the facility, and a report was filed; however, no money was located, and no suspects were identified. The form did not indicate any staff or residents were questioned regarding the missing money. The grievance log entry contained no documentation to indicate the facility conducted any further investigation. The bottom of the form indicated the grievance was resolved and the resident was informed of the outcome. During an interview on 08/30/2022 at 3:35 PM, the surveyor asked the Administrator for a copy of the investigation of R#55's grievance regarding missing money. During an interview on 08/30/2022 at 4:43 PM, the Administrator and the Director of Nursing (DON) stated they had no documented investigation to provide for review.

Based on interviews, record review, facility policy review, and review of an incident report and police report, it was determined the facility failed to investigate an allegation of staff-to-resident physical abuse for one (Resident [R] #13) of one sampled resident reviewed for abuse. Findings included: Review of a facility policy titled, Freedom of Abuse, Neglect and Exploitation; Abuse Prevention: Fast Alerts, dated January 2022, revealed, Investigation. All alleged violations involving mistreatment, sexual inappropriate behaviors, and abuse or neglect will be thoroughly investigated by the facility under the direction of the Administrator and in accordance with state and federal law. The policy listed the steps of the investigation included the following: - 2. Interview the resident or other resident witnesses. - 4. Interview the staff member implicated. Interviewer is to document the staff member's knowledge and/or version of the incident in a written narrative that is dated and signed. - 5. Interview all staff on that unit, as well as other staff or other available witnesses. Review of an Admission Record revealed R#13 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an admission Minimum Data Set (MDS) dated [DATE] revealed R#13 had a Brief Interview for Mental Status (BIMS) score of 3, indicating the resident had severe cognitive impairment. The MDS indicated R#13 exhibited physical, verbal, and other behavioral symptoms directed toward others on one to three days during the seven-day assessment period. Review of an incident report, dated 07/17/2022 at 11:00 PM, revealed Licensed Practical Nurse (LPN) RRR approached R#13 with medications, and the resident refused to take them. The LPN informed the resident of the importance of taking the medications. Per the report, the resident then stood up over the nurse and stated, I'm not taking no medication from no fat [expletive] nurse. LPN RRR returned to the medication cart, and R#13 came and stood behind the nurse. LPN RRR instructed the resident to go to his/her room. Per the report, the resident proceeded to grab LPN RRR and began striking the nurse with his/her hands. The nurse screamed for help, and another resident and staff began to separate the resident from the nurse. The report indicated 911 was activated, and other appropriate parties were made aware. According to the report, R#13 had dementia, was often combative and resistive to care, and frequently refused to take medications, which made it very difficult to keep the resident stable and the behaviors controlled. Review of the police incident report, dated 07/17/2022, revealed an officer was dispatched to the facility and upon arrival, spoke with LPN RRR, who informed the office that one of the residents hit her. LPN RRR reported that R#13 used a closed fist to hit the nurse in the chest and back, then the other nurses were able to get R#13 off of her and call the police. The report indicated upon speaking with the resident, R#13 alleged that he/she wanted to use the bathroom and the nurse hit him/her. R#13 reported that LPN RRR punched him/her several times. The report indicated LPN RRR was evaluated by emergency medical services (EMS), and R#13 was transported by EMS to the hospital for further evaluation. During an interview on 08/31/2022 at 10:07 AM, R#35 stated he/she witnessed the entire incident between R#13 and LPN RRR. R#35 stated he/she was in bed and the incident occurred outside the door to his/her room. According to R#35, R#13 approached LPN RRR and asked about his/her medicine. R#35 stated the nurse instructed R#13 to go back to his/her room and stated she would bring the resident's medication, but R#13 stated, I want my [expletive] medicine now. The nurse again instructed R#13 to return to his/her room and R#13 began to hit the nurse in her face and chest. R#35 stated the nurse started to scream for help, put her hands up to protect herself, and eventually pushed R#13 away. R#35 stated R#13 had a closed fist and hit the nurse at least three times, but maybe more. R#35 stated, it all happened so fast. Per R#35, two staff members responded and walked R#13 back to his/her room. R#35 indicated he/she spoke with the police officer who came to the facility and informed the officer that R#13 started the altercation when R#13 hit LPN RRR. R#35 stated LPN RRR was nice to R#13 throughout the entire incident. Review of a quarterly MDS dated [DATE] revealed R#35 had a BIMS score of 10, indicating moderate cognitive impairment. During an interview on 09/01/2022 at 2:20 PM, the Director of Nursing stated the Administrator was the abuse coordinator and that abuse should be investigated and reported to the State Agency within two hours. During an interview on 08/30/2022 at 12:53 PM, the Administrator stated she talked with staff about the incident between R#13 and LPN RRR; however, she did not get statements from the staff or document anything she had done to investigate the allegation. During a follow-up interview on 08/31/2022 at 10:20 AM, the Administrator confirmed there was no investigation into R#13's allegations related to the incident that occurred on 07/17/2022 between R#13 and LPN RRR.

Based on record review, interviews, and facility policy titled Change of Condition/Incident Reporting, the facility failed to notify the responsible party (RP) of a resident's change of condition. The RP was not notified of a hospital transfer or notified when the resident returned from the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] #19] of one resident reviewed for notification of changes of condition. Findings included: Review of a policy dated August 2021 and titled Change of Condition/Incident Reporting indicated, If there is an actual change in condition, the resident's physician is notified promptly and validated as to information. Family/Responsible Party notified promptly. A review of an Admission Record revealed the facility admitted R#19 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a Minimum Data Set (MDS) assessment, dated 07/04/2022, revealed R#19 had severe cognitive impairment as evidenced by a Staff Assessment for Mental Status (SAMS). Per the MDS, the resident was totally dependent on staff for activities of daily living, had a [CONDITION(S)], and had impaired speech. A review of a progress note, dated 07/09/2022 at 11:23 AM, revealed R#19 was transferred to a hospital for percutaneous endoscopic gastrostomy (PEG; feeding tube) tube replacement. There was no documentation the RP was notified of R#19's hospital transfer. A review of a progress note, dated 07/09/2022 at 11:56 PM, revealed R#19 returned from the hospital with a new gastrostomy tube (G-tube) and was positive for COVID-19. There was no documentation the RP was notified of R#19's return to the facility, G-tube placement, or COVID-19 positive status. During an interview on 08/30/2022 at 11:24 AM, the RP confirmed the facility failed to provide notification on 07/09/2022 that R#19 had been transferred to the hospital for a PEG tube replacement and had not been notified that R#19 had returned from the hospital with a positive COVID-19 diagnosis. During an interview on 09/01/2022 at 10:35 AM, Registered Nurse (RN) QQ reported the decision to send a resident to a hospital involved her discretion and/or notification of family. RN QQ reported she attempted to contact the RP for R#19 once and did not get an answer. RN QQ reported she failed to document the attempt to contact R#19's RP but should have. During an interview on 09/01/2022 at 1:23 PM, Director of Nursing (DON) KK reviewed R#19's chart and reported there was no documented communication with the RP regarding the resident's changes in condition, noting there should have been. On 09/01/2022 at 3:12 PM, the Administrator reported the RP should have been notified of R#19's transfer to the hospital and positive COVID-19 diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on interview and record review, the facility failed to ensure that care plans were revised to address significant weight loss for two residents (R#6 and R#8) from a total sample of 17 residents. On [DATE] a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) LL were informed of the Immediate Jeopardy (IJ) on [DATE] at 1:55 p.m. The noncompliance related to the first IJ was identified to have existed on [DATE]. The noncompliance related to the second IJ was identified to have existed on [DATE]. 1.) The first IJ is outlined as follows: Resident (R) #5 was admitted to the facility on [DATE] and required bilateral below the knee amputations (BKA's) due to severe peripheral artery disease (PAD) with occlusion on [DATE]. Upon return from hospitalization status post [MEDICAL RECORD OR PHYSICIAN ORDER] . R#5 was diagnosed on [DATE] at the hospital emergency room with a wound infection to the left BKA. R#5 underwent a revision to the left BKA on [DATE] and returned to the facility the same day. The facility again failed to clarify/obtain treatment orders on return from the hospital on [DATE]. There was no evidence of wound care being provided from [DATE] through [DATE]. In addition, the left BKA revision site was not accurately assessed by nursing staff on hospital return and a scheduled follow up appointment with the surgeon was not kept on [DATE]. The resident expired at the facility on [DATE]. The death certificate listed diabetes as the cause of death. 2.) The second IJ is outlined as follows: R#10, a [AGE] year-old resident with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Weights for R#10 trended down from 89 pounds on [DATE] to 83 pounds on [DATE], despite repeated increases of bolus g-tube nutritional supplement formula. The last increase was on [DATE]. There was no evidence that a documented plan from the Nurse Practitioner (NP) on [DATE] for a follow-up weight and Registered Dietician (RD) evaluation in two weeks was followed. However, a nutritional assessment was completed on [DATE] when the RD acknowledged that there was no [DATE] weight but indicated that the ordered nutritional supplement formula and water flushes met the resident's needs. Despite R#10's downtrend of weight, even with incremental increases in the nutritional supplement formula, no weight was obtained, to continue to monitor his progress, after [DATE], until [DATE]. On [DATE], a weight of 75.8 pounds was documented. There is no acknowledgement of the [DATE] weight of 75.8 pounds, which reflects actual, further significant weight loss. On [DATE] there was a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . However, no weights were obtained between [DATE] through [DATE], except when surveyor inquired on [DATE]. In addition, during an observation on [DATE] at 3:30 p.m., Licensed Practical Nurse (LPN) BB administered the incorrect amount of bolus g-tube formula to R#10 (administered 237 milliliters instead of 320 milliliters). Review of the Medication Administration Records (MAR) revealed no evidence that the physician ordered bolus nutritional supplement formula was administered as scheduled for 28 times in [DATE] and 27 times in [DATE]. There was also repeated, systemic failure to implement pertinent interventions to address weight loss and/or nutrition and hydration risk for five residents (R#6, R#8, R#12, R#13, and R#14). R#6 and R#8 received nutrition and hydration via gastrostomy tube. R#12, R#13 and R#14 received nutrition and hydration orally. There was also evidence of a systemic failure related to dietary services to ensure that there was an adequate number of dietary staff and that the dietary staff had the skill set to carry out the functions of the food and nutrition services in the facility. Dietary staff failed to follow menus and individualized food plans for correct portion size to ensure residents' nutritional needs were met. R#12 and R#14 were to receive double portions of food because they were nutritionally compromised. By not receiving double portions, they were put at risk for further weight loss and/or poor nutritional status. The Immediate Jeopardies were related to the facility's noncompliance with the requirements at 42 C.F.R. 483.21(b)(1) Develop/Implement Comprehensive Care Plan (F656, Scope/Severity: K); 42 C.F.R. 483.21(b) Comprehensive Care Plans (F657, Scope/Severity: K); 42 C.F.R. 483.25 Quality of Care (F684, Scope/Severity: J); 42 C.F.R. 483.25(g)(1)(2) Nutrition/Hydration Status and Maintenance (F692, Scope/Severity: K); 42 C.F.R. 483.60(a)(3) Sufficient Dietary Support Personnel (F802, Scope/Severity: K); 42 C.F.R. 483.60(c)(,d+[DATE]), Menus and Nutritional Adequacy (F803, Scope/Severity: K); 42 C.F.R. 483.70 Administration (F835, Scope/Severity: K); 42 C.F.R. 483.70(d) Governing body (F837, Scope/Severity: K); 42 C.F.R. 483.75(g)(2) QAPI/QAA Improvement Activities (F867, Scope/Severity: K). Additionally. Substandard Quality of Care was identified with the requirements at 42 C.F.R. 483.25 Quality of Care (F684, Scope/Severity: J); and 42 C.F.R. 483.25(g)(1)(2), Nutrition/Hydration Status and Maintenance (F692, Scope/Severity: K). At the time of exit on [DATE], the IJ remained ongoing. Findings include: 1. Resident #6 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the clinical record revealed that R#6 was dependent on nursing staff for nutrition and hydration via her gastrostomy tube. Quarterly Minimum Data Set (MDS) assessments, dated [DATE] and [DATE] were completed by nursing staff. The assessments both documented no significant weight loss of 5% or more in a month or 10% or more in six months. A significant weight loss was identified between the two MDS assessments in an [DATE] RD assessment. However, the comprehensive care plan was not revised to include R#6's significant weight loss. Review of the clinical record revealed an [DATE] Dietary Progress Note, from the RD, that identified a significant weight loss and possible incorrect weight from [DATE] and [DATE]. The dietary note documented an [DATE] weight of 161.3 pounds and an [DATE] weight of 185.2 pounds. With the 161.3-pound weight, that was a significant weight loss of 23.9 pounds in 90 days (12.9%). The RD recommended changing the gastrostomy tube nutritional supplement formula from Glucerna 1.2 at 45 ml per hour for 24 hours to Glucerna 1.5 at 45 ml per hour for 22 hours. On [DATE], in a Dietary Progress Note, the RD documents that there is no [DATE] weight and documented the same concerns from her [DATE] dietary note, and again recommended to change the gastrostomy tube nutritional supplement formula order to address the weight loss. A weight obtained on [DATE] documented a further weight loss from 161.5 pounds on [DATE] to 154.6 pounds, a further loss of 6.9 pounds. 2. Resident #8 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the clinical record revealed that R#8 received all nutrition and hydration via gastrostomy tube. A Quarterly Minimum Data Set (MDS) assessment, dated [DATE] and an Annual MDS assessment, dated [DATE] were completed by nursing staff. The assessments both documented a significant weight loss of 5% or more in a month or 10% or more in six months. However, the comprehensive care plan was not revised to include R#8's significant weight loss. The Registered Dietician assessed R#8 on [DATE] and documented in a Dietary Progress Note that he triggered for a severe weight loss. His BMI at 136.6 pounds was 18.5 (normal). The notes included the weight fluctuation from 148 pounds on [DATE] to 165 pounds on [DATE] to 136.6 pounds on [DATE]. The RD recommended weekly weights for four weeks to determine accurate weight. The NP documented weight loss on [DATE] and included a plan to continue the current gastrostomy tube feedings and water flushes and weights weekly. The RD assessed R#8 again on [DATE] and documented, in a Dietary Progress Note, a [DATE] weight of 134.2 pounds and calculated the BMI at 18.2 (now underweight) and 11.1% weight loss in 180 days. The RD recommended increasing the gastrostomy tube nutritional supplement formula from [MEDICATION(S)] 60 ml per hour to 70 ml per hour. Further review of the clinical record revealed that the RD recommendation to increase the [MEDICATION(S)] was ordered on [DATE]. Additional weights obtained for [DATE] and [DATE]: ,d+[DATE] (134#), ,d+[DATE] (135.8), ,d+[DATE] (135.8), ,d+[DATE] (135.9), and ,d+[DATE] (135.9) indicated R#8 remained within an underweight BMI of 18.4 (based off the [DATE] weight of 135.9#). During an interview on [DATE] at 10:25 a.m. DON LL (as of [DATE]) stated that the facility's weight system was broken; the facility needed systems and education. Cross reference to F692

Based on observation and staff interviews, the facility failed to ensure there was adequate dietary support personnel to prepare, cook and serve meals to 65 of 70 residents receiving an oral diet. On [DATE] a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) LL were informed of the Immediate Jeopardy (IJ) on [DATE] at 1:55 p.m. The noncompliance related to the first IJ was identified to have existed on [DATE]. The noncompliance related to the second IJ was identified to have existed on [DATE]. 1.) The first IJ is outlined as follows: Resident (R) #5 was admitted to the facility on [DATE] and required bilateral below the knee amputations (BKA's) due to severe peripheral artery disease (PAD) with occlusion on [DATE]. Upon return from hospitalization status post bilateral BKA's on [DATE], the facility failed to clarify/obtain treatment orders for the surgical wounds. R#5 was diagnosed on [DATE] at the hospital emergency room with a wound infection to the left BKA. R#5 underwent a revision to the left BKA on [DATE] and returned to the facility the same day. The facility again failed to clarify/obtain treatment orders on return from the hospital on [DATE]. There was no evidence of wound care being provided from [DATE] through [DATE]. In addition, the left BKA revision site was not accurately assessed by nursing staff on hospital return and a scheduled follow up appointment with the surgeon was not kept on [DATE]. The resident expired at the facility on [DATE]. The death certificate listed diabetes as the cause of death. 2.) The second IJ is outlined as follows: R#10, a [AGE] year-old resident with a diagnosis of [CONDITION(S)] was dependent on staff and received all nutrition and hydration through a gastrostomy tube (g-tube). Weights for R#10 trended down from 89 pounds on [DATE] to 83 pounds on [DATE], despite repeated increases of bolus g-tube nutritional supplement formula. The last increase was on [DATE]. There was no evidence that a documented plan from the Nurse Practitioner (NP) on [DATE] for a follow-up weight and Registered Dietician (RD) evaluation in two weeks was followed. However, a nutritional assessment was completed on [DATE] when the RD acknowledged that there was no [DATE] weight but indicated that the ordered nutritional supplement formula and water flushes met the resident's needs. Despite R#10's downtrend of weight, even with incremental increases in the nutritional supplement formula, no weight was obtained, to continue to monitor his progress, after [DATE], until [DATE]. On [DATE], a weight of 75.8 pounds was documented. There is no acknowledgement of the [DATE] weight of 75.8 pounds, which reflects actual, further significant weight loss. On [DATE] there was a physician's order for biweekly weights (between ,d+[DATE] and [DATE]), and if weight decreased, resume continuous nutritional supplement feedings via g-tube. However, no weights were obtained between [DATE] through [DATE], except when surveyor inquired on [DATE]. In addition, during an observation on [DATE] at 3:30 p.m., Licensed Practical Nurse (LPN) BB administered the incorrect amount of bolus g-tube formula to R#10 (administered 237 milliliters instead of 320 milliliters). Review of the Medication Administration Records (MAR) revealed no evidence that the physician ordered bolus nutritional supplement formula was administered as scheduled for 28 times in [DATE] and 27 times in [DATE]. There was also repeated, systemic failure to implement pertinent interventions to address weight loss and/or nutrition and hydration risk for five residents (R#6, R#8, R#12, R#13, and R#14). R#6 and R#8 received nutrition and hydration via gastrostomy tube. R#12, R#13 and R#14 received nutrition and hydration orally. There was also evidence of a systemic failure related to dietary services to ensure that there was an adequate number of dietary staff and that the dietary staff had the skill set to carry out the functions of the food and nutrition services in the facility. Dietary staff failed to follow menus and individualized food plans for correct portion size to ensure residents' nutritional needs were met. R#12 and R#14 were to receive double portions of food because they were nutritionally compromised. By not receiving double portions, they were put at risk for further weight loss and/or poor nutritional status. The Immediate Jeopardies were related to the facility's noncompliance with the requirements at 42 C.F.R. 483.21(b)(1) Develop/Implement Comprehensive Care Plan (F656, Scope/Severity: K); 42 C.F.R. 483.21(b) Comprehensive Care Plans (F657, Scope/Severity: K); 42 C.F.R. 483.25 Quality of Care (F684, Scope/Severity: J); 42 C.F.R. 483.25(g)(1)(2) Nutrition/Hydration Status and Maintenance (F692, Scope/Severity: K); 42 C.F.R. 483.60(a)(3) Sufficient Dietary Support Personnel (F802, Scope/Severity: K); 42 C.F.R. 483.60(c)(,d+[DATE]), Menus and Nutritional Adequacy (F803, Scope/Severity: K); 42 C.F.R. 483.70 Administration (F835, Scope/Severity: K); 42 C.F.R. 483.70(d) Governing body (F837, Scope/Severity: K); 42 C.F.R. 483.75(g)(2) QAPI/QAA Improvement Activities (F867, Scope/Severity: K). Additionally. Substandard Quality of Care was identified with the requirements at 42 C.F.R. 483.25 Quality of Care (F684, Scope/Severity: J); and 42 C.F.R. 483.25(g)(1)(2), Nutrition/Hydration Status and Maintenance (F692, Scope/Severity: K). At the time of exit on [DATE], the IJ remained ongoing. Findings include: Observation and interview during the lunch meal service on [DATE] at 12:05 p.m., revealed two dietary staff working in the kitchen. Cook NN stated they have been working with two dietary staff on the day shift for the past three months. She stated three people would be better because they have to prepare, cook, serve and clean. She stated they also have been without a Dietary Manager for three months. She stated corporate told them two was enough to work in the kitchen. She stated since they have been without a Dietary Manager, she must place the food orders, do the schedule, print tray cards and cook. Registered Dietician MM stated on [DATE] at 12:15 p.m. that ideally, they need three staff in the kitchen, especially since Cook NN has been acting as the Dietary Manager and having to order food. During an interview with Dietary Aide OO on [DATE] at 4:25 p.m., she stated when there are only two people working in the kitchen, you just have to cut corners. She stated for example, the menu for supper today included pineapple upside down cake but there was not time to cook it because she was asked to help with lunch today. She and the night shift cook usually work from 11:45 a.m. to 7:15 p.m. When they come in, they normally set up the drinks for lunch then she organizes the tray cards and starts making desserts for supper. They also use plastic plates, bowls, and plastic silverware because it is easier and less to wash. She stated they have been short of help for the past two to three months. During an interview with Dietary Aide RR on [DATE] at 1:00 p.m., she stated corporate told them about three months ago that two people were enough to work in the kitchen on day shift. She stated day shift has to do breakfast and lunch and wash dishes and that it was just too much. At times they don't have time to make dessert for lunch or supper. She stated she has talked to the Administrator about it several times and he tells her Just work with me, I'm trying to get people in.

Based on observation, staff interview and review of the Week One Menu, the facility failed to ensure dietary staff were serving the correct portion sizes of pureed food and regular diets according to the menu and failed to serve double portions to two residents (R) (#12 and #14) who had a history of weight loss. There were 65 residents with oral diets. On [DATE] a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) LL were informed of the Immediate Jeopardy (IJ) on [DATE] at 1:55 p.m. The noncompliance related to the first IJ was identified to have existed on [DATE]. The noncompliance related to the second IJ was identified to have existed on [DATE]. 1.) The first IJ is outlined as follows: Resident (R) #5 was admitted to the facility on [DATE] and required bilateral below the knee amputations (BKA's) due to severe peripheral artery disease (PAD) with occlusion on [DATE]. Upon return from hospitalization status post bilateral BKA's on [DATE], the facility failed to clarify/obtain treatment orders for the surgical wounds. R#5 was diagnosed on [DATE] at the hospital emergency room with a wound infection to the left BKA. R#5 underwent a revision to the left BKA on [DATE] and returned to the facility the same day. The facility again failed to clarify/obtain treatment orders on return from the hospital on [DATE]. There was no evidence of wound care being provided from [DATE] through [DATE]. In addition, the left BKA revision site was not accurately assessed by nursing staff on hospital return and a scheduled follow up appointment with the surgeon was not kept on [DATE]. The resident expired at the facility on [DATE]. The death certificate listed diabetes as the cause of death. 2.) The second IJ is outlined as follows: R#10, a [AGE] year-old resident with a diagnosis of [CONDITION(S)] was dependent on staff and received all nutrition and hydration through a gastrostomy tube (g-tube). Weights for R#10 trended down from 89 pounds on [DATE] to 83 pounds on [DATE], despite repeated increases of bolus g-tube nutritional supplement formula. The last increase was on [DATE]. There was no evidence that a documented plan from the Nurse Practitioner (NP) on [DATE] for a follow-up weight and Registered Dietician (RD) evaluation in two weeks was followed. However, a nutritional assessment was completed on [DATE] when the RD acknowledged that there was no [DATE] weight but indicated that the ordered nutritional supplement formula and water flushes met the resident's needs. Despite R#10's downtrend of weight, even with incremental increases in the nutritional supplement formula, no weight was obtained, to continue to monitor his progress, after [DATE], until [DATE]. On [DATE], a weight of 75.8 pounds was documented. There is no acknowledgement of the [DATE] weight of 75.8 pounds, which reflects actual, further significant weight loss. On [DATE] there was a physician's order for biweekly weights (between ,d+[DATE] and [DATE]), and if weight decreased, resume continuous nutritional supplement feedings via g-tube. However, no weights were obtained between [DATE] through [DATE], except when surveyor inquired on [DATE]. In addition, during an observation on [DATE] at 3:30 p.m., Licensed Practical Nurse (LPN) BB administered the incorrect amount of bolus g-tube formula to R#10 (administered 237 milliliters instead of 320 milliliters). Review of the Medication Administration Records (MAR) revealed no evidence that the physician ordered bolus nutritional supplement formula was administered as scheduled for 28 times in [DATE] and 27 times in [DATE]. There was also repeated, systemic failure to implement pertinent interventions to address weight loss and/or nutrition and hydration risk for five residents (R#6, R#8, R#12, R#13, and R#14). R#6 and R#8 received nutrition and hydration via gastrostomy tube. R#12, R#13 and R#14 received nutrition and hydration orally. There was also evidence of a systemic failure related to dietary services to ensure that there was an adequate number of dietary staff and that the dietary staff had the skill set to carry out the functions of the food and nutrition services in the facility. Dietary staff failed to follow menus and individualized food plans for correct portion size to ensure residents' nutritional needs were met. R#12 and R#14 were to receive double portions of food because they were nutritionally compromised. By not receiving double portions, they were put at risk for further weight loss and/or poor nutritional status. The Immediate Jeopardies were related to the facility's noncompliance with the requirements at 42 C.F.R. 483.21(b)(1) Develop/Implement Comprehensive Care Plan (F656, Scope/Severity: K); 42 C.F.R. 483.21(b) Comprehensive Care Plans (F657, Scope/Severity: K); 42 C.F.R. 483.25 Quality of Care (F684, Scope/Severity: J); 42 C.F.R. 483.25(g)(1)(2) Nutrition/Hydration Status and Maintenance (F692, Scope/Severity: K); 42 C.F.R. 483.60(a)(3) Sufficient Dietary Support Personnel (F802, Scope/Severity: K); 42 C.F.R. 483.60(c)(,d+[DATE]), Menus and Nutritional Adequacy (F803, Scope/Severity: K); 42 C.F.R. 483.70 Administration (F835, Scope/Severity: K); 42 C.F.R. 483.70(d) Governing body (F837, Scope/Severity: K); 42 C.F.R. 483.75(g)(2) QAPI/QAA Improvement Activities (F867, Scope/Severity: K). Additionally. Substandard Quality of Care was identified with the requirements at 42 C.F.R. 483.25 Quality of Care (F684, Scope/Severity: J); and 42 C.F.R. 483.25(g)(1)(2), Nutrition/Hydration Status and Maintenance (F692, Scope/Severity: K). At the time of exit on [DATE], the IJ remained ongoing. Findings include: 1. Review of the planned menu for Monday, Week One, documented that one cup of spaghetti and meat sauce were planned for residents receiving a regular diet and a pureed diet. However, during an observation of the lunch meal service on [DATE] at 12:25 p.m., dietary staff NN was observed serving three ounces (,d+[DATE] cup) of the meat sauce and three ounces of the pureed spaghetti. During an interview with Registered Dietician MM on [DATE] at 1:50 p.m., she stated staff should have served four ounces (,d+[DATE] cup) of the meat sauce and four ounces of spaghetti noodles. 2. R#12 had a physician's order since [DATE] for regular concentrated sweets diet, pureed texture with double portions for lunch and supper. However, during observations of the lunch meal on [DATE] at 12:26 p.m., and [DATE] at 1:00 p.m., the resident was not served double portions. Observation of the diet card that was on the resident's lunch tray revealed the portion size was specified as double portion. During an observation of the meal service tray line on [DATE] at 12:25 p.m., the dietary staff was observed serving only regular portions on the resident's plate. Although the dietary aide called out a puree diet to staff plating the food, she did not include double portions. During an interview with Cook NN on [DATE] at 2:45 p.m., she was not aware the resident was supposed to have double portions. 3. R#14 had a diet order since [DATE] that included a no added salt, mechanical soft texture, double portion, ground meat diet. However, during an observation on [DATE] at 12:20 p.m., R#14 was observed with a lunch tray with single portions of beef stew, peppers and onions, cooked carrots, a roll, and orange cream ice cream cup. During the observation, Certified Nursing Assistant (CNA) PP stated that she usually assists R#14 to eat and that he usually eats everything. During a subsequent interview on [DATE] at 12:05 p.m. CNA PP stated that R#14 ate 85% of his lunch meal on [DATE]. During an observation on [DATE] at 12:30 p.m., R#14 was again observed to have been served a lunch tray with only single portions of ground chicken, mixed vegetables, a biscuit, rice with gravy, apple crisp, and an orange cream ice cream cup.

Based on observation, interview, review of the facility policy titled Nutrition and Weight Management Standard, and record review, the facility failed to ensure that nutritional interventions were implemented as care planned for four residents (R#6, R#12, R#13, and R#14) and surgical wound treatments were provided as care planned for one resident (R#5), from a total sample of 17 residents. On [DATE] a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) LL were informed of the Immediate Jeopardy (IJ) on [DATE] at 1:55 p.m. The noncompliance related to the first IJ was identified to have existed on [DATE]. The noncompliance related to the second IJ was identified to have existed on [DATE]. 1.) The first IJ is outlined as follows: Resident (R) #5 was admitted to the facility on [DATE] and required bilateral below the knee amputations (BKA's) due to severe peripheral artery disease (PAD) with occlusion on [DATE]. Upon return from hospitalization status post [MEDICAL RECORD OR PHYSICIAN ORDER] . R#5 was diagnosed on [DATE] at the hospital emergency room with a wound infection to the left BKA. R#5 underwent a revision to the left BKA on [DATE] and returned to the facility the same day. The facility again failed to clarify/obtain treatment orders on return from the hospital on [DATE]. There was no evidence of wound care being provided from [DATE] through [DATE]. In addition, the left BKA revision site was not accurately assessed by nursing staff on hospital return and a scheduled follow up appointment with the surgeon was not kept on [DATE]. The resident expired at the facility on [DATE]. The death certificate listed diabetes as the cause of death. 2.) The second IJ is outlined as follows: R#10, a [AGE] year-old resident with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Weights for R#10 trended down from 89 pounds on [DATE] to 83 pounds on [DATE], despite repeated increases of bolus g-tube nutritional supplement formula. The last increase was on [DATE]. There was no evidence that a documented plan from the Nurse Practitioner (NP) on [DATE] for a follow-up weight and Registered Dietician (RD) evaluation in two weeks was followed. However, a nutritional assessment was completed on [DATE] when the RD acknowledged that there was no [DATE] weight but indicated that the ordered nutritional supplement formula and water flushes met the resident's needs. Despite R#10's downtrend of weight, even with incremental increases in the nutritional supplement formula, no weight was obtained, to continue to monitor his progress, after [DATE], until [DATE]. On [DATE], a weight of 75.8 pounds was documented. There is no acknowledgement of the [DATE] weight of 75.8 pounds, which reflects actual, further significant weight loss. On [DATE] there was a physician's order for biweekly weights (between ,d+[DATE] and [DATE]), and if weight decreased, resume continuous nutritional supplement feedings via g-tube. However, no weights were obtained between [DATE] through [DATE], except when surveyor inquired on [DATE]. In addition, during an observation on [DATE] at 3:30 p.m., Licensed Practical Nurse (LPN) BB administered the incorrect amount of bolus g-tube formula to R#10 (administered 237 milliliters instead of 320 milliliters). Review of the Medication Administration Records (MAR) revealed no evidence that the physician ordered bolus nutritional supplement formula was administered as scheduled for 28 times in [DATE] and 27 times in [DATE]. There was also repeated, systemic failure to implement pertinent interventions to address weight loss and/or nutrition and hydration risk for five residents (R#6, R#8, R#12, R#13, and R#14). R#6 and R#8 received nutrition and hydration via gastrostomy tube. R#12, R#13 and R#14 received nutrition and hydration orally. There was also evidence of a systemic failure related to dietary services to ensure that there was an adequate number of dietary staff and that the dietary staff had the skill set to carry out the functions of the food and nutrition services in the facility. Dietary staff failed to follow menus and individualized food plans for correct portion size to ensure residents' nutritional needs were met. R#12 and R#14 were to receive double portions of food because they were nutritionally compromised. By not receiving double portions, they were put at risk for further weight loss and/or poor nutritional status. The Immediate Jeopardies were related to the facility's noncompliance with the requirements at 42 C.F.R. 483.21(b)(1) Develop/Implement Comprehensive Care Plan (F656, Scope/Severity: K); 42 C.F.R. 483.21(b) Comprehensive Care Plans (F657, Scope/Severity: K); 42 C.F.R. 483.25 Quality of Care (F684, Scope/Severity: J); 42 C.F.R. 483.25(g)(1)(2) Nutrition/Hydration Status and Maintenance (F692, Scope/Severity: K); 42 C.F.R. 483.60(a)(3) Sufficient Dietary Support Personnel (F802, Scope/Severity: K); 42 C.F.R. 483.60(c)(,d+[DATE]), Menus and Nutritional Adequacy (F803, Scope/Severity: K); 42 C.F.R. 483.70 Administration (F835, Scope/Severity: K); 42 C.F.R. 483.70(d) Governing body (F837, Scope/Severity: K); 42 C.F.R. 483.75(g)(2) QAPI/QAA Improvement Activities (F867, Scope/Severity: K). Additionally. Substandard Quality of Care was identified with the requirements at 42 C.F.R. 483.25 Quality of Care (F684, Scope/Severity: J); and 42 C.F.R. 483.25(g)(1)(2), Nutrition/Hydration Status and Maintenance (F692, Scope/Severity: K). At the time of exit on [DATE], the IJ remained ongoing. Findings include: Per the facility Policy and Procedure titled Nutrition and Weight Management Standard, weekly weights should be done on the following residents: Residents who have a 5% weight loss in 30 days, Residents who have a 7.5% weight loss in 90 days and residents who have a 10% weight loss in 180 days. 1. Resident #6 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the clinical record revealed that R#6 was dependent on nursing staff for nutrition and hydration via her gastrostomy tube. A care plan, dated [DATE], was developed that included R#6 required nutrition via a gastrostomy tube related to dysphagia. The care plan included an intervention for nursing staff to obtain weights as indicated. A review of physician's orders revealed an order since [DATE] for weights monthly. However, there was no evidence that a weight was obtained as ordered and care planned for [DATE]. Review of the clinical record revealed an [DATE] Dietary Progress Note, from the RD, that identified a significant weight loss and possible incorrect weights for [DATE] and [DATE]. The dietary note documented an [DATE] weight of 161.3 pounds and an [DATE] weight of 185.2 pounds. With the 161.3-pound weight, that was a significant weight loss of 23.9 pounds in 90 days (12.9%). On [DATE], the RD recommended changing the gastrostomy tube nutritional supplement formula from Glucerna 1.2 at 45 ml per hour for 24 hours to Glucerna 1.5 at 45 ml per hour for 22 hours. There is no evidence that the [DATE] RD recommendation was acted on or the weight discrepancy addressed. On [DATE], in a Dietary Progress Note, the RD documents that there is no [DATE] weight and documented the same concerns from her [DATE] dietary note, and again recommended to change the gastrostomy tube nutritional supplement formula order to address the weight loss. However, there is no evidence the [DATE] RD recommendations were acted on until [DATE], after further weight loss. A weight obtained on [DATE] documented a further weight loss from 161.5 pounds on [DATE] to 154.6 pounds, a further loss of 6.9 pounds. During an interview on [DATE] at 3:00 p.m. R#6's physician confirmed that he would expect the RD recommendations to be acted on by nursing staff and provided to him or the NP to review. Cross reference to F692 2. Resident #14 resided at the facility since [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . There was a care plan in place that R#14 had the potential for a nutritional problem. The care plan problem included that he was at risk for weight loss, had cognitive and communication impairments, was on a therapeutic diet, and required assistance with meals. The care plan included interventions for staff to provide and serve his diet as ordered and weights per policy. However, R#14 was not served the correct diet for two lunch meals on [DATE] and [DATE] and a monthly weight was not obtained for [DATE] as ordered and care planned. R#14 had a diet order since [DATE] that included a no added salt, mechanical soft texture, double portion, ground meat diet. However, during an observation on [DATE] at 12:20 p.m. R#14 was observed with a lunch tray with single portions of beef stew, peppers and onions, cooked carrots, a roll, and orange cream ice cream cup. During the observation, Certified Nursing Assistant (CNA) PP stated that she usually assists R#14 to eat and that he usually eats everything. During a subsequent interview on [DATE] at 12:05 p.m. CNA PP stated that R#14 ate 85% of his lunch meal on [DATE]. During an observation on [DATE] at 12:30 p.m. R#14 was again observed to have been served a lunch tray with only single portions of ground chicken, mixed vegetables, a biscuit, rice with gravy, apple crisp, and an orange cream ice cream cup. A review of monthly weights in the clinical record since [DATE] revealed weights of 121.2 pounds on [DATE], 119 pounds on [DATE], and 119 pounds on [DATE]. An additional weight obtained on [DATE], after surveyor inquiry, reflected a further weight loss to 115.6 pounds. A review R#14's physician's orders revealed an order since [DATE] for weights to be obtained monthly. However, a further review of the clinical record revealed no weights were obtained for [DATE] as ordered and care planned. Cross reference to F692 3. Resident #12 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had a care plan since [DATE] for at risk for weight loss; history of dysphagia, requires assist with meals, on pureed diet, double portions for lunch and supper with the following interventions: double portions with lunch and supper, supplements as ordered and weights per facility protocol. The care plan was revised on [DATE] to reflect an actual weight loss and as having a history of protein malnutrition with interventions for diet with double portions as ordered, supplement as ordered, and weights as indicated. The resident had a physician's order since [DATE] for regular concentrated sweets diet, pureed texture with double portions for lunch and supper. However, during observations of the lunch meal on [DATE] at 12:26 p.m., and [DATE] at 1:00 p.m., the resident was not served double portions. Observation of the diet card that was on the resident's lunch tray revealed the portion size was specified as double portion. Refer to F692. 4. Resident #13 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had a care plan since [DATE] for at risk for weight loss with an intervention to weigh per physician orders or facility protocol. Review of the weight record for R#13 revealed the following: The resident had a 16.2% weight loss in one month from 101 pounds on [DATE] to 84.6 pounds on [DATE], a 17.9% weight loss in three months from 103 pounds on [DATE] to 84.6 pounds on [DATE], and a 16.1% weight loss from 103 pounds on [DATE] to 86.4 pounds on [DATE]. The Registered Dietician evaluated the resident on [DATE] and noted a weight loss of 16.4 pounds x 30 days (16.2% loss) and a weight loss of 18.4 pounds x 90 days (17.9% severe weight loss). She further noted a BMI of 14.5 (underweight). On [DATE] the RD evaluated the resident and noted weights for [DATE]as 86.2 pounds and [DATE] as 84.6 pounds with a BMI of 14.8 (underweight) with a 16.3% weight loss in 180 days. Per review of the Weight record, there was no evidence the weights were checked every week consistently despite the resident having a significant weight loss. The resident's weights were only obtained once in [DATE], twice in [DATE], once in [DATE], there were no weights in September and twice in [DATE]. Refer to F692. 5. Resident #5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was also admitted with bilateral deep tissue injuries (DTI) to both heels that continued to deteriorate requiring bilateral below the knee amputations (BKA) due to severe peripheral artery disease on [DATE]. On [DATE] the resident returned from the hospital with discharge instructions for wound care of amputation sites. However, there were no specific wound care instructions/orders and there was no evidence staff called the physician to clarify the wound care instructions until [DATE] after a follow up appointment with the surgeon on that day. The resident had a [DATE] care plan for surgical wound to bilateral legs status post [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] a physician's order was obtained to clean the left and right BKA sites with wound cleanser, apply [MEDICATION(S)] Ag Advantage and cover with dry dressing every other day. However, review of the [DATE] and [DATE] Treatment Administration Record (TAR) revealed there was no documentation treatment had been completed to the bilateral BKA's from [DATE] until [DATE] when the order was changed to clean the left and right below knee amputation sites with wound cleanser, apply Calcium Alginate AG and cover with dry dressing every other day. Review of the [DATE] TAR indicated the wound care was only completed five of 14 scheduled times. Refer to F684.

Based on record review, review of the Job Summary's for Nursing Home Administrator and Director of Nursing, and staff interviews, facility administration failed to effectively oversee the facility's nutrition system for residents receiving nutrition and hydration via non-oral and oral routes. On [DATE] a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) LL were informed of the Immediate Jeopardy (IJ) on [DATE] at 1:55 p.m. The noncompliance related to the first IJ was identified to have existed on [DATE]. The noncompliance related to the second IJ was identified to have existed on [DATE]. 1.) The first IJ is outlined as follows: Resident (R) #5 was admitted to the facility on [DATE] and required bilateral below the knee amputations (BKA's) due to severe peripheral artery disease (PAD) with occlusion on [DATE]. Upon return from hospitalization status post [MEDICAL RECORD OR PHYSICIAN ORDER] . R#5 was diagnosed on [DATE] at the hospital emergency room with a wound infection to the left BKA. R#5 underwent a revision to the left BKA on [DATE] and returned to the facility the same day. The facility again failed to clarify/obtain treatment orders on return from the hospital on [DATE]. There was no evidence of wound care being provided from [DATE] through [DATE]. In addition, the left BKA revision site was not accurately assessed by nursing staff on hospital return and a scheduled follow up appointment with the surgeon was not kept on [DATE]. The resident expired at the facility on [DATE]. The death certificate listed diabetes as the cause of death. 2.) The second IJ is outlined as follows: R#10, a [AGE] year-old resident with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Weights for R#10 trended down from 89 pounds on [DATE] to 83 pounds on [DATE], despite repeated increases of bolus g-tube nutritional supplement formula. The last increase was on [DATE]. There was no evidence that a documented plan from the Nurse Practitioner (NP) on [DATE] for a follow-up weight and Registered Dietician (RD) evaluation in two weeks was followed. However, a nutritional assessment was completed on [DATE] when the RD acknowledged that there was no [DATE] weight but indicated that the ordered nutritional supplement formula and water flushes met the resident's needs. Despite R#10's downtrend of weight, even with incremental increases in the nutritional supplement formula, no weight was obtained, to continue to monitor his progress, after [DATE], until [DATE]. On [DATE], a weight of 75.8 pounds was documented. There is no acknowledgement of the [DATE] weight of 75.8 pounds, which reflects actual, further significant weight loss. On [DATE] there was a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . However, no weights were obtained between [DATE] through [DATE], except when surveyor inquired on [DATE]. In addition, during an observation on [DATE] at 3:30 p.m., Licensed Practical Nurse (LPN) BB administered the incorrect amount of bolus g-tube formula to R#10 (administered 237 milliliters instead of 320 milliliters). Review of the Medication Administration Records (MAR) revealed no evidence that the physician ordered bolus nutritional supplement formula was administered as scheduled for 28 times in [DATE] and 27 times in [DATE]. There was also repeated, systemic failure to implement pertinent interventions to address weight loss and/or nutrition and hydration risk for five residents (R#6, R#8, R#12, R#13, and R#14). R#6 and R#8 received nutrition and hydration via gastrostomy tube. R#12, R#13 and R#14 received nutrition and hydration orally. There was also evidence of a systemic failure related to dietary services to ensure that there was an adequate number of dietary staff and that the dietary staff had the skill set to carry out the functions of the food and nutrition services in the facility. Dietary staff failed to follow menus and individualized food plans for correct portion size to ensure residents' nutritional needs were met. R#12 and R#14 were to receive double portions of food because they were nutritionally compromised. By not receiving double portions, they were put at risk for further weight loss and/or poor nutritional status. The Immediate Jeopardies were related to the facility's noncompliance with the requirements at 42 C.F.R. 483.21(b)(1) Develop/Implement Comprehensive Care Plan (F656, Scope/Severity: K); 42 C.F.R. 483.21(b) Comprehensive Care Plans (F657, Scope/Severity: K); 42 C.F.R. 483.25 Quality of Care (F684, Scope/Severity: J); 42 C.F.R. 483.25(g)(1)(2) Nutrition/Hydration Status and Maintenance (F692, Scope/Severity: K); 42 C.F.R. 483.60(a)(3) Sufficient Dietary Support Personnel (F802, Scope/Severity: K); 42 C.F.R. 483.60(c)(,d+[DATE]), Menus and Nutritional Adequacy (F803, Scope/Severity: K); 42 C.F.R. 483.70 Administration (F835, Scope/Severity: K); 42 C.F.R. 483.70(d) Governing body (F837, Scope/Severity: K); 42 C.F.R. 483.75(g)(2) QAPI/QAA Improvement Activities (F867, Scope/Severity: K). Additionally. Substandard Quality of Care was identified with the requirements at 42 C.F.R. 483.25 Quality of Care (F684, Scope/Severity: J); and 42 C.F.R. 483.25(g)(1)(2), Nutrition/Hydration Status and Maintenance (F692, Scope/Severity: K). At the time of exit on [DATE], the IJ remained ongoing. Findings include The facility had a Job Summary for the Licensed Nursing Home Administrator. The job summary included that the primary purpose of the Nursing Home Administrator position was to oversee the day-to-day operation of the facility and to review organizational performance. The job duties included to oversee that nursing services, social service programs, activity programs, food service programs and medical services were planned, implemented, and evaluated to meet resident needs to maximize resident quality of life and quality of care. The facility had a Job Summary for the Director of Nursing (DON). The job summary included that the primary purpose of the DON position was to plan, organize, develop, and direct the overall operation of the Nursing Department to ensure that the highest degree of quality care is maintained at all times. The job duties and responsibilities included administrative functions, committee meeting functions, personnel functions, nursing care functions, safety and sanitation, equipment and supply functions, care plan and assessment functions, budgeting and planning functions, resident rights responsibilities, working conditions, and staff development functions. A review of the list of management changes at the facility revealed that the facility had four different DON's since [DATE], three of them being since [DATE]. The facility DON's with their dates of service were as follows: DON JJ ([DATE]-[DATE]), DON II ([DATE]-[DATE]), and DON LL since [DATE]. Regional Nurse Consultant (RNC) KK served as interim DON between DON's II and LL. The Administrator began at the facility on [DATE]. Facility Administration, including the Administrator and prior DON's, failed to consistently and effectively oversee areas of the facility that were included in their job descriptions. 1. Administration failed to ensure that nutritional interventions were implemented as care planned for four residents (R#6, R#12, R#13, and R#14). Cross refer to F656. 2. Administration failed to ensure that care plans were revised to address significant weight loss for two residents (R#6 and R#8). Cross refer to F657. 3. Administration failed to ensure that significant weight loss was addressed timely for three residents (R#6, R#10, and R#13), failed to ensure RD recommendations were acted on for five residents (R#6, R#8, R#12, R#13, and R#14), failed to ensure one resident received adequate hydration (R#6), failed to ensure that one resident received the physician ordered amount of nutritional supplement formula via gastrostomy tube (R#10), and failed to ensure that two residents (R#12 and R#14) received the correct food portions at meals. Cross refer to F692. 4. Administration failed to ensure there was adequate dietary support personnel to prepare, cook and serve meals to 70 residents. Cross refer to F802. 5. Administration failed to ensure dietary staff were serving the correct portion sizes of pureed food and regular diets according to the menu and failed to serve double portions to two residents (R#12 and R#14) who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] Cross refer to F803. 6. Administration failed to ensures concerns were identified and QAPI plans implemented related to leadership and the weight management process including not following Registered Dietician (RD) recommendations, significant weight loss not addressed timely, weights not obtained routinely, water flushes and nutritional supplements not administered via gastrostomy tubes as ordered, food portions not served as planned and/or ordered, inadequate dietary staff, and nutrition care plans not revised and/or implemented. Cross refer to F867. During an interview on [DATE] at 10:25 a.m. DON LL (as of [DATE]) stated that the facility's weight system was broken; the facility needed systems and education. During an interview on [DATE] at 10:45 a.m. the Administrator stated he was aware weights were not being obtained and addressed it at the [DATE] QA (Quality Assurance) meeting. However, he was not aware resident weights were not obtained the following month in [DATE]. He stated that he found out RD recommendations were not being acted on and had an additional RD and Certified Dietary Manager (CDM) coming in to assist in getting caught up because the RD that was usually at the facility had been out. The Administrator stated that he started at the facility on [DATE] and had a DON who was out more than she was at the facility and then he had an interim DON after that toward the end of [DATE] (before DON LL started on [DATE]).

Based on observation, staff interviews and review of the facility policy titled, Quality Assurance Performance Improvement Management the facility's Governing Body failed to ensure the QAPI program was effective in identifying, developing, and implementing corrective actions to address concerns with nutrition and weight management; and failed to oversee dietary staffing to ensure adequate dietary staff to prepare, cook and serve meals. The census was 70. On [DATE] a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) LL were informed of the Immediate Jeopardy (IJ) on [DATE] at 1:55 p.m. The noncompliance related to the first IJ was identified to have existed on [DATE]. The noncompliance related to the second IJ was identified to have existed on [DATE]. 1.) The first IJ is outlined as follows: Resident (R) #5 was admitted to the facility on [DATE] and required bilateral below the knee amputations (BKA's) due to severe peripheral artery disease (PAD) with occlusion on [DATE]. Upon return from hospitalization status post [MEDICAL RECORD OR PHYSICIAN ORDER] . R#5 was diagnosed on [DATE] at the hospital emergency room with a wound infection to the left BKA. R#5 underwent a revision to the left BKA on [DATE] and returned to the facility the same day. The facility again failed to clarify/obtain treatment orders on return from the hospital on [DATE]. There was no evidence of wound care being provided from [DATE] through [DATE]. In addition, the left BKA revision site was not accurately assessed by nursing staff on hospital return and a scheduled follow up appointment with the surgeon was not kept on [DATE]. The resident expired at the facility on [DATE]. The death certificate listed diabetes as the cause of death. 2.) The second IJ is outlined as follows: R#10, a [AGE] year-old resident with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Weights for R#10 trended down from 89 pounds on [DATE] to 83 pounds on [DATE], despite repeated increases of bolus g-tube nutritional supplement formula. The last increase was on [DATE]. There was no evidence that a documented plan from the Nurse Practitioner (NP) on [DATE] for a follow-up weight and Registered Dietician (RD) evaluation in two weeks was followed. However, a nutritional assessment was completed on [DATE] when the RD acknowledged that there was no [DATE] weight but indicated that the ordered nutritional supplement formula and water flushes met the resident's needs. Despite R#10's downtrend of weight, even with incremental increases in the nutritional supplement formula, no weight was obtained, to continue to monitor his progress, after [DATE], until [DATE]. On [DATE], a weight of 75.8 pounds was documented. There is no acknowledgement of the [DATE] weight of 75.8 pounds, which reflects actual, further significant weight loss. On [DATE] there was a physician's order for biweekly weights (between ,d+[DATE] and [DATE]), and if weight decreased, resume continuous nutritional supplement feedings via g-tube. However, no weights were obtained between [DATE] through [DATE], except when surveyor inquired on [DATE]. In addition, during an observation on [DATE] at 3:30 p.m., Licensed Practical Nurse (LPN) BB administered the incorrect amount of bolus g-tube formula to R#10 (administered 237 milliliters instead of 320 milliliters). Review of the Medication Administration Records (MAR) revealed no evidence that the physician ordered bolus nutritional supplement formula was administered as scheduled for 28 times in [DATE] and 27 times in [DATE]. There was also repeated, systemic failure to implement pertinent interventions to address weight loss and/or nutrition and hydration risk for five residents (R#6, R#8, R#12, R#13, and R#14). R#6 and R#8 received nutrition and hydration via gastrostomy tube. R#12, R#13 and R#14 received nutrition and hydration orally. There was also evidence of a systemic failure related to dietary services to ensure that there was an adequate number of dietary staff and that the dietary staff had the skill set to carry out the functions of the food and nutrition services in the facility. Dietary staff failed to follow menus and individualized food plans for correct portion size to ensure residents' nutritional needs were met. R#12 and R#14 were to receive double portions of food because they were nutritionally compromised. By not receiving double portions, they were put at risk for further weight loss and/or poor nutritional status. The Immediate Jeopardies were related to the facility's noncompliance with the requirements at 42 C.F.R. 483.21(b)(1) Develop/Implement Comprehensive Care Plan (F656, Scope/Severity: K); 42 C.F.R. 483.21(b) Comprehensive Care Plans (F657, Scope/Severity: K); 42 C.F.R. 483.25 Quality of Care (F684, Scope/Severity: J); 42 C.F.R. 483.25(g)(1)(2) Nutrition/Hydration Status and Maintenance (F692, Scope/Severity: K); 42 C.F.R. 483.60(a)(3) Sufficient Dietary Support Personnel (F802, Scope/Severity: K); 42 C.F.R. 483.60(c)(,d+[DATE]), Menus and Nutritional Adequacy (F803, Scope/Severity: K); 42 C.F.R. 483.70 Administration (F835, Scope/Severity: K); 42 C.F.R. 483.70(d) Governing body (F837, Scope/Severity: K); 42 C.F.R. 483.75(g)(2) QAPI/QAA Improvement Activities (F867, Scope/Severity: K). Additionally. Substandard Quality of Care was identified with the requirements at 42 C.F.R. 483.25 Quality of Care (F684, Scope/Severity: J); and 42 C.F.R. 483.25(g)(1)(2), Nutrition/Hydration Status and Maintenance (F692, Scope/Severity: K). At the time of exit on [DATE], the IJ remained ongoing. Findings include: A review of the facility policy titled Quality Assurance Performance Improvement Management dated [DATE] documented, in part, the following: Authority: The Governing Body of this facility shall be ultimately responsible for the QAPI Performance Improvement Program. The Administrator represents the Governing Body of this facility. Review of the QAPI Committee Meeting Agenda/ Minutes revealed meetings held on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] with the Administrator present for all meetings except the [DATE] meeting. No other members of the governing body were present for any of the above meetings. During the [DATE] meeting, weights were discussed. However, there was no discussion regarding dietary staffing. During interview and observation of the lunch meal service on [DATE] at 12:05 p.m., there were two dietary staff observed working in the kitchen. Cook NN stated they have been working with two dietary staff on the day shift for the past three months. She stated three people would be better because they have to prepare, cook, serve and clean. She stated they also have been without a Dietary Manager for three months. She stated corporate told them two was enough to work in the kitchen. She stated since they have been without a Dietary Manager, she must place the food orders, do the schedule, print tray cards and cook. Registered Dietician MM stated on [DATE] at 12:15 p.m. that ideally, they need three staff in the kitchen, especially since Cook NN has been acting as the Dietary Manager and having to order food. During an interview with the Administrator on [DATE] at 3:10 p.m. and 3:35 p.m., he stated when he started employment at the facility in [DATE], the kitchen was already staffed with two people. He stated the kitchen staff have not complained to him about only having two people in kitchen and did not know who from corporate told them they could only have two staff in the kitchen. During an interview with Dietary Aide RR on [DATE] at 1:00 p.m., she stated corporate told them about three months ago that two people were enough to work in the kitchen on day shift. She stated day shift has to do breakfast and lunch and wash dishes and that it was just too much. At times they don't have time to make dessert for lunch or supper. She stated she has talked to the Administrator about it several times and he tells her just work with me, I'm trying to get people in. Refer to F802.

Based on record review, staff interviews, and review facility policy titled Quality Assurance Performance Improvement (QAPI) Management, the facility failed to identify concerns and effectively implement QAPI plans related to leadership and the weight management process including not following Registered Dietician (RD) recommendations, significant weight loss not addressed timely, weights not obtained routinely, water flushes and nutritional supplements not administered via gastrostomy tubes as ordered, food portions not served as planned and/or ordered, inadequate dietary staff, and nutrition care plans not revised and/or implemented. The facility census was 70 residents. On [DATE] a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) LL were informed of the Immediate Jeopardy (IJ) on [DATE] at 1:55 p.m. The noncompliance related to the first IJ was identified to have existed on [DATE]. The noncompliance related to the second IJ was identified to have existed on [DATE]. 1.) The first IJ is outlined as follows: Resident (R) #5 was admitted to the facility on [DATE] and required bilateral below the knee amputations (BKA's) due to severe peripheral artery disease (PAD) with occlusion on [DATE]. Upon return from hospitalization status post [MEDICAL RECORD OR PHYSICIAN ORDER] . R#5 was diagnosed on [DATE] at the hospital emergency room with a wound infection to the left BKA. R#5 underwent a revision to the left BKA on [DATE] and returned to the facility the same day. The facility again failed to clarify/obtain treatment orders on return from the hospital on [DATE]. There was no evidence of wound care being provided from [DATE] through [DATE]. In addition, the left BKA revision site was not accurately assessed by nursing staff on hospital return and a scheduled follow up appointment with the surgeon was not kept on [DATE]. The resident expired at the facility on [DATE]. The death certificate listed diabetes as the cause of death. 2.) The second IJ is outlined as follows: R#10, a [AGE] year-old resident with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Weights for R#10 trended down from 89 pounds on [DATE] to 83 pounds on [DATE], despite repeated increases of bolus g-tube nutritional supplement formula. The last increase was on [DATE]. There was no evidence that a documented plan from the Nurse Practitioner (NP) on [DATE] for a follow-up weight and Registered Dietician (RD) evaluation in two weeks was followed. However, a nutritional assessment was completed on [DATE] when the RD acknowledged that there was no [DATE] weight but indicated that the ordered nutritional supplement formula and water flushes met the resident's needs. Despite R#10's downtrend of weight, even with incremental increases in the nutritional supplement formula, no weight was obtained, to continue to monitor his progress, after [DATE], until [DATE]. On [DATE], a weight of 75.8 pounds was documented. There is no acknowledgement of the [DATE] weight of 75.8 pounds, which reflects actual, further significant weight loss. On [DATE] there was a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . However, no weights were obtained between [DATE] through [DATE], except when surveyor inquired on [DATE]. In addition, during an observation on [DATE] at 3:30 p.m., Licensed Practical Nurse (LPN) BB administered the incorrect amount of bolus g-tube formula to R#10 (administered 237 milliliters instead of 320 milliliters). Review of the Medication Administration Records (MAR) revealed no evidence that the physician ordered bolus nutritional supplement formula was administered as scheduled for 28 times in [DATE] and 27 times in [DATE]. There was also repeated, systemic failure to implement pertinent interventions to address weight loss and/or nutrition and hydration risk for five residents (R#6, R#8, R#12, R#13, and R#14). R#6 and R#8 received nutrition and hydration via gastrostomy tube. R#12, R#13 and R#14 received nutrition and hydration orally. There was also evidence of a systemic failure related to dietary services to ensure that there was an adequate number of dietary staff and that the dietary staff had the skill set to carry out the functions of the food and nutrition services in the facility. Dietary staff failed to follow menus and individualized food plans for correct portion size to ensure residents' nutritional needs were met. R#12 and R#14 were to receive double portions of food because they were nutritionally compromised. By not receiving double portions, they were put at risk for further weight loss and/or poor nutritional status. The Immediate Jeopardies were related to the facility's noncompliance with the requirements at 42 C.F.R. 483.21(b)(1) Develop/Implement Comprehensive Care Plan (F656, Scope/Severity: K); 42 C.F.R. 483.21(b) Comprehensive Care Plans (F657, Scope/Severity: K); 42 C.F.R. 483.25 Quality of Care (F684, Scope/Severity: J); 42 C.F.R. 483.25(g)(1)(2) Nutrition/Hydration Status and Maintenance (F692, Scope/Severity: K); 42 C.F.R. 483.60(a)(3) Sufficient Dietary Support Personnel (F802, Scope/Severity: K); 42 C.F.R. 483.60(c)(,d+[DATE]), Menus and Nutritional Adequacy (F803, Scope/Severity: K); 42 C.F.R. 483.70 Administration (F835, Scope/Severity: K); 42 C.F.R. 483.70(d) Governing body (F837, Scope/Severity: K); 42 C.F.R. 483.75(g)(2) QAPI/QAA Improvement Activities (F867, Scope/Severity: K). Additionally. Substandard Quality of Care was identified with the requirements at 42 C.F.R. 483.25 Quality of Care (F684, Scope/Severity: J); and 42 C.F.R. 483.25(g)(1)(2), Nutrition/Hydration Status and Maintenance (F692, Scope/Severity: K). At the time of exit on [DATE], the IJ remained ongoing. Findings include: The facility had a Quality Assurance Performance Improvement Management policy, dated [DATE]. The policy's overview included that the Quality Assurance Performance Improvement (QAPI) program provided an opportunity for the facility to assess current practices and procedures in order to determine a plan for improvement in the quality of care. The purpose of the QAPI program was to develop, implement, and maintain an ongoing program designed to monitor and evaluate customer satisfaction and the quality of resident care, pursue methods to improve quality care and other facility services, and to resolve identified problems. The policy also included that the QAPI committee would meet at least monthly and more often as needed. A review of QAPI Committee Meeting Agenda/Minutes form sign-in section revealed that the following staff members were part of the committee: Administrator, Medical Director, Director of Nursing, Assistant Director of Nursing, Social Services Director, Activities Director, Minimum Data Set (MDS) Coordinator, Admissions Director, Dietary Manager, Housekeeping Supervisor, Maintenance Director, Unit Managers and Business Office Manager. Further review of the sign-in section of the QAPI committee meeting form, from previously held meetings, revealed that additional facility staff, including therapy, central supply, medical records and additional nursing staff also attended the meetings at times. The facility had held QAPI meetings on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. During an interview on [DATE] at 3:00 p.m. the Administrator confirmed that he oversees the QA committee meetings. He stated that the committee meets monthly, but that they had not had a meeting in [DATE] due to the presence of the surveyors. He stated that their most recent meeting was on [DATE]. During an interview on [DATE] at 10:45 a.m. the Administrator stated he was aware weights were not being obtained, and he had addressed it at the [DATE] QA meeting. However, he was not aware resident weights were not obtained the following month in [DATE]. He stated that he found out RD recommendations were not being acted on and had an additional RD and Certified Dietary Manager (CDM) coming in to assist in getting caught up because the RD that was usually at the facility had been out. A review of the [DATE] QAPI Committee Meeting Agenda/Minutes form revealed notes under the nursing section that documented all residents needed weights ASAP (as soon as possible) and that weekly weights were discussed on weight loss and residents with gastrostomy tubes. During an interview on [DATE] at 10:25 a.m. DON LL (as of [DATE]) stated that the facility's weight system was broken; the facility needed systems and education. Despite discussing the need for weights on all residents and weekly weights on residents with weight loss and gastrostomy tubes, the facility's QAPI process failed to follow up to ensure the weights were obtained as discussed. In addition, the facility's QAPI process failed to identify multiple additional nutrition system concerns for residents receiving nutrition and hydration via oral and non-oral routes including RD recommendations not acted on, significant weight loss not addressed timely, water flushes and nutritional supplements not administered via gastrostomy tubes as ordered, food portions not served as ordered, inadequate dietary staff, and nutrition care plans not revised and/or implemented for R#6, R#8, R#10, R#12, R#13, and R#14. Cross refer to F692.

Based on observation, interview, record review and review of facility policy titled Nutrition and Weight Management Standard, the facility failed to ensure that significant weight loss was addressed timely for three residents (R) (R#6, R#10, and R#13), failed to act on Registered Dietician (RD) recommendations for five residents (R#6, R#8, R#12, R#13, and R#14), failed to ensure one resident received adequate hydration (R#6), failed to ensure that one resident received the physician ordered amount of nutritional supplement formula via gastrostomy tube (R#10), and failed to ensure that two residents (R#12 and R#14) received the correct food portions at meals from a total sample of 17 residents. On [DATE] a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) LL were informed of the Immediate Jeopardy (IJ) on [DATE] at 1:55 p.m. The noncompliance related to the first IJ was identified to have existed on [DATE]. The noncompliance related to the second IJ was identified to have existed on [DATE]. 1.) The first IJ is outlined as follows: Resident (R) #5 was admitted to the facility on [DATE] and required bilateral below the knee amputations (BKA's) due to severe peripheral artery disease (PAD) with occlusion on [DATE]. Upon return from hospitalization status post [MEDICAL RECORD OR PHYSICIAN ORDER] . R#5 was diagnosed on [DATE] at the hospital emergency room with a wound infection to the left BKA. R#5 underwent a revision to the left BKA on [DATE] and returned to the facility the same day. The facility again failed to clarify/obtain treatment orders on return from the hospital on [DATE]. There was no evidence of wound care being provided from [DATE] through [DATE]. In addition, the left BKA revision site was not accurately assessed by nursing staff on hospital return and a scheduled follow up appointment with the surgeon was not kept on [DATE]. The resident expired at the facility on [DATE]. The death certificate listed diabetes as the cause of death. 2.) The second IJ is outlined as follows: R#10, a [AGE] year-old resident with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Weights for R#10 trended down from 89 pounds on [DATE] to 83 pounds on [DATE], despite repeated increases of bolus g-tube nutritional supplement formula. The last increase was on [DATE]. There was no evidence that a documented plan from the Nurse Practitioner (NP) on [DATE] for a follow-up weight and Registered Dietician (RD) evaluation in two weeks was followed. However, a nutritional assessment was completed on [DATE] when the RD acknowledged that there was no [DATE] weight but indicated that the ordered nutritional supplement formula and water flushes met the resident's needs. Despite R#10's downtrend of weight, even with incremental increases in the nutritional supplement formula, no weight was obtained, to continue to monitor his progress, after [DATE], until [DATE]. On [DATE], a weight of 75.8 pounds was documented. There is no acknowledgement of the [DATE] weight of 75.8 pounds, which reflects actual, further significant weight loss. On [DATE] there was a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . However, no weights were obtained between [DATE] through [DATE], except when surveyor inquired on [DATE]. In addition, during an observation on [DATE] at 3:30 p.m., Licensed Practical Nurse (LPN) BB administered the incorrect amount of bolus g-tube formula to R#10 (administered 237 milliliters instead of 320 milliliters). Review of the Medication Administration Records (MAR) revealed no evidence that the physician ordered bolus nutritional supplement formula was administered as scheduled for 28 times in [DATE] and 27 times in [DATE]. There was also repeated, systemic failure to implement pertinent interventions to address weight loss and/or nutrition and hydration risk for five residents (R#6, R#8, R#12, R#13, and R#14). R#6 and R#8 received nutrition and hydration via gastrostomy tube. R#12, R#13 and R#14 received nutrition and hydration orally. There was also evidence of a systemic failure related to dietary services to ensure that there was an adequate number of dietary staff and that the dietary staff had the skill set to carry out the functions of the food and nutrition services in the facility. Dietary staff failed to follow menus and individualized food plans for correct portion size to ensure residents' nutritional needs were met. R#12 and R#14 were to receive double portions of food because they were nutritionally compromised. By not receiving double portions, they were put at risk for further weight loss and/or poor nutritional status. The Immediate Jeopardies were related to the facility's noncompliance with the requirements at 42 C.F.R. 483.21(b)(1) Develop/Implement Comprehensive Care Plan (F656, Scope/Severity: K); 42 C.F.R. 483.21(b) Comprehensive Care Plans (F657, Scope/Severity: K); 42 C.F.R. 483.25 Quality of Care (F684, Scope/Severity: J); 42 C.F.R. 483.25(g)(1)(2) Nutrition/Hydration Status and Maintenance (F692, Scope/Severity: K); 42 C.F.R. 483.60(a)(3) Sufficient Dietary Support Personnel (F802, Scope/Severity: K); 42 C.F.R. 483.60(c)(,d+[DATE]), Menus and Nutritional Adequacy (F803, Scope/Severity: K); 42 C.F.R. 483.70 Administration (F835, Scope/Severity: K); 42 C.F.R. 483.70(d) Governing body (F837, Scope/Severity: K); 42 C.F.R. 483.75(g)(2) QAPI/QAA Improvement Activities (F867, Scope/Severity: K). Additionally. Substandard Quality of Care was identified with the requirements at 42 C.F.R. 483.25 Quality of Care (F684, Scope/Severity: J); and 42 C.F.R. 483.25(g)(1)(2), Nutrition/Hydration Status and Maintenance (F692, Scope/Severity: K). At the time of exit on [DATE], the IJ remained ongoing. Findings include: 1. Review of the clinical record revealed R#10 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He received all nutrition and hydration via a gastrostomy tube. The NP also included a baseline of failure to thrive in her notes. A review of the clinical record, including weights, NP notes and orders revealed orders since [DATE] of incrementally increasing R#10's gastrostomy tube feedings to address weight loss and to promote tolerance of the increase in nutrition supplement volume. On [DATE], weight was 89 pounds. On [DATE], weight was 88 pounds. On [DATE] the nutritional supplement formula was changed from continuous to a bolus of 200 milliliters (ml) of 2cal (nutritional formula) four times per day with 100 ml water flush. On [DATE], weight was 86.6 pounds. On [DATE] the 2cal nutritional supplement formula was increased to 240 ml with 100 ml water flush four times per day. On [DATE] weight was 83 pounds. On [DATE] the 2cal formula was increased to 240 ml five times per day. On [DATE], weight was 83 pounds. On [DATE] an RD assessment documented that at 83 pounds, the Body Mass Index (BMI) was 16.3 (underweight) and that R#10's weights were continuing to trend down. On [DATE] the 2cal formula was increased to 320 ml five times a day. On [DATE] the NP noted the 83-pound weight (from August) and recapped the 2cal formula increase to 320cc five times per day (from [DATE]). The Plan section of the note included to follow-up weight and RD evaluation in two weeks. The NP note also includes discussed with nursing. However, there is no evidence the plan to obtain a follow-up weight and RD evaluation was acted on and/or carried out. A review of the clinical record revealed no further nutritional assessment of R#10 until [DATE]. On [DATE], the RD documented that there were no [DATE] weights and again documented the 83-pound weight from [DATE] and the BMI of 16.3 (underweight). Her nutritional calculations determine that the resident's ordered feedings and flushes meet his needs. Despite R#10's weight loss and the NP increasing the gastrostomy tube feedings (last on [DATE]), no weights were obtained to continue to monitor his progress after [DATE], until [DATE]. On [DATE] the weight was documented as 75.8 pounds, a further decline of 7.6 pounds from 83 pounds (on [DATE]), which was a 9.1% weight loss in two months. On [DATE] the NP documented conflicting information in her notes. Her note incorrectly included that the resident gained 4 pounds in 6 weeks and had a current weight of 102 pounds. However, her note also included that no weight was documented since the change of the formula schedule (which was on [DATE]). The plan section of the note included to weigh R#10 biweekly, discussed with the DON, and continue bolus formula feedings five times per day, and if weight declines, change R#10 back to a continuous rate (instead of bolus). There is no documented acknowledgement of the 75.8-pound weight obtained on [DATE] that already reflected a further significant weight loss. During an interview on [DATE] at 3:40 p.m. DON LL stated that she was not aware of the plan to weigh R#10 biweekly. During an interview on [DATE] at 1:20 p.m., RD MM stated that she was at the facility on [DATE] and reviewed weights and discussed with the DON. RD MM stated that the weight of 75.8 pounds, dated [DATE] in the electronic clinical record, was not in the system (when she reviewed weights on [DATE]). She stated she was unsure if someone added the weight in later and back dated it. RD MM provided the [DATE] computer generated weight report she had received, and the weight report did not include the [DATE] weight of 75.8 pounds for R#10. However, RD MM stated that she did discuss R#10 with the NP that week. After the NP Note on [DATE] with conflicting information, an order was entered into R#10's electronic clinical record on [DATE], by the NP as follows: patient scheduled for biweekly weights. Needs weight ASAP (as soon as possible), if weight has decreased, resume continuous feedings. However, further review of the clinical record revealed no weights were obtained ASAP, or after [DATE], until after surveyor inquiry on [DATE]. During an observation on [DATE] at 5:15 p.m. LPN BB weighed R#10 and obtained a weight of 76.6 pounds. After the weight obtained on [DATE], no further weights were obtained and documented during the [DATE] through [DATE] scheduled time frame of the biweekly order. There was no further assessment of R#10's nutritional status after the RD assessment on [DATE], even after the further decline in weight to 75.8 pounds on [DATE], until after surveyor inquiry on [DATE]. On [DATE] the RD assessed R#10 and documented the [DATE] weight of 75.8 pounds, a BMI of 14.8 (underweight), a 7.6-pound (9.1%) loss in 90 days, and a 12.2 pound (13.90%) loss in 180 days (severe weight loss). The RD Note included a new recommendation for R#10 to receive, via gastrostomy tube, a continuous rate 2cal nutritional supplement formula at 40 ml per hour for 22 hours and 150 ml of water flushes every 4 hours and weekly weights until stable. In addition to R#10's weight loss not being thoroughly monitored and addressed after [DATE], R#10 was observed to receive an insufficient amount of nutritional supplement formula. R#10 had the order since [DATE] for 320 ml of 2cal nutritional supplement formula to be administered five times a day with 100 ml of water four times per day. During an interview on [DATE] at 3:30 p.m. with R#10's nurse, LPN BB incorrectly stated that R#10 received five cartons of 2cal per day. Observation of a carton of 2cal revealed it is only 237 ml. After the interview with LPN BB on [DATE] at 3:30 p.m., a new order was entered into R#10's electronic record by LPN BB, timed at 4:00 p.m., that documented for R#10 to get 327 ml (was previously 320 ml) of 2cal formula five times per day with 100 ml water flush. During an observation on [DATE] from 4:08 p.m. to 4:28 p.m., surveyor observed LPN BB administer one carton of 2cal (237ml) with 100 ml of water, which was the incorrect amount of 2cal based on the current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition to R#10's weight loss not being thoroughly monitored and addressed after [DATE] and R#10 being observed receiving the incorrect amount of nutritional supplement formula via gastrostomy tube, there was incomplete documentation of the 2cal nutritional supplement formula being administered during the time frame of significant weight loss. Review of the clinical record revealed #10's weights showed a decrease in weight from 83 pounds (on [DATE]) to 75.8 pounds (on [DATE]), despite an increase in 2cal nutritional supplement formula on [DATE]. A review of the [DATE] and [DATE] Medication Administration Records (MAR's) revealed multiple blank entries that did not document that the ordered feedings were administered as scheduled by licensed nursing staff. For [DATE], after the last increase in the 2cal nutritional supplement formula on [DATE], 28 of the 93 times the supplement was scheduled to be administered, were blank. For [DATE] of the 150 times the supplement was scheduled to be administered were blank. During an interview on [DATE] at 3:00 p.m. R#10's weight loss from 83 pounds to 75.8 pounds was discussed with his physician. When the surveyor asked if there would be a reason R#10's weight wound decrease to 75.8 pounds even though his nutritional supplement formula was increased, the physician stated he did not know; he was not aware of anything new going on with R#10 and that R#10 was dependent (on staff) for nutrition and hydration. He further stated that a 9 % weight loss needed to be addressed and he would expect the facility to carry out the NP's orders for weights. 2. Resident #6 was admitted to the facility on [DATE]. A review of NP Notes revealed that R#6 was transferred to the facility for [CONDITION(S)] downsizing and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the clinical record revealed that R#6 was dependent on nursing staff for nutrition and hydration via her gastrostomy tube. R#6 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . In further review of the clinical record, including physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Therefore, both bolus water flush orders (120 ml every four hours and 150 ml every four hours) would have been active at the same time, as of [DATE]. However, in reviewing the [DATE] MAR, the [DATE] water flush order (for 150 ml every four hours) was only initialed as being administered on [DATE] and [DATE]. After that the order is not initialed, by licensed nursing staff, on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . After [DATE], the 150 ml every four hours water flush order does not appear on any more MAR's and the 120 ml water flush order stopped after [DATE]. On [DATE], the 120 ml every four hours bolus water flush order (ordered on [DATE]) was discontinued by the NP. A review of the order revealed an administrative note on the discontinued order that documented that the flush was discontinued and increased to 150 ml. However, no order for 150 ml of water was entered into R#6's electronic clinical record after [DATE], until after surveyor inquiry on [DATE], at which time, the [DATE] 150cc flush order was revised by licensed nursing staff and reappeared on the [DATE] MAR. Even though there was no evidence of a 150 ml every four hours water flush order being written and implemented after the 120 ml every four hours water flush order was discontinued on [DATE], the RD calculated it into determining that R#6's fluid needs were met in the [DATE] and [DATE] assessments. During an interview on [DATE] at 1:20 p.m. the RD stated that she pulls the order summaries report and looks at that for current orders. If there is no water flush order, she will note that and recommend one. She stated she does not know why it would not be on the MARS, she does not look at them, but she would have noted no flush order if the order summary report did not include one. In absence of a bolus water flush order (after [DATE] until surveyor inquiry on [DATE]), R#6 did have a medication flush order of 30 ml of water before and after medication and 5 ml of water between medications. A review of a [DATE] email from the RD to the DON, revealed that based on information provided by the DON and the current orders in the clinical record, R#6 would receive 485 ml of water from her current medications plus 751 ml of water from her current enteral nutrition order for a total of 1236 ml of water. Her current fluid needs range was 1400- 1750 ml of water therefore the medication flush order and free water (from the enteral nutrition order) would meet 88% of her fluid needs. The RD's response also included that she would aim for ,d+[DATE] % of fluid needs met. During an interview on [DATE] at 3:00 p.m. when R#6's physician was questioned if 88% of fluids needs being met was adequate, he responded that he personally would prefer it to be right at 100%, but he did not know of any harm it caused R#6. He stated however, over a period of time it could lead to dehydration. In addition to there being no evidence of a bolus water flush being administered after [DATE] until surveyor inquiry on [DATE], R#6 experienced a significant weight loss and possible weight discrepancy that were not addressed timely. During an interview on [DATE] at 3:40 p.m. when questioned about the facility's process for obtaining and responding to RD recommendations, the DON stated that the RD does a review, goes home, and completes a report, faxes it back to the facility, the recommendations are put in the physician's folder, and the recommendations are carried out if he or the NP agrees with to them. During an interview on [DATE] at 4:40 p.m. Unit Manager AA stated that after the RD comes in, she types of recommendations and sends them to the facility. Then, the NP reviews to see if she agrees with the recommendations. Unit Manager AA stated that the RD recommendations are written up on individual forms for each resident. If the NP agrees with them, the nurses write an order, print out a copy of the order (from the electronic clinical record), attach it to the recommendation form and put it in the DON's box. Unit Manager AA stated if the NP does not agree with the RD recommendation, the NP will write that on the form, and it goes in the DON's box and are filed in her office. Review of the clinical record for R#6 revealed an [DATE] Dietary Progress Note, from the RD, that identified a significant weight loss and possible incorrect weights on [DATE] and [DATE]. The dietary note documented an [DATE] weight of 161.3 pounds and an [DATE] weight of 185.2 pounds. With the 161.3-pound weight, that was a significant weight loss of 23.9 pounds in 90 days (12.9%). On [DATE], the RD recommended changing the gastrostomy tube nutritional supplement formula from Glucerna 1.2 at 45 ml per hour for 24 hours to Glucerna 1.5 at 45 ml per hour for 22 hours. There is no evidence that the [DATE] RD recommendation was acted on or the weight discrepancy addressed. On [DATE], in a Dietary Progress Note, the RD documented that there is no [DATE] weight and documented the same concerns from her [DATE] dietary note, and again recommended to change the gastrostomy tube nutritional supplement formula order to address the weight loss. However, there is no evidence the [DATE] RD recommendations were acted on until [DATE], after further weight loss. A weight obtained on [DATE] documented a further weight loss from 161.5 pounds on [DATE] to 154.6 pounds, a further loss of 6.9 pounds. During an interview on [DATE] at 3:00 p.m. R#6's physician confirmed that he would expect the RD recommendations to be acted on by nursing staff and provided to him or the NP to review. In addition to there being no evidence of a bolus water flush being administered after [DATE] until surveyor inquiry on [DATE], and R#6 experiencing a significant weight loss and possible weight discrepancy that were not addressed timely, R#6 was observed on [DATE] to not be receiving water at the correct rate via gastrostomy tube. Review of the clinical record revealed a bolus water flush of 150 ml every four hours was ordered since [DATE]. However, during an observation on [DATE] at 10:30 a.m. the water flush rate was set incorrectly on the gastrostomy pump at 40 ml per hour (which would be a total of 160 ml of water in four hours), not 150 ml every four hours as ordered. 3. Resident #8 was admitted to the facility on [DATE]. Review of the clinical record revealed R#8 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R#8 received all nutrition and hydration via gastrostomy tube. Review of the clinical record revealed R#8 had a weight fluctuation from April to [DATE]. The [DATE] weight was 148 pounds, the [DATE] weight was 165 pounds, and the [DATE] weight was 136.6 pounds. A Nurse's Note entry on [DATE] documented addressing the notable weight increase from 148 pounds on [DATE] to 165 pounds on [DATE], that the weight was taken twice to verify, and the resident would be weighed weekly for four weeks for accuracy. However, a review of the clinical records revealed no further weights after [DATE] until [DATE], at which time R#8's weight was 136.6 pounds. During an interview on [DATE] at 2:00 p.m. DON LL stated she was unable to locate any additional weights. The RD assessed R#8 on [DATE] and documented in a Dietary Progress Note that he triggered for a severe weight loss. His BMI at 136.6 pounds was 18.5 (normal). The notes included the weight fluctuation from 148 pounds on [DATE] to 165 pounds on [DATE] to 136.6 pounds on [DATE]. The RD recommended weekly weights for four weeks to determine accurate weight. After the RD recommendation on [DATE] for weekly weights for four weeks, weights of 136.6 pounds on [DATE] and 134.2 pounds on [DATE] were documented. However, there was no evidence additional weekly weights were obtained until [DATE], at which time R#8 remained at 134.2 pounds. The NP documented the weight loss on [DATE] and included a plan to continue the current gastrostomy tube feedings and water flushes and weights weekly. The RD assessed R#8 again on [DATE] and documented, in a Dietary Progress Note, the [DATE] weight of 134.2 pounds and calculated the BMI at 18.2 (now underweight) and 11.1% weight loss in 180 days. The RD recommended increasing the gastrostomy tube nutritional supplement formula from [MEDICATION(S)] 60 ml per hour to 70 ml per hour. Further review of the clinical record revealed that the RD recommendation to increase the [MEDICATION(S)] was ordered on [DATE]. On [DATE] an order was written by the NP for weekly weights to be obtained every Wednesday for weight loss, for 30 days (start date [DATE] through [DATE]). However, the weekly weight order was not carried out consistently. Clinical record review revealed weights were obtained on [DATE], [DATE] and [DATE] but not again until [DATE], [DATE] and [DATE]. Additional weights obtained on [DATE] (134), [DATE] (135.8), [DATE] (135.8), [DATE] (135.9), and [DATE] (135.9) indicated R#8 remained within an underweight BMI of 18.4 (based off the [DATE] weight of 135.9). During interviews on [DATE] at 10:25 a.m. and [DATE] at 2:00 p.m., DON LL, who was new to the facility as of [DATE], stated that restorative staff had been obtaining weights but had previously been pulled to the floor, so weights were not being obtained. She stated the system was broken and that the facility needed systems and education. 4. Resident #14 was admitted to the facility on [DATE]. Review of the clinical record revealed R#14 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R#14 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the clinical record revealed a [DATE] Dietary Progress Note by the RD that documented a [DATE] weight of 118.2 pounds, BMI 20.3 (normal), a weight loss of 15.8 pounds in 90 days (11.8%), 17.6 pound weight loss in 180 days (13.1% severe weight loss) and that weight continued to trend down for 30 days. On [DATE] weight was 122 pounds and on [DATE] weight was 118.2 pounds. The note included that R#14 was fed by nursing staff at mealtime. The RD recommended to increase the house nutritional supplement to 120 ml four times daily. However, further review of the clinical record revealed no evidence that the RD recommendation to increase the nutritional supplement for significant weight loss was addressed. R#14 had a diet order since [DATE] that included a no added salt, mechanical soft texture, double portion, ground meat diet. However, during an observation on [DATE] at 12:20 p.m. R#14 was observed with a lunch tray with single portions of beef stew, peppers and onions, cooked carrots, a roll and orange cream ice cream cup. During the observation, Certified Nursing Assistant (CNA) PP stated that she usually assists R#14 to eat and that he usually eats everything. During a subsequent interview on [DATE] at 12:05 p.m. CNA stated that R#14 ate 85% of his lunch meal on [DATE]. During an observation on [DATE] at 12:30 p.m. R#14 was again observed to have been served a lunch tray with only single portions of ground chicken, mixed vegetables, a biscuit, rice with gravy, apple crisp, and an orange cream ice cream cup. A review of monthly weights for R#14 in the clinical record since [DATE] revealed weights of 121.2 pounds on [DATE], 119 pounds on [DATE], and 119 pounds on [DATE]. An additional weight obtained on [DATE], after surveyor inquiry, reflected a further weight loss to 115.6 pounds. 5. Review of the clinical record revealed R#12 was admitted to the facility on [DATE] diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . However, during observations of the lunch meal on [DATE] at 12:26 p.m., and [DATE] at 1:00 p.m., R#12 was not served double portions. Observation of the diet card that was on the resident's lunch tray revealed the portion size was specified as double portion. During an observation of the meal service tray line on [DATE] at 12:25 p.m., the dietary staff was observed serving only regular portions on the resident's plate. Although the dietary aide called out a puree diet to staff plating the food, she did not include double portions. During an interview with Cook NN on [DATE] at 2:45 p.m., she was not aware the resident was supposed to have double portions. Review of the 2021 Weight Record for R#12 revealed the following weights in pounds: [DATE]- 143, [DATE]-133, [DATE]- 128, [DATE]- 114, [DATE]- 116, [DATE]- 111, [DATE]- 114.6, [DATE]- 115, [DATE]- 115, [DATE]- 116, [DATE]- 119, [DATE]- 116, [DATE]- 113.6, [DATE]- 108, [DATE]- 105.2, no [DATE] weights, [DATE]- 97.8, and [DATE]- 96. The resident was evaluated by the RD on [DATE], [DATE] and [DATE] who noted weight loss and a BMI of 21.9. There were no recommendations given and noted the resident was receiving double portions at lunch and supper and Med Pass 2.0 120 cubic centimeters (cc) three times a day. The NP noted on [DATE] the resident had a gastrointestinal bleed with significant weight loss. She noted unexplained weight loss was worsening and continue Med Pass 120 cc three times a day. She further noted the resident was receiving double portions. There was not a [DATE] RD evaluation for R#12. However, on [DATE] the RD noted a weight of 113.6 for [DATE] with a BMI of 21.5. She further calculated a 29.4-pound weight loss x 180 days (20.6% severe wt. loss) and recommended sugar free ice cream with lunch and supper. Per review of the Physician Recommendation Sheet for R#12 dated [DATE] with the recommendation for the ice cream, there was no evidence this was communicated to the physician as the recommendation was not acted on by noting either a reject or accept. Observation of the resident's lunch meals on [DATE] at 12:26 p.m., [DATE] at 1:00 p.m. and [DATE] at 1:00 p.m., R#12 was not served ice cream. The NP noted on [DATE] that the resident's weight was 108 pounds with chronic weight loss since [DATE]. She noted failure to thrive and worsening weight loss of unknown etiology. Med Pass 120 cc three times a day and ice cream with lunch and supper. On [DATE] the NP noted the resident's weight has not stabilized despite aggressive interventions. Review of the clinical record revealed no RD evaluation done in [DATE]. On [DATE] the NP noted a follow up evaluation of weight loss. Continue double portions. The [DATE] RD evaluation noted a weight of 105.2 on [DATE] with a BMI of 19.9. Indicated a loss of 10.8 pounds x 90 days (9.3%) and 22.8 pounds x 180 days (17.8% severe wt. loss). The RD recommended to increase House Supplement 120 cc to four times a day. However, review of the [DATE] MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The [DATE] MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The NP noted on [DATE] worsening weight loss, weight 97.8 pounds. She further noted the colonoscopy was completed [DATE] with no acute process found. No etiology for weight loss identified. In summary, despite R#12 having ongoing significant weight loss since February 2021, there was no evidence the facility responded or acted on the RD recommendations for Sugar Free ice cream on [DATE] and no evidence the facility responded or acted on the RD recommendation on [DATE] to increase the Med pass 120 cc to four times per day until [DATE]. The resident was also observed to be served regular portions of food instead of double portions. The resident was also not w[TRUNCATED]

Based on record review, review of the facility policy titled Skin Management Standard, and staff interviews, the facility failed to clarify and obtain treatment orders after one resident (R) (#5) had a bilateral below knee amputation (BKA), failed to provide treatment to the BKA, failed to accurately assess R#5's surgical wound with a drain and failed to ensure the resident went to a scheduled follow-up appointment with the surgeon from a sample of two residents with surgical wounds. On [DATE] a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) LL were informed of the Immediate Jeopardy (IJ) on [DATE] at 1:55 p.m. The noncompliance related to the first IJ was identified to have existed on [DATE]. The noncompliance related to the second IJ was identified to have existed on [DATE]. 1.) The first IJ is outlined as follows: Resident (R) #5 was admitted to the facility on [DATE] and required bilateral below the knee amputations (BKA's) due to severe peripheral artery disease (PAD) with occlusion on [DATE]. Upon return from hospitalization status post [MEDICAL RECORD OR PHYSICIAN ORDER] . R#5 was diagnosed on [DATE] at the hospital emergency room with a wound infection to the left BKA. R#5 underwent a revision to the left BKA on [DATE] and returned to the facility the same day. The facility again failed to clarify/obtain treatment orders on return from the hospital on [DATE]. There was no evidence of wound care being provided from [DATE] through [DATE]. In addition, the left BKA revision site was not accurately assessed by nursing staff on hospital return and a scheduled follow up appointment with the surgeon was not kept on [DATE]. The resident expired at the facility on [DATE]. The death certificate listed diabetes as the cause of death. 2.) The second IJ is outlined as follows: R#10, a [AGE] year-old resident with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Weights for R#10 trended down from 89 pounds on [DATE] to 83 pounds on [DATE], despite repeated increases of bolus g-tube nutritional supplement formula. The last increase was on [DATE]. There was no evidence that a documented plan from the Nurse Practitioner (NP) on [DATE] for a follow-up weight and Registered Dietician (RD) evaluation in two weeks was followed. However, a nutritional assessment was completed on [DATE] when the RD acknowledged that there was no [DATE] weight but indicated that the ordered nutritional supplement formula and water flushes met the resident's needs. Despite R#10's downtrend of weight, even with incremental increases in the nutritional supplement formula, no weight was obtained, to continue to monitor his progress, after [DATE], until [DATE]. On [DATE], a weight of 75.8 pounds was documented. There is no acknowledgement of the [DATE] weight of 75.8 pounds, which reflects actual, further significant weight loss. On [DATE] there was a physician's order for biweekly weights (between ,d+[DATE] and [DATE]), and if weight decreased, resume continuous nutritional supplement feedings via g-tube. However, no weights were obtained between [DATE] through [DATE], except when surveyor inquired on [DATE]. In addition, during an observation on [DATE] at 3:30 p.m., Licensed Practical Nurse (LPN) BB administered the incorrect amount of bolus g-tube formula to R#10 (administered 237 milliliters instead of 320 milliliters). Review of the Medication Administration Records (MAR) revealed no evidence that the physician ordered bolus nutritional supplement formula was administered as scheduled for 28 times in [DATE] and 27 times in [DATE]. There was also repeated, systemic failure to implement pertinent interventions to address weight loss and/or nutrition and hydration risk for five residents (R#6, R#8, R#12, R#13, and R#14). R#6 and R#8 received nutrition and hydration via gastrostomy tube. R#12, R#13 and R#14 received nutrition and hydration orally. There was also evidence of a systemic failure related to dietary services to ensure that there was an adequate number of dietary staff and that the dietary staff had the skill set to carry out the functions of the food and nutrition services in the facility. Dietary staff failed to follow menus and individualized food plans for correct portion size to ensure residents' nutritional needs were met. R#12 and R#14 were to receive double portions of food because they were nutritionally compromised. By not receiving double portions, they were put at risk for further weight loss and/or poor nutritional status. The Immediate Jeopardies were related to the facility's noncompliance with the requirements at 42 C.F.R. 483.21(b)(1) Develop/Implement Comprehensive Care Plan (F656, Scope/Severity: K); 42 C.F.R. 483.21(b) Comprehensive Care Plans (F657, Scope/Severity: K); 42 C.F.R. 483.25 Quality of Care (F684, Scope/Severity: J); 42 C.F.R. 483.25(g)(1)(2) Nutrition/Hydration Status and Maintenance (F692, Scope/Severity: K); 42 C.F.R. 483.60(a)(3) Sufficient Dietary Support Personnel (F802, Scope/Severity: K); 42 C.F.R. 483.60(c)(,d+[DATE]), Menus and Nutritional Adequacy (F803, Scope/Severity: K); 42 C.F.R. 483.70 Administration (F835, Scope/Severity: K); 42 C.F.R. 483.70(d) Governing body (F837, Scope/Severity: K); 42 C.F.R. 483.75(g)(2) QAPI/QAA Improvement Activities (F867, Scope/Severity: K). Additionally. Substandard Quality of Care was identified with the requirements at 42 C.F.R. 483.25 Quality of Care (F684, Scope/Severity: J); and 42 C.F.R. 483.25(g)(1)(2), Nutrition/Hydration Status and Maintenance (F692, Scope/Severity: K). At the time of exit on [DATE], the IJ remained ongoing. Findings include: Review of an undated policy titled Skin Management Standard noted a section titled Intact Surgical Wounds had the following protocol: 1. Clean with approved wound cleanser. 2. Apply dressing per physician order. 3. Change dressing as directed by physician. 4. Sites left uncovered per physician order should be monitored daily until healed. Review of the clinical record revealed R#5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was also admitted with bilateral deep tissue injuries (DTI) to both heels that continued to deteriorate requiring bilateral below the knee amputations (BKA) due to severe peripheral artery disease on [DATE]. On [DATE] the resident returned from the hospital with discharge instructions for wound care of amputation sites. However, there were no specific wound care instructions/orders and there was no evidence staff called the physician to clarify the wound care instructions until [DATE] after a follow up appointment with the surgeon on that day. The [DATE] Surgeon Progress Note documented the left BKA stump had central wound dehiscence and exposed bone with a revision of the left stump scheduled for [DATE]. On [DATE] a physician's order was obtained to clean the left and right BKA sites with wound cleanser, apply [MEDICATION(S)] Ag Advantage and cover with dry dressing every other day. However, review of the [DATE] and [DATE] Treatment Administration Record (TAR) revealed there was no documentation treatment had been completed to the bilateral BKA's from [DATE] to [DATE] when the order was changed to clean the left and right below knee amputation sites with wound cleanser, apply Calcium Alginate AG and cover with dry dressing every other day. Review of the [DATE] TAR indicated the wound care was only completed five of 14 scheduled times. The [DATE] Nursing Progress Note documented treatments completed, left stump noted to be macerated with thick greenish yellow discharge, bone protruding and had a foul odor. The note further indicated the nurse was sending the resident to the emergency room for evaluation per nursing judgment. Review of the [DATE] Emergency Department Note revealed an infection of the left BKA stump with purulent drainage from the BKA wound. The resident was treated with an intravenous antibiotic while in the emergency room and was sent back to the facility with a prescription for an oral antibiotic, [MEDICATION(S)] 800 milligrams/160 milligrams twice a day for seven days. R#5 had surgery to the left stump as scheduled. Review of the [DATE] Operative Report revealed a Pre-Op diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Operative Note also indicated the surgeon closed the wound using sutures and staples over a Penrose drain. The resident was discharged back to the facility the same day on [DATE] with discharge instructions to follow up at the surgeon's office on [DATE] at 3:10 p.m. Further review of the discharge instructions revealed there were no wound care instructions for how to care for the operative site nor did it include instructions for the care of the Penrose drain. There was no evidence staff called the physician or the hospital to clarify or obtain wound care orders for the surgical site or for the Penrose drain. There was also no evidence the resident went to the follow up appointment scheduled for [DATE]. During an interview with the Registered Nurse at the surgeon's office on [DATE] at 2:15 p.m., she confirmed the resident never showed up for the follow up appointment on [DATE] at 3:10 p.m. She also stated that the Operative note stated a Penrose drain was in place and patients usually have a follow-up appointment ten to fourteen days later to remove the drain. During an interview with Treatment Nurse HH on [DATE] at 12:30 p.m., she stated the resident did not have a Penrose drain when she returned from the hospital on [DATE]. She stated the resident had retention straps under the suture line. She described the retention straps as looking like an electrical cord that was off-white in color, the length of the suture line. This would also fit the description of a drain. During an interview with Licensed Practical Nurse BB on [DATE] at 11:00 a.m., she stated when the resident returned from surgery on [DATE], the resident's stump was wrapped with bandages and she did not remove them. She stated on the days she did wound care to the stump, there was not a drain in place, only a retention strap. During an interview with Director of Nursing LL on [DATE] at 3:45 p.m., she stated she would expect the staff to call the physician to clarify the discharge instructions for surgical wound to the amputation sites when the resident returned from the hospital on [DATE] and [DATE]. She stated she talked to the Registered Nurse at the surgeon's office today who told her she spoke to the surgeon's Physician's Assistant who said the resident did have drains in place on [DATE] and would have continued treatment with [MEDICATION(S)] AG three times a week. During a subsequent interview with Director of Nursing LL on [DATE] at 10:45 a.m., she stated that she questioned if Treatment Nurse HH thought the drain was retention straps and really did not know what drains looked like. The [DATE] Wound/Skin Note documented the left BKA had 15 staples with a retention strap in place. Review of the clinical record revealed no documentation that specified a drain in the left BKA. The [DATE] Wound Note indicated the left BKA remained dry with 15 staples intact with retention strap, scant amount of serosanguinous drainage, no odor, warmth, swelling or redness. It further noted there was moderate amount of pain associated with surgical site. The [DATE] Wound Note documented the left BKA presents with mushy feeling and some serosanguinous drainage. No odor, warmth or swelling. Remains with retention strap in place, painful during wound care. Doctor's office called and appointment for [DATE] scheduled. The resident expired on [DATE]. The Death Certificate noted the immediate cause of death as diabetes. During an interview with the Medical Director on [DATE] at 3:10 p.m., he stated when the resident returned from the hospital on [DATE] with no specific orders for treatment to the bilateral BKA's, he would expect the wound nurse to get involved. He stated they could call a doctor and get orders for treatment. He stated a fresh stump would especially need daily dressing changes. Although the Medical Director would not specify if not doing treatments to the bilateral BKA's would have caused infection or a further decline to the left BKA, he stated not doing treatments would certainly not help prevent infection. After the Medical Director read the [DATE] Operative Report, he stated a drain would need some attention and monitoring and he would expect the staff to call for treatment orders. He stated he was not sure about a retention strap in place but stated retention sutures could be used to keep the suture line intact. He stated the retention sutures used at this hospital were orange in color. The Medical Director then showed the surveyor a picture of retention sutures that were going across a suture line, not parallel as described by Treatment Nurse HH. He stated normally a drain would stay in place about a week.

Based on record review, resident interview, staff interview, hospital history and physical examination [REDACTED]"X") who was assessed to be at risk for falls and required mechanical lift transfer, but was transferred by a pivot transfer. A total of seven (7) residents were sampled. The failure to ensure mechanical lift transfer for Resident "X" resulted in actual harm, when Resident "X" was lowered to the floor during transfer and sustained a fractured arm and leg. Findings include: Resident "X"'s November 2014 Quarterly Minimum Data Set assessment documented diagnoses, in Section I-Active Diagnoses, including, but not limited to, Hypertension and [DIAGNOSES REDACTED], and Section C - Cognitive Patterns documented a Brief Interview for Mental Status Score of 13, indicating he/she was cognitively intact. Resident "X"'s Care Plan identified a risk for falls and specified that he/she was total-lift status. However, a 01/02/2015, 5:25 p.m. Nurse's Notes entry documented that as certified nursing assistants (CNAs) were transferring Resident "X" from chair-to-bed by pivot transfer (rather than mechanical lift transfer as required), Resident "X" began "going down". This Nurse's Notes entry documented that Resident "X" complained of right arm and left thigh pain, and a 01/02/2015 Radiology Report documented X-ray results revealing a moderately displaced [MEDICAL CONDITION] shaft of the right humerus and a minimally displaced left femur fracture. A 01/03/2015, 7:30 a.m. Nurse's Notes entry documented that Emergency Medical Services staff arrived to transport Resident "X" to the hospital, and the hospital history and physical examination [REDACTED]. The facility's investigation into the 01/02/2015 incident involving Resident "X" revealed facility Action Record forms for CNA "SS" and CNA "ZZ" documenting that, although Resident "X" required lift transfer, these CNAs used a stand-and-pivot transfer (rather mechanical lift transfer) to transfer Resident "X", and he/she sustained right humerus and left femur fractures. During an interview with Resident "X" conducted on 01/28/2015 at 5:45 p.m., the resident acknowledged that two (2) CNAs had transferred him/her from the chair to the bed with their hands rather than a lift. Resident "X" stated that he/she was transferred using a mechanical lift, and that he/she had told the CNAs that he/she was dead weight and they were conducting the transfer incorrectly, but the CNAs lifted her anyway. He/she stated that during this transfer, he/she slipped to the floor. During a 01/28/2015, 5:05 p.m. interview, the Director of Nursing (DON) acknowledged that on 01/02/2015, Resident "X" was lifted by CNA "SS" and CNA "ZZ" during transfer without the use of a lift and that the resident slid to the floor. The DON further stated that for any resident, CNA staff were to review the Resident Care Sheets posed inside resident closets for information and instructions on how to transfer each resident. During an interview conducted on 01/29/2015 at 2:10 p.m., CNA "SS" acknowledged that he/she had assisted with Resident "X"'s 01/02/2015 transfer when the resident was lowered to the floor. CNA "SS" stated he/she was aware he/she should have referred to Resident "X"'s Resident Care Sheet, but acknowledged that he/she did not check the Resident Care Sheet for Resident "X" before transferring the resident without a mechanical lift. CNA "SS" further acknowledged that he/she should have used a mechanical lift during the transfer of Resident "X". During a subsequent telephone interview with CNA "SS" conducted on 04/02/2015 at 12:35 p.m., CNA "SS" stated that he/she was knowledgeable about the procedures related to the use of mechanical lifts. CNA "SS" also stated that he/she knew how to access resident Care Plans and where resident Care Plans were located. CNA "SS" acknowledged, however, that during the transfer of Resident "X" on 01/02/2015, he/she and another CNA involved in the transfer did not use the mechanical lift as the resident's Care Plan required, and the resident was injured. During interviews conducted on 04/02/2015 at 11:50 a.m., CNAs "DD", "EE", "FF", "GG", and "HH" all stated that the facility had provided orientation training on how to use equipment, including mechanical lifts, and on location of resident Care Plans for reference. Based on the above, Resident "X" required transfer via mechanical lift. However, despite having received training regarding the use of mechanical lifts and resident transfer procedures, CNAs "SS" and "ZZ" failed to demonstrate competency when they transferred Resident "X" on 01/02/2015 by pivot transfer rather than mechanical lift. Resident "X" slid to the floor, was diagnosed with [REDACTED]. The facility therefore failed to ensure the safe transfer of Resident "X", and the resident was lowered to the floor and sustained injury. Cross refer to F323 for more information regarding Resident "X".

Based on record review, staff interview, hospital history and physical examination [REDACTED]"X") who was assessed to be at risk for falls and whose Care Plan specified transfer via mechanical lift. The total survey sample consisted of seven (7) residents. The failure of the facility to ensure mechanical lift transfer for Resident "X", as specified by the Care Plan, resulted in actual harm for Resident "X", who was lowered to the floor during a chair-to-bed transfer and sustained a fractured arm and leg. Findings include: Record review revealed the Quarterly Minimum Data Set assessment of November 2014 to document, in Section I-Active Diagnoses, that Resident "X" had [DIAGNOSES REDACTED]. Section G - Functional Status documented Resident "X"'s limitation/impairment in Range of Motion in the upper/lower extremities on both sides, and that he/she was totally dependent on staff for transfer. Review of the Care Plan for Resident "X" revealed a Problem/Need, originally dated October of 2014, which identified the resident to be at risk for falls related to reasons which included the [DIAGNOSES REDACTED]. An Approach included on the Care Plan to address the resident's risk for falls specified that the resident was to be transferred via total lift with the assistance of two (2) staff. However, despite the Care Plan of Resident "X" specifying the use of a lift during transfers as referenced above, a 01/02/2015, 5:25 p.m. Nurse's Notes entry for Resident "X" documented that certified nursing assistants (CNAs) transferred the resident from chair-to-bed by pivot transfer (instead of a lift, as required). This Nurse's Notes entry documented that Resident "X" could not bear weight and began "going down", and due to the complaint of pain, an order for [REDACTED]. The 01/02/2015 Radiology Report for Resident "X" documented a moderately displaced fracture involving the proximal shaft of the right humerus, and a minimally displaced left femur fracture. A hospital History and Physical (H&P) Examination form for Resident "X" then documented hospital transfer and admission on 01/03/2015, and documented the resident's [DIAGNOSES REDACTED]. Review of the facility's investigation into the incident referenced above during which Resident "X" sustained fractures of the humerus and femur revealed Action Record forms for CNAs "SS" and "ZZ" which documented that these CNAs failed to follow the resident's plan of care. These Action Forms documented that CNAs "SS" and "ZZ" transferred Resident "X" using a stand-and-pivot transfer on 01/02/2015 and the resident was found with right humeral and left femur fractures. During an interview conducted on 01/28/2015 at 5:05 p.m., the Director of Nursing acknowledged that on 01/02/2015, Resident "X" was lifted by CNAs "SS" and "ZZ" without a lift, and the resident slid to the floor. Based on the above, Resident "X" had [DIAGNOSES REDACTED]. On 01/02/2015, however, CNAs "SS" and "ZZ" transferred Resident "X" via pivot transfer, rather than mechanical lift as specified by the Care Plan. Resident "X" slid to the floor and was later diagnosed with [REDACTED]. Cross refer to F323 for more information regarding Resident "X".

Based on record review, resident interview, staff interview, hospital history and physical examination [REDACTED]"X") who was assessed to be at risk for falls, and who required mechanical lift transfer, was transferred by mechanical lift. The total survey sample was seven (7) residents. This failure to transfer Resident "X" via mechanical lift as required resulted in actual harm for Resident "X", who was lowered to the floor during transfer from the chair to the bed and sustained a fractured arm and leg. Findings include: Record review for Resident "X" revealed a Quarterly Minimum Data Set (MDS) assessment having an Assessment Reference Date of November 2014 which documented in Section I - Active [DIAGNOSES REDACTED]. Section C - Cognitive Patterns of this MDS documented Resident "X" to have a Brief Interview for Mental Status Summary Score of 13, indicating the resident was cognitively intact. Further review of the MDS assessment of Resident "X" referenced above revealed that Section G - Functional Status documented the resident had limitation in Range of Motion and impairment in both the upper and lower extremities on both sides, and that the resident was totally dependent on two-plus staff persons for transfer between surfaces. The Care Plan of October 2014 for Resident "X" identified that the resident was at risk for falls and specified that the resident was of a total-lift status. A Nurse's Notes entry of 01/02/2015, timed at 5:25 p.m., for Resident "X" documented that certified nursing assistants (CNAs) were transferring the resident from a Broda chair to the bed by way of a pivot transfer. This Nurse's Notes entry documented that Resident "X" could not stand or bear weight due to his/her [DIAGNOSES REDACTED]. The Nurse's Notes entry documented that Resident "X" was then placed in bed and began complaining of pain in the right upper arm and left thigh, and an order for [REDACTED]. A Physician's Telephone Orders form of 01/02/2015 for Resident "X" specified a STAT X-ray of the right arm humerus, elbow, and forearm related to pain, and a STAT X-ray of the left leg femur and tibula/fibula related to pain. A Nurse's Notes entry of 01/02/2015, timed at 8:00 p.m., for Resident "X" documented that the X-ray technician had arrived and conducted an X-ray of the resident's right arm and left leg (in accordance with the Physician's Telephone Orders form referenced above). Review of the Radiology Report listing a Date of Service date of 01/02/2015 for Resident "X" revealed X-ray results which included a recent moderately displaced fracture involving the proximal shaft of the right humerus, and a recent left femur fracture with minimal displacement. A subsequent Nurse's Notes entry of 01/03/2015, timed at 7:30 a.m., for Resident "X" documented the X-ray results which revealed fractures of the right humerus and left femur and that the resident would be transferred to the hospital emergency room (ER) for evaluation. This Nurse's Notes entry documented physician notification and that Emergency Medical Services (EMS) 911 was called, and that at 7:40 a.m., EMS staff arrived to transport the resident to the ER. The hospital History and Physical (H&P) Examination form for Resident "X" documented the resident's hospital transfer, documented a hospital admission date of [DATE], and documented the resident's [DIAGNOSES REDACTED]. This hospital H&P Examination form documented, in the Reason for Admission section, that Resident "X" was admitted to the hospital due to the left distal femur fracture and the right proximal humerus fracture, and that surgery was planned. A Nurse's Notes entry of 01/07/2015, timed at 11:50 a.m., for Resident "X" documented that the resident was readmitted to the nursing facility from the hospital. This Nurse's Notes entry documented that at the time of facility readmission, Resident "X" had two (2) staples in the mid-upper arm, nine (9) staples in the upper right arm at the shoulder, and nineteen (19) staples to the left thigh. Review of the facility's investigation into the 01/02/2015 incident involving Resident "X" referenced above revealed a facility Action Record form dated 01/07/2015 for CNA "SS", and an Action Record form dated 01/09/2015 for CNA "ZZ", which documented that these CNAs failed to follow the resident's plan of care and incorrectly transferred the resident. These Action Forms for CNA "SS" and CNA "ZZ" indicated that Resident "X" required lift transfer with the assistance of two (2) staff, and that this transfer requirement was listed on the resident's Resident Care Sheet. These Action Forms further documented, however, that CNA "SS" and CNA "ZZ" utilized a stand-and-pivot transfer (rather than a mechanical lift transfer as required) to transfer Resident "X" on 01/02/2015, and the resident was subsequently found to have fractures of the right humerus and left femur. During an interview with Resident "X" conducted on 01/28/2015 at 5:45 p.m., the resident stated that two (2) CNAs had transferred him/her from the chair to the bed with their hands rather than a lift, and that he/she slipped to the floor. During an interview with the Director of Nursing (DON) conducted on 01/28/2015 at 5:05 p.m., the DON acknowledged that on 01/02/2015, Resident "X" was lifted by CNA "SS" and CNA "ZZ" during transfer without the use of a mechanical lift and that the resident slid to the floor. The DON further stated that for any resident, CNA staff were to review the Resident Care Sheets posed inside resident closets to obtain information and instructions on how to transfer each resident. During an interview with CNA "SS" conducted on 01/29/2015 at 2:10 p.m., CNA "SS" acknowledged that he/she had assisted with transferring Resident "X" on 01/02/2015 when Resident "X" was lowered to the floor during the transfer. CNA "SS" acknowledged that he/she should have used a mechanical lift during this transfer, but that a lift was not used. Based on the above, Resident "X" had [DIAGNOSES REDACTED]. However, on 01/02/2015, two CNA staff transferred the resident using a pivot transfer rather than a mechanical lift. During this transfer, Resident "X" slid to the floor, complained of pain, was diagnosed with [REDACTED]. The facility therefore failed to ensure the safe transfer of Resident "X", and the resident was lowered to the floor and sustained injury.