Every finding on record at Rainbow Rehab and Healthcare

Based on policy review, incontinent brief manufacturer directions, medical record review, hospital record review, facility investigation review, observation, and interview, the facility failed to protect the Residents' right to be free from neglect when they failed to provide necessary care and services to meet the needs of the Resident for 1 of 6 (Resident #1) sampled residents reviewed for a change of condition and altered mental status. Resident #1, a vulnerable Resident who was cognitively intact, with a full code status was found with an acute change in condition on 7/10/2024 at approximately 10:56 AM. The facility failed to notify the physician and the family at that time. The facility failed to document a nursing assessment, vital signs, or neurological assessment until approximately 3:00 PM, which was 4 hours later. Resident #1 experienced lethargy, changes in speech pattern, gurgling respirations, and subsequently became unresponsive to verbal and tactile stimulation. The facility notified Emergency Medical Services (EMS) more than 4 hours after the change in condition, and Resident #1 was transferred to the emergency room of Hospital #1 on 7/10/2026 at approximately 4:00 PM. Resident #1 was diagnosed with an acute cerebrovascular accident ((CVA)-stroke) and carotid artery stenosis (narrowing of the carotid arteries in the neck which carry blood and oxygen to the brain). In the emergency room a urinalysis was performed which identified semen in the Resident's urine. Resident #1 was transferred to Hospital #2 for a higher level of care on the evening of 7/10/2026, where a forensic nurse conducted a rape kit and examination on 7/11/2026 and found bruising on the inside of the Resident's right thigh and a tear on the lower part of the Resident's vagina. The facility's failure to identify an acute change in condition, protect the Resident from neglect, and transfer to the hospital timely, resulted in Immediate Jeopardy for Resident #1. Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified related to the facility's failure to use its resources effectively to attain and maintain the highest practicable well-being of a vulnerable resident, and to ensure systems and processes were implemented to provide supervision and assistance to ensure the resident environment was free of neglect. The Administrator and the Regional Nurse Consultant were notified of the Immediate Jeopardy (IJ) at F-600 on 7/17/2026 at 7:42 PM, in the conference room. The facility was cited at F-600 at a scope and severity of J which is Substandard Quality of Care. The IJ began on 7/10/2026 through 7/18/2026, the IJ was removed on 7/19/2026. An acceptable Removal Plan, which removed the immediacy of the Jeopardy for F-600, was received on 7/19/2026 at 2:11 PM. The Removal Plan was verified and validated onsite by the surveyor on 7/20/2026 through 7/22/2026 through review of the in-service training records and audits, review of the facility's policy, observations, and staff interviews. A partial extended survey was conducted on 7/19/2026 through 7/22/2026. The facility's non-compliance at F-600 continues at a scope and severity of D for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction. The findings include: 1. Review of the facility policy titled, Abuse, Neglect and Exploitation, dated 10/24/2022, revealed .It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property .Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercation .Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse and mental abuse .Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm .Neglect means failure of the 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 .Criminal sexual abuse is serious bodily injury/harm .serious bodily injury includes sexual intercourse with a resident by force or incapacitation or through threats of harm to the resident .The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written .Existing staff will receive annual education through planned in-services and as needed .Training topics will include .Prohibiting and preventing all forms of abuse, neglect, misappropriation of resident property, and exploitation .Identifying what constitutes abuse, neglect .Recognizing signs of abuse, neglect .Reporting process for abuse, neglect .including injuries of unknown sources .Establishing a safe environment . to the extent possible .for preventing sexual abuse .The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse . Review of the undated facility policy titled, TENNESSEE STATE SPECIFIC RESIDENT RIGHTS, revealed .The nursing home shall establish and implement written policies and procedures setting forth the rights of residents for the protection and preservation of dignity, individuality and, to the extent medically feasible, independence. Residents and their families or other representatives shall be fully informed, and documentation shall be maintained in the resident's file of the following rights.To be free from mental and physical abuse. Review of the facility policy titled, Incontinence, dated 10/26/2023, revealed, .Based on the resident's comprehensive assessment, all residents that are incontinent will receive appropriate treatment and services .The facility must ensure that residents who are continent of bladder and bowel upon admission receive appropriate treatment, services, and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain .Residents that are incontinent of bladder or bowel will receive appropriate treatment to prevent infections and to restore continence to the extent possible . 2. Review of (Named Incontinent Briefs) manufacturer directions dated 2026, revealed .The wetness indicator strip.is designed to help staff identify if a resident has urinated.The indicator will detect urine, perspiration, and loose stool but will not be activated by solid bowel movements.Staff should change.in accordance with their facility practices, along with proper peri care [cleaning of the genital and anal area] procedures. 3. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses including Hypertension, Fracture of Superior Rim of Right Pubis (pelvic fracture), Encounter for Fracture with Routine Healing, Osteoarthritis, and Overactive Bladder. Review of the facility's Nursing admission Evaluation, dated 7/8/2026, revealed .Arrived at facility via [by way of] [Named medical transport] at 1722 [5:22 PM]. Awake, alert and oriented x [time] 4 [a person is fully conscious and aware of person, place, time, and situation].Noted bruising in bilateral antecubital [the triangular depression located on the front side of the elbow joint] areas from previous IV [intravenous, meaning inside or within a vein in order to give medicines or fluid directly into a person's bloodstream] administration.Pain increase with movement. Can not sit or stand without increasing pain past tolerated. Able to make needs and wants known. Review of the Care Plan for Resident #1 dated 7/8/2026, revealed .Resident has episodes of bladder/bowel incontinence related to depression, generalized weakness, impaired mobility, pain, physical limitations.assist resident with toileting needs.provide peri-care after each incontinent episode; apply house barrier cream after incontinence care.Resident has impaired skin integrity as evidenced by POA [present on admission] right gluteus [right buttocks] MASD [moisture associated skin damage] related to confined to a bed all or most of the time.incontinent of bladder and bowel.requires staff assistance to reposition.apply barrier cream after incontinent episodes.assist with turning and repositioning.Provide incontinence care as needed. Review of the POC [point of care] Legend Report, dated 7/8/2026 through 7/10/2026, revealed Resident #1 had documentation of bladder and bowel incontinence checks as follows: 7/8/2026 - 21:42 (9:42 PM) 7/9/2026 - 04:11 - (4:11 AM) 7/9/2026 - 12:01 PM 7/9/2026 - 21:38 (9:38 PM) 7/10/2026 - 05:31 (5:31 AM) 7/10/2026 - 11:09 AM 7/10/2026 - 20:18 (8:18 PM) Resident #1 was not in the facility at this time. Review of the medical record revealed Resident #1 was not provided incontinent care every 2 hours or as needed. Resident #1 was only provided incontinent care 2 times on 7/10/2026, at 5:30 AM and 11:09 AM. Review of the facility's Skin Issues, for Resident #1 dated 7/9/2026 at 9:07 AM, revealed .Skin Issue: Moisture Associated Skin Damage (MASD).Right Gluteus.incontinence associated dermatitis.present on admission.measurements length (cm) [centimeters] 0.74.width (cm) 0.81.depth (cm) 0.1.area (cm) 0.64.exudate [wound drainage] type serous: clear watery fluid, which is separated from solid elements.additional care: incontinence management.moisture barrier.moisture control.turning/[and/or] repositioning program.care of skin issues.moisture barrier.signs and symptoms of infection.change/shift positions frequently. Review of the facility's Order Listing Report for Resident #1 dated 7/9/2026, revealed .Cleanse with wound cleanser or normal saline. Pat dry. Apply [Named absorbent dressing]. Cover with foam dressing. (Right Gluteus) every day shift every Mon [Monday], Thu [Thursday] Sat [Saturday] related to IRRITANT CONTACT DERMATITIS DUE TO FECAL, URINARY OR DUAL INCONTINENCE. Review of the 5-day Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) assessment was not coded. Resident #1's urinary continence was coded as always incontinent. Review of the facility's Skilled Daily - Medically Complex note for Resident #1 dated 7/10/2026 at 2:01 PM, revealed .oriented to: person.Most Recent Blood Pressure: 140/60 Date: 7/10/2026 10:56 [AM].Most Recent Pulse 64 Date: 7/10/2026 10:56 [AM].Most Recent Respiration 17.0 Date: 7/10/2026 10:58 [AM].Most recent O2 sats [oxygen saturations] 98 % [percent] Date: 7/10/2026 10:58 [AM].room air.Most Recent Temp 97.0 [degrees Fahrenheit].route.forehead.Date: 7/10/2026 10:58 [AM]. Review of the facility's Skilled Daily - Medically Complex Note for Resident #1 dated 7/10/2026 at 2:01 PM, revealed the facility failed to obtain updated vital signs and failed to complete an updated nursing assessment. Review of the facility's SBAR [Situation, Background, Assessment, Recommendation] Communication Form and progress note for Resident #1 dated 7/10/2026 at 3:33 PM, revealed .change in condition.Lethargic nonverbal to commands.started 7/10/2026.Most Recent Blood Pressure: 140/60 Date: 7/10/2026 10:56 [AM].Most Recent Pulse 64 Date: 7/10/2026 10:56 [AM].Most Recent Respiration 17.0 Date: 7/10/2026 10:58 [AM].Most recent O2 sats 98 % Date: 7/10/2026 10:58 [AM].room air.Most Recent Temp 97.0.route.forehead.Date: 7/10/2026 10:58 [AM].Decreased consciousness.Decreased mobility.Very lethargic.BP low O2 sat @ [at] 91 [%] on room air. Review of the medical record showed no additional vital signs were obtained during Resident #1's change of condition. Review of the medical record revealed no documentation of additional vital signs or assessment of Resident #1 following the documentation on 7/10/2026 at 10:56 AM, There was no documentation the physician or family was notified until 3:33 PM. Review of the Transfer Form for Resident #1 dated 7/10/2026 at 3:40 PM, revealed .alert, disoriented, but cannot follow simple instructions.Code Status Full.Transfer is.unplanned.Altered Mental Status. Most Recent Blood Pressure: 140/60 Date: 7/10/2026 10:56 [AM].Most Recent Pulse 64 Date: 7/10/2026 10:56 [AM].Most Recent Respiration 17.0 Date: 7/10/2026 10:58 [AM].Most Recent O2 sat [oxygen saturations] 98 % [percent] Date: 7/10/2026 10:58[AM].room air.Most Recent Temp 97.0.route.forehead.Date: 7/10/2026 10:58 [AM]. There was no documentation on the facility's Transfer Form, dated 7/10/2026 at 3:40 PM, of a current nursing assessment or current vital signs. Review of the Nurses Note for Resident #1 dated 7/10/2026 at 4:00 PM, revealed .Resident noted with a change in condition noted very lethargic, not able to communicate, Resident noted very weak not able to keep eyes open, head up. Or talk.VSS [vital signs stable].This nurse call [Named Doctor] and doctor gave order to send resident out. Review of Resident #1's medication administration record dated July 2026, revealed the following medications were documented as given on 7/11/2026 and 7/12/2026: Amlodipine Besylate 10 mg (milligrams) one tablet by mouth one time a day Bupropion 300 mg one tablet by mouth one time a day Lovastatin 40 mg one tablet by mouth one time a day Omeprazole 20 mg 2 tablets by mouth one time a day Oxybutynin Chloride ER (extended release) 15 mg one tablet by mouth one time a day Calcium 600+ D plus Minerals one tablet by mouth two times a day Carvedilol 6.25 mg one tablet by mouth every 12 hours Review of the medical record revealed Resident #1 was discharged from the facility on 7/10/2026 and was not present in the facility to receive the scheduled medications on 7/11/2026 and 7/12/2026. 4. Review of the (Named Hospital #1) Emergency/Urgent Care Emergency Department (ED) Physician ED note dated 7/10/2026 at 5:27 PM, revealed .DATE/TIME PATIENT SEEN.7/10/2026 16:29 [4:29 PM] PT [patient/Resident #1] arrived via [Named emergency service] from [Named Facility] for AMS [Altered Mental Status], last known well 1200 [12:00 PM] today, patient non-verbal on arrival, not moving right arm and appears to have a facial droop on right side, will not follow commands.Contraindications [circumstance where a particular medication could be harmful] to Thrombolytic Therapy [IV medications to stop blood clots].Thrombolytic and Endovascular Stroke Treatment Exclusion/ Delay.Time last known well unknown or greater than 4.5 hours prior to treatment initiation [treatment window for initiating Thrombolytic Therapy].Impression.Acute CVA [cerebrovascular accident] and Carotid artery stenosis. Review of Hospital #1's Emergency/Urgent Care lab report for Resident #1 dated 7/10/2026 at 6:30 PM, revealed .UA [urinalysis].Turbid [cloudy, hazy, or milky] (abnormal) UA Sperm Rare (abnormal).UA Blood 2+ [plus]. Resident #1 was transferred to Hospital #2's Neurological (neuro) Intensive Care Unit (NICU) for a higher level of care by the ambulance service on 7/10/2026 at 8:02 PM. 5. Review of Hospital #2's Nursing Narrative, for Resident #1 dated 7/11/2026 at 3:47 AM, revealed .During in and out catheterization this am [morning], 2 tears around pt's [patient's/Resident #1] vagina noted. This was done after seeing results of pt's UA from [Named City (Hospital #1)] showing sperm present. Calls to nursing management made to determine how to proceed and/or report to authorties [authorities]. Review of Hospital #2's Nursing Narrative for Resident #1 dated 7/11/2026 at 6:16 PM, revealed .At approximately 0800 [8:00] [Named Police Department] @ [at] bedside for report of possible sexual assault @ [Named Facility].At approximately 1330 [1:30 PM] Forensic [Named Nurse Practitioner] arrived at bedside to perform sexual assault exam; exam concluded @ approximately 15:30 [3:30 PM] [Named Police Department] arrived at bedside to collaborate. Review of Hospital #2's Consultation Note, for Resident #1 dated 7/13/2026 at 12:17 PM, revealed .Chief Complaint: lethargy, AMS [altered mental status.seen at [Named Hospital #1] and sent here.The patient is. female admitted on [DATE], for an acute cerebrovascular accident (CVA) presenting with altered mental status, aphasia, facial droop, and right hemiparesis [injury to the left side of the brain].The primary diagnoses for this admission were acute CVA due to severe bilateral carotid artery stenosis, expressive aphasia [partial loss of the ability to produce language], and right hemiparesis.Thrombolytic therapy was not administered due to the patient being outside the treatment window, and neurointerventional procedures were not indicated.The patient was NPO [nothing by mouth] until a dysphagia screen [swallow exam] could be passed, and a NG [nasogastric tube is a tube placed in the nose and down into the stomach] was placed for medication administration.PHYSICAL EXAM.BLE [bilateral lower extremities] responds to painful stimuli, BUE [bilateral upper extremities] moves on commands, weak RUE [right upper extremity].Non-verbal.Follows commands slowly with prompting. 6. During an interview on 7/17/2026 at 4:26 PM, the facility Administrator was asked what was being done to protect the residents to ensure a safe environment (after the incident with Resident #1). The Administrator stated, .started our abuse in-service, we interviewed all residents with a BIMS of 8 or higher.did skin checks on all people with a BIMS of 7 or lower.interviewed all the staff to see if they had any concerns of other staff members or any residents.all staff were making rounds.viewed visitor logs.reviewed all the video.we kind of narrowed it down based on the warrant that it was a male. The Administrator was asked if anything had been implemented (since the incident with Resident #1) to ensure residents were kept in a safe environment. The Administrator stated, .We've been through our normal process, interviewed the residents, went back and asked some of the residents close by those rooms if they heard anything and they did not.other than our normal process to keep people safe.I don't know what else I could have done at this point. The Administrator was asked if there was a process for changing the exit door codes to prevent entry of unauthorized persons. The Administrator stated, .no, just change the code as needed. The Administrator was asked when the last time the door code was changed. The Administrator stated, .I would have to ask when they were changed. The Administrator was asked if there were any residents currently in the facility who are sexually aggressive. The Administrator stated, Not that I'm aware of. The Administrator was asked how he was made aware of the alleged sexual misconduct with Resident #1. The Administrator stated, .around 2 o'clock, the staff told me a police officer had shown up and wanted to look in [Named Room where Resident #1 resided].possible crime scene.I left here around 6 [6:00 PM].then I got a call from [Named Police Officer] who said he was leaving the search warrant processing in the room.I showed up at 7:45 PM, and they were finishing up, he handed me a copy of the search warrant. The Administrator was asked if he left while the police were in his building. The Administrator stated, .yes.just that one officer was here at that time.nobody told me the forensic team showed up.my Assistant Director of Nursing [ADON] was here.but she may have left.I'm not sure. The Administrator stated he reviewed the video of the hall outside of Resident #1's room in its entirety from start to finish on the following Wednesday (7/15/2026). The Administrator was asked if any new processes had been implemented since the allegation of sexual misconduct. The Administrator stated, .I don't think so.we had a good process in place. The Administrator was asked to explain what the process was for transferring a resident with an altered mental status. The Administrator stated, .I would have to defer to nursing. The Administrator was asked whether they would call 911 if a patient had altered mental status. The Administrator stated, I would have to defer to nursing. During an interview at Hospital #2 on 7/18/2026 at 9:31 AM, Registered Nurse (RN) H said he was the house supervisor at Hospital #2 and was familiar with Resident #1. RN H stated, .when I came in last Saturday morning [7/11/2026] process was started.[Resident #1] admitted from [Named City (Hospital #1)], a urine drug screen found sperm cells in her urine.night shift charge nurse notified [Named] police department.I am the one who did the APS [Adult Protective Services] notification. RN H was asked if he assessed Resident #1. RN H stated, I did I assisted the investigator [forensic Nurse Practitioner (NP)] who came out and did the rape kit .[forensic NP] affiliated with the police department .I know they are doing an investigation, and some actions have been taken. RN H was asked what Resident #1's status was at that time. RN H stated, She was arousable to painful stimuli, completely aphasic [unable to speak, write, or understand speech because of damage to the brain], [Resident #1 was] moving .can't remember if it was left or right and was out [unable to move] on the other side.pretty significant L [left] MCA stroke [when a stroke blocks the middle cerebral artery of the brain and is caused by a clot].[I] was actually here Sunday as well.very rudimentary [basic] conversation.yes, no.I don't know what her current [status is]. RN H was asked was he in the room when the rape kit was completed. RN H stated, For part of it.takes about 2 hours.actually in there assisting when she [Forensic NP] was taking pictures of some of the affected areas.[Resident #1] was very lethargic, minimally responsive at the time when the examiner was doing her analysis.nonverbal and semi-conscious. RN H was asked did he observe any abnormalities [during the examination]. RN H stated, Yes, small tear at the bottom of her [Resident #1] vagina and she had some bruising on the back of her thighs and inner part of the thighs.looked suspiciously like somebody's hand, like somebody grabbed her that way.there's photographic evidence . RN H was asked was that photographic evidence part of the Hospital's chart. RN H stated, It will be with [named] police department . During an observation and interview in the Resident's room at Hospital #2 on 7/18/2026 beginning at 9:50 AM, Resident #1 was propped to her left side, a nasogastric tube was in her left nostril, her knees were bent, and she was covered with a sheet pulled up to her upper chest. Resident #1 was nonverbal but would [NAME] her brow (forehead) and very slowly nod when asked questions. Resident #1 was asked if she was in pain and she furrowed her brow and then very slowly nodded no. Resident #1 was asked if she knew how long she had been in the hospital with the same response. Resident #1 did not respond to any other questions. During an interview at Hospital #2 on 7/18/2026 at 10:00 AM, RN H accompanied this surveyor to the lobby. RN H stated, She [Resident #1] definitely had some vaginal trauma. During a telephone (phone) interview on RN I's cellular phone at Hospital #1 with RN I present on 7/18/2026 at 11:11 AM, the Laboratory (Lab) Director for Hospital #1 confirmed she was aware of the sperm found in Resident #1's UA. The Lab Director was asked how the lab would identify sperm in the urine. The Lab Director stated, A urinalysis with micro [microscopic - viewed under a microscope] .is ran. We have rules written in if everything is negative [we] don't look at the microscopic.[if we identify] flags [we look under the microscope] .during that exam they identified some sperm and reported those out. The Lab Director said the sperm was identified on the initial exam, and they did not have an alert value to immediately alert the physician for sperm. During a telephone interview on 7/18/2026 at 1:36 PM, RN K who worked at Hospital #2 said she recalled Resident #1. RN K was asked about the day she came in and cared for Resident #1 (7/11/2026). RN K stated, Got report from night shift that [Resident #1] transfer [transferred] from [named Hospital #1] and that the UA showed sperm in the UA which is not something that is typically tested for .would have been if they saw it.looked under [the] microscope.she [night shift nurse] had already informed the house supervisor.charge nurse, called adult protective services.police came and mainly dealt with [named RN H]. [Resident #1's] Son came up and .Forensic NP she came and did her exam. RN K reported Resident #1 was there for a stroke workup and she had a left MCA stroke, and that side of the brain controls speech, language and understanding. RN K said Resident #1 was aphasic and wasn't speaking. RN K reported she had to put in a NG tube to give aspirin and plavix (a medication that prevents blood clots). RN K was asked did she assess Resident #1's perineal area (the area located between the thighs that extends from the genital region to the anus). RN K stated, Yeah, at one point the [Forensic] NP doing sexual assault exam asked me to send some lab work.straight cath [(catheter) insertion of a straight cath to empty the bladder].when I [was] getting ready to urine cath, the [Forensic NP] was also there and she had what appeared to be a vaginal tear right at the base [of the vagina].bruising in her inner thigh, I hate to speculate but about the size of a thumb print maybe. During an interview on 7/20/2026 at 12:03 PM, Certified Nursing Assistant (CNA) A was asked if she cared Resident #1 (while she was in the facility) and what assistance was provided. CNA A confirmed Resident #1 was alert and oriented, incontinent of bowel and bladder, wore incontinent briefs during the day, and required assistance of staff to turn and reposition. CNA A was asked how often she would check for incontinence care and did Resident #1 have skin issues such as wounds or bruises. CNA A stated, .I'm not sure if she had skin issues or wounds, I may have changed her once that night.we are supposed to check incontinence every 2 hours and reposition then. CNA A was asked if she charted residents' incontinence episodes. CNA A stated, Yes, we should chart in her POC [PLAN OF CARE]. CNA A was asked did she chart the incontinent care provided to Resident #1. CNA A stated, .yes . During an interview on 7/20/2026 at 12:40 PM, facility CNA B was asked if she took care of Resident #1 (while she was in the facility). CNA B stated, .She was very nice, alert to everything.she was incontinent and wore incontinent briefs.we had to help her with turning in the bed. CNA B was asked how Resident #1 felt on her last day at the facility (7/10/2026). CNA B stated, .she seemed good early that morning, but was different after about 1030 AM. CNA B was asked if she told anyone about the change in Resident #1. CNA B stated, I told the charge nurse she was hard to wake up and seemed different. CNA B was asked if she seen any bruising or wounds on Resident #1 and how often she performed incontinent care. CNA B stated, .I didn't notice bruising.don't recall skin issues either, but I checked her once that day that I remember.I just changed her brief around 10:30 while she was in bed, then she was sent out that afternoon by the nurse. CNA B was asked if she charted the incontinent care she provided. CNA B stated, Yes, I document incontinent care in the charting system. During an interview on 7/20/2026 at 1:19 PM, RN D was asked if she did a nursing assessment on Resident #1 on admission to the facility. RN D stated, Yes, I assessed her skin on 7/9/2026, she had moisture associated skin damage to her right buttock, I looked at her whole body and seen small bruises on her arms where she had IV's and scabbing to her left and right toes.she was alert, cheerful, her goal was for therapy.she needed help with bed mobility and incontinence care.she stated she had been incontinent for years. RN D was asked how often Resident #1 required changing of her brief for incontinence. RN D stated, she required every 2 hours or more if needed.especially with her MASD on her buttock.I didn't see her the day she was discharged . During an interview on 7/20/2026 at 4:22 PM, Certified Occupational Therapist Assistant (COTA) E was asked if she cared for Resident #1 on the day she was discharged (7/10/2026). COTA E stated, .yes, she participated well before breakfast, she was talking alert and oriented.I split my time with her and was going back later in the day.At 11:00 AM I was trying to arouse her, but she wasn't arousing.the Unit Manager was there and said they were going to send her out. During a phone interview on 7/20/2026 at 7:27 PM, Physical Therapist Assistant (PTA) C was asked if she provided therapy to Resident #1 on 7/10/2026. PTA C stated, Yes, I tried to arouse her prior to lunch it was somewhere around 11 [11:00] AM, she was out of it.the Unit Manager assisted me getting her in the wheelchair, it was maximum assist, took both of us to get her to the chair.the nurse said they would check her out when I brought her back.I took her to the therapy room, but I noticed her right arm was stiff, and she had excessive leaning to her right side.her eyes were barely open looking up. I took her straight back to her room sitting in her wheelchair I knew the Unit Manager was aware she wasn't acting the same as the day before, I told the CNA as I left the room, that she was in her wheelchair and to check on her.as I passed the charge nurse, I told her the same, to check on her. During a phone interview on 7/21/2026 at 12:06 PM, the Doctor of Nursing Practice (DNP) was asked if she was Resident #1's Primary Care DNP. The DNP stated, .I never met her but was planning to see her on Friday.the only thing I know is that she had a change of condition.the facility called me after 3:00 PM [7/10/2026]. The DNP was asked did the facility notify you when the change of condition first started occurring. The DNP stated, .no.no one contacted me regarding any changes for that resident.the unit manager called me sometime after 3 [3:00] PM.I instructed her to send the patient to the ER [emergency room].the facility takes it upon themselves if she is having symptoms and should have called 911 [emergency telephone number]. The DNP was asked when should the facility do timely nursing assessments. The DNP stated, .when the change of condition is starting to occur.I would hope they would call the Physician or NP immediately and document their findings. During a phone interview on 7/22/2026 at 9:08 AM, the ADON was asked if she had been notified on 7/10/2026 by the unit manager of Resident #1's change of condition and a suspected bruise to the Resident's right cheek. The ADON stated, I don't recall. The ADON was asked was she awar

Based on the 2026 American Heart Association/American Stoke Association (AHA/ASA) Guidelines, facility policy review, hospital record review, medical record review, facility documentation review, emergency medical transportation review, and interview, the facility failed to provide treatment and care in accordance with professional standards of practice for 1 of 6 (Resident #1) sampled residents reviewed for physical injuries, timely assessments, and emergency transfer for a change in condition. Resident #1, a vulnerable Resident who was cognitively intact, with a full code status, was found with an acute change in condition and altered mental status on the morning of 7/10/202 at approximately 10:56 AM. The facility failed to call 911 (emergency phone number) immediately upon noticing the Resident's change of condition. Resident #1 was transferred to the hospital for evaluation between 4:00 PM and 4:30 PM, approximately 5 hours later. During her transfer to Hospital #1 emergency room (ER) on the afternoon of 7/10/2026, emergency medical services (EMS) personnel identified a contusion to Resident #1's right cheek that the facility staff were unaware of. The facility's failure to respond to the Resident's acute change in condition and altered mental status and provide timely assessments resulted in a delay in treatment which prevented the ER from administering clot busting medications (medications that dissolve blood clots that cause strokes). Resident #1 was diagnosed with an acute cerebrovascular accident (CVA-stroke) and carotid stenosis (narrowing or blockage of the carotid arteries in the neck which carry blood and oxygen to the brain). Resident #1, who was admitted to the facility as awake, alert and oriented times (x) 4 (a person who is fully conscious and aware of person, place, time, and situation), was nonverbal at this time and had a nasogastric (NG) tube per hospital records and family interviews. At the time of the survey no written incident report was provided, and the facility investigation was incomplete. The facility should take immediate action to ensure timely identification and notification of changes in residents' condition, and timely assessments to protect residents from serious injury, serious harm, serious impairment, or death. The facility's failure to provide care and services to Resident #1 resulted in Immediate Jeopardy (IJ), (a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident) for Resident #1. The Administrator and the Regional Nurse Consultant were notified of the Immediate Jeopardy (IJ) at F-689 on 7/17/2026 at 7:42 PM, in the conference room. After supervisory review on 8/4/2026, the deficiency was changed to F-684, and the deficiency number was amended on the IJ template and provided to the facility. The facility was cited at F-684 at a scope and severity of J which is Substandard Quality of Care. The IJ began on 7/10/2026 through 7/18/2026, the IJ was removed on 7/19/2026. An acceptable Removal Plan, which removed the immediacy of the Jeopardy identified for the facility's failure to provide timely assessments and emergency transfers for a change in condition, was received on 7/19/2026 at 12:50 PM. The Removal Plan was verified and validated onsite by the surveyor on 7/20/2026 through 7/22/2026 through review of the in-service training records and audits, review of the facility's policy, observations, and staff interviews. The Removal Plan provided covered the areas cited in F-684. A partial extended survey was conducted on 7/19/2026 through 7/22/2026. The facility's non-compliance at F-684 continues at a scope and severity of D for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction. The findings include: 1. Review of the AHA/ASA 2026 Guidelines published 1/26/2026, revealed .This updated guideline is intended to provide a comprehensive, up-to-date, evidence-based set of recommendations.from prehospital evaluation through acute treatment.Clinical practice guidelines for stroke provide recommendations applicable to patients with or at risk of developing cerebrovascular disease.Stroke is a leading cause of death and disability.This guideline aims to cover the full course of the emergency evaluation and early management of the patient with AIS [Acute Ischemic Stroke].Lack of awareness of stroke warning signs and the need to call 9-1-1 [emergency number] in the case of stroke symptoms contributes to delays to hospital arrival and has the potential to reduce patients' eligibility for reperfusion therapies [methods of restoring blood flow].IVT [(Intravenous thrombolytics) administration of medications through an IV line to stop blood clots] is proven to benefit.patients.when administered within 4.5 hours of symptom onset. Data from RCTs [Randomized Clinical Trials] and the AHA Get With the Guidelines (GWTG)-Stroke registry show that the earlier the treatment, the greater the benefit, which diminishes over time.Prompt clinical assessment by trained professionals is essential to determine whether presenting neurological deficits are disabling. 2. Review of the facility policy titled, Notification of Changes, dated 8/29/2024, revealed .The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, resident's representative when there is a change requiring notification.Circumstances requiring notification include.Significant change in the resident's physical, mental, or psychological condition such as deterioration in health, mental or psychosocial status. This may include Life- threatening conditions, or Clinical complications. Review of the facility policy titled, Incidents and Accidents Reporting dated 8/11/2022, revealed .It is the policy of this facility for staff to utilize electronic and/or approved forms to report, investigate, and review any incidents or accidents that occur, on facility property and may involve or allegedly involve a resident. Accident refers to any unexpected or unintentional incident, which results or may result in injury or illness to a resident.An incident is defined as an occurrence or situation that is not consistent with the routine care of a resident or with the routine operation of the organization.The purpose of incident reporting is.Assuring that appropriate and immediate interventions are implemented and corrective actions are taken to prevent recurrences and improve the management of resident care.Incidents that rise to the level of abuse, misappropriation, or neglect, will be managed and reported according to the facility's abuse prevention policy.In the event of an incident or accident, immediate assistance will be provided or securement of the area will be initiated unless it places one at risk of harm.Any injuries will be assessed by the licensed nurse or practitioner and the affected individual will not be moved until safe to do so.The supervisor or other designee will be notified of the incident/accident, report any injuries or other findings, and obtain orders, if indicated, which may include transportation to the hospital dependent on the nature of the injury.The resident's family or representative will be notified of the incident/accident and any orders obtained or if the resident is to be transported to the hospital.Documentation should include the date, time, nature of the incident, location, initial findings, immediate interventions, notifications and orders obtained or follow-up interventions.If an incident /accident was witnessed by other people, the supervisor or designee will obtain the witnesses' account. 3. Review of Hospital #1's admission H&P [History and Physical] dated 7/2/2026 at 10:56 AM, revealed .CHIEF COMPLAINT.Pt [patient/Resident #1] arrived.from home for a fall that she had yesterday and injured right hip and she also has bruising to right side of face.she fell onto her right side she reports no dizziness.she did slightly hit her head but denies any loss of consciousness. 4. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], for rehabilitation following hospitalization at Hospital #1 with diagnoses including Hypertension, Fracture of Superior Rim of Right Pubis (pelvic fracture), Encounter for Fracture with Routine Healing, Osteoarthritis, and Overactive Bladder. Review of the facility's Nursing admission Evaluation, dated 7/8/2026, revealed Resident #1 arrived at the facility at 5:22 PM. Resident #1 was awake, alert and oriented x 4, and bruising was documented to the inside bend of her elbows bilaterally. Resident #1 experienced pain with movement and could not sit or stand without increased pain. The admission Evaluation did not document bruising to the right side of Resident #1's face. Review of the Care Plan for Resident #1 dated 7/8/2026, revealed .Resident is at risk for falls/injury related to bladder incontinence, decreased strength and endurance, functional problems, generalized weakness, high risk for falls, history of falls.Resident has an impaired musculoskeletal status related to osteoarthritis, fracture of R [right] pubic ramus [crack or break in the pelvis], muscle weakness, unsteadiness on feet, abnormalities of gait and mobility. Review of the 5-day Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) assessment was not coded. Review of the medical record revealed Resident #1 experienced an acute change in condition on 7/10/2026 at approximately 10:56 AM. Review of the facility's SBAR [Situation, Background, Assessment, Recommendation] Communication Form and progress note dated 7/10/2026 at 3:33 PM, revealed Resident #1 experienced a change in condition including lethargy, decreased consciousness, and decreased mobility. Further review revealed Resident #1's vital signs were obtained at 10:56 AM and documented in the note at 3:33 PM. Resident #1's vital signs were as follows: Blood pressure (BP)-140/60 Pulse-64 Respirations-17 Oxygen saturation-91 percent (%) on room air Temperature-97 degrees Fahrenheit Review of the facility's Transfer Form, dated 7/10/2026 at 3:40 PM, revealed Resident #1 could not follow simple instructions and experienced an altered mental status (AMS). There was no documentation of a bruise or contusion to Resident #1's right cheek. Review of a Nurses' Note dated 7/10/2026 at 4:00 PM, revealed Resident #1 was observed with lethargy, weakness, inability to communicate, and was unable to hold her eyes open and keep her head up. The Doctor of Nursing Practice (DNP) was notified and orders were given to send the Resident to the Emergency room. The vital signs documented at 4:00 PM were from 10:56 AM. There were no current vital signs documented. Review of Resident#1's medical record revealed no documentation a head-to-toe nursing assessment was completed, no documentation of vital signs in the medical record after 10:56 AM, and no documentation that 911 was called related to Resident #1's altered mental status or her change of condition. 5. Review of the (Named Ambulance service) Patient Care Record for Resident #1 dated 7/10/2026, revealed .Clinical Impression.Provider's Primary.Altered mental status.Provider's Secondary.weakness.Chief Complaint Altered mental status.Vitals stable.16:01 [4:01 PM] BP [blood pressure] 97/39.HR [heart rate] 69.RESP [respirations] 18.Unable to complete.stroke scale.responded immediately to nursing home with no lights and sirens.upon arrival.found patient semi-Fowlers [patient lies on back with head and body elevated at an angle of 30-45 degrees].in facility bed.patient's chief complaint is altered mental status.nursing staff stated patient's baseline mental status was A [alert] & [and] O[oriented] x 4.nursing staff state they had minimal information about patient due to patient being a new admit [admitted [DATE]].nursing staff stated they were unaware of contusion on face. Nursing staff stated patient had not had any recent falls.Patient noted to have no facial droop.contusion noted to right cheek.IV [intravenous-inside a vein] attempted and unsuccessful.patient was successfully transferred to stretcher via [by way of] drawsheet method and properly secured with all straps and rails.[by] 2 in a semi-Fowler's position.patient was transported to ambulance and loaded without incident or complaint.Patient was transported with no lights and sirens to [Named Hospital #1] Upon arrival patient was unloaded and transferred to facility via draw sheet method by EMS [emergency medical services] without incident.patient left in care of [Named Nurse]. 6. Review of the (Named Hospital #1's) Emergency/Urgent Care Emergency Department (ED) Physician progress note dated 7/10/2026 at 5:27 PM, revealed Resident #1 arrived at the ED via ambulance for AMS with a last known well time of 12:00 PM (time prior to hospital arrival that the patient was at their current baseline state of health). Resident #1 was non-verbal, was not moving her right arm, appeared to have right-sided facial droop, and would not follow commands. ED staff were unable to treat Resident #1 with Thrombolytic Therapy (medications to dissolve blood clots inside arteries and veins) due to the time that had lapsed since she was at her baseline. Resident #1 was diagnosed with an acute stroke and carotid artery stenosis. 7. During an interview on 7/20/2026 at 11:25 AM, the Chief Operating Officer of the (Named Ambulance Service) confirmed after reviewing Resident #1's 7/10/2026 transportation log, the facility should have called 911 during this emergency transportation to the local emergency room. During an interview on 7/20/2026 at 12:03 PM, Certified Nursing Assistant (CNA) A confirmed she had provided care to Resident #1 while in the facility. CNA A was unable to recall any bruising to Resident #1's skin. During an interview on 7/20/2026 at 12:40 PM, CNA B confirmed she provided care to Resident #1 on 7/10/2026. CNA B stated, .she seemed good early that morning, but was different after about 10:30 AM. CNA B was asked if she told anyone about the change in Resident #1. CNA B stated, I told the charge nurse she was hard to wake up and seemed different. CNA B was unable to recall if Resident #1 had any bruising to her skin. During an interview on 7/20/2026 at 1:19 PM, Registered Nurse (RN) D was asked if she performed a nursing assessment on Resident #1 on admission. RN D stated, Yes, I assessed her skin on 7/9/2026, she had moisture associated skin damage [MASD] to her right buttock, I looked at her whole body and seen small bruises on her arms where she had IVs and scabbing to her left and right toes. RN D was asked if there was bruising on any other parts of the Resident's body. RN D stated, .I was focused on her right buttock.I didn't see her the day she was discharged . During an interview on 7/20/2026 at 4:22 PM, Certified Occupational Therapist Assistant (COTA) E confirmed she treated Resident #1 before breakfast on 7/10/2026 and the resident was alert and participated in therapy. COTA E stated, .I split my time with her and was going back later in the day.At 11:00 AM I was trying to arouse her, but she wasn't arousing.the Unit Manager was there and said they were going to send her out. During a phone interview on 7/20/2026 at 7:27 PM, Physical Therapist Assistant (PTA) C confirmed she provided care to Resident #1 on 7/10/2026. PTA C stated, .I tried to arouse her prior to lunch it was somewhere around 11 [11:00] AM, she was out of it.the Unit Manager assisted me getting her in the wheelchair, it was maximum assist, took both of us to get her to the chair.the nurse said they would check her out when I brought her back.I took her to the therapy room, but I noticed her right arm was stiff, and she had excessive leaning to her right side.her eyes were barely open looking up. I took her straight back to her room sitting in her wheelchair . PTA C confirmed the Unit Manager was aware Resident #1 was not the same as the day before. PTA C stated, .I told the CNA as I left the room, that she was in her wheelchair and to check on her [Resident #1].as I passed the charge nurse, I told her the same, to check on her. During a telephone interview on 7/21/2026 at 12:06 PM, the Doctor of Nursing Practice (DNP) was asked if she was Resident #1's Primary Care DNP. The DNP stated, .I never met her but was planning to see her on Friday.the only thing I know is that she had a change of condition.the facility called me after 3:00 PM [on 7/10/2026]. The DNP confirmed the facility did not call when Resident #1's change in condition first started occurring. The DNP stated, .no.no one contacted me regarding any changes for that resident.the unit manager called me sometime after 3 [3:00] PM.I instructed her to send the patient to the ER [Emergency Room].the facility takes it upon themselves if she is having symptoms and should have called 911 [emergency telephone number]. The DNP confirmed timely assessment should be completed when residents experience changes in condition, the assessment should be documented in the medical record, and the Physician or DNP should be notified immediately. During a telephone interview on 7/22/2026 at 9:08 AM, the ADON was unable to recall if she had been notified of Resident #1's change in condition or of the lack of documentation related to the change in condition on 7/10/2026. The ADON confirmed she was notified about a bruise to Resident #1's cheek. The ADON was asked if she assessed Resident #1 after being told of a bruise to the Resident's right cheek. The ADON stated, .I did not meet her.or see a bruise.but seen it documented on the EMS run report the following week. During an interview on 7/22/2026 at 9:41 AM, the Regional Director of Clinical Services stated the facility was unaware of the bruise to Resident #1's right cheek until Monday (7/13/2026) or Tuesday (7/14/2026), after the Resident was transferred to the hospital on (Friday) 7/10/2026. The Regional Director of Clinical Services was asked if the facility's documentation of Resident #1's change of condition and the nursing assessments documentation were accurate. The Regional Director of Clinical Services stated, No. During an interview on 7/22/2026 at 10:59 AM, the Administrator stated the facility was not aware of the bruising to Resident #1's right cheek until Monday (7/13/2026) or Tuesday (7/14/2026), 3-4 days after Resident #1's transfer to Hospital #1's ER. The Administrator stated, .the bruise is part of our big investigation of the abuse allegation.we seen the [Named Ambulance] report, but our nurses never captured that in our medical record. The Administrator stated, .if the bruise was there, it should have been documented. The Administrator was asked if staff identified a bruise to a resident, while at the bedside during a transfer to the hospital, should Administration have been made aware and should have Administration investigated that. The Administrator stated, Yes. During an interview on 7/22/2026 at 11:58 AM, Paramedic L confirmed the ambulance service transfer did not use lights and sirens during Resident #1's transportation to Hospital #1's emergency room. Paramedic L was asked to describe Resident #1's presenting condition when the Ambulance Service arrived in the Resident's room. Paramedic L stated, .altered mental status.could not follow commands.painful response.yellow bruise the size of a [NAME] to the right upper cheek of her face.nurses couldn't tell me anything.we waited 10 minutes for a nurse to come to the room.she [the nurse] didn't know if she was on blood thinners.stated they [nurses] didn't know much about her [Resident #1] she was a new admit.we were in the room [ROOM NUMBER] to 30 minutes.her [Resident #1] eyes were intermittently moving.she was a full code.vital signs were normal.wasn't critical.seems like they should have called hours ago but for some reason they didn't. Paramedic L was asked should Resident #1's transfer been treated as an emergent transfer with lights and a siren. Paramedic L stated, .it's a judgement call.we base it on different factors. Paramedic L was asked if Resident #1 could have been in a stroke crisis. Paramedic L stated, .yes. During a phone interview on 7/22/2026 at 12:33 PM, the Medical Director (MD) confirmed Resident #1's change of condition and nursing assessments on 7/10/2026 should have been accurately performed and documented in the medical record, and the MD and Nurse Practitioner (NP) should have been notified immediately when the patient's change of condition started occurring. The MD confirmed the 911 emergency ambulance services should have been utilized during Resident #1's change of condition and her transfer to the hospital emergency room. During an interview on 7/22/2026 at 1:00 PM, Licensed Practical Nurse (LPN) F confirmed she provided care to Resident #1 on 7/9/2026 and 7/10/2026. LPN F stated, .the first day I seen her was on Thursday 7/9/2026, she was alert and oriented, needed assistance from staff for turning in the bed, she didn't get up by herself. LPN F confirmed she gave Resident #1 medications on the morning of 7/10/2026 and she was unable to recall any bruising to the resident's skin. LPN F stated, She was hurting some that morning, but she said she was good. LPN F was asked when she saw Resident #1 again. LPN F stated, I saw therapy rolling her back to her room around 11:30 AM.shortly after that, cannot say what time, maybe a few minutes, a CNA called me to her room. I looked at her and she was kind of out of it. LPN F was asked what she observed. LPN F stated, She was sitting in her wheelchair leaning forward with head down tilted to the left.nonverbal and no eye contact, looking in a daze.so I asked the CNAs to lay her down. LPN F was asked if she obtained vital signs or performed an assessment of Resident #1 and where did she document that. LPN F stated, .I completed a skilled assessment around 2:00 PM, I used the vital signs from earlier that day, around 11:00 AM, I think. LPN F confirmed she did not perform a head-to-toe assessment of Resident #1 at that time. LPN F was asked if she should have completed an assessment, documented it in the medical record, and notified the physician. LPN F stated, .I didn't assess the patient and document.but yes, I should have.I was just completing the skilled note before my shift was over.It was a day.was no excuse I was just overwhelmed.nothing I can say. LPN F was asked if Resident #1 had a change in condition with her altered mental status. LPN F stated, Yes. LPN F confirmed her Unit Manager knew the resident had a change, and she (the Unit Manager) called the primary DNP. LPN F confirmed she did not go back into Resident #1's room after the order was received to transfer the resident to the ER. During an interview on 7/22/2026 at 3:10 PM, LPN G confirmed she was the Unit Manager on Resident #1's hall on 7/10/2026. LPN G was asked about Resident #1's condition on 7/10/2026. LPN G confirmed she had assisted therapy in getting Resident #1 dressed and up for therapy on 7/10/2026. LPN G stated she told the Charge Nurse that Resident #1 was less talkative and to follow up with the resident after therapy. LPN G confirmed she did not do an assessment on the resident or document any changes in condition in Resident #1's medical record. LPN G was asked if the charge nurse followed up on Resident #1 and documented her assessment. LPN G stated, .I didn't see it documented in the chart. LPN G was asked if the vital signs on the transfer sheet was a new set of vital signs or vitals gotten earlier in the day. LPN G stated, .not sure.I didn't obtain or document the vital signs in the medical record.I called the [Named DNP] around 3:20 PM.I then went back to the room after the ambulance arrived.I observed a total decline.more lethargic.less responsive.making moaning gurgling noises . LPN G was asked where she documented her nursing assessment of her change of condition. LPN G stated, .I expected the licensed nurse to document the resident's change of condition because she was the nurse for the patient. LPN G confirmed a nursing assessment should have been completed and documented for Resident #1 when the change in condition was identified. LPN G was asked if this (lack of assessment) affected Resident #1's outcome. LPN G stated, .it could have. LPN G confirmed she reported Resident #1's change in condition to the ADON. LPN G was asked when she thought the change of condition occurred. LPN G stated, .probably before noon.we should have reacted sooner. LPN G was asked if she called 911 or an Ambulance Service to transport Resident #1 to the ER. LPN G stated, .I should have called 911.I called [Named Ambulance Service]. LPN G was unaware if the ambulance service came to the facility with lights and sirens on, and if the ambulance service left the facility after picking up the Resident with lights and sirens. LPN G said this was an emergent change of condition. LPN G confirmed she was not aware of a bruise to Resident #1's cheek until paramedics pointed it out during the transfer to the ER and she notified the ADON of the bruise. LPN G was unable to recall the appearance of the bruise at the time of the interview. During an interview on 7/22/2026 at 3:15 PM, the Director of Nursing (DON) confirmed that during an admission physical assessment, the licensed nurse should look at the whole body for any issues or concerns. The DON was asked would an adequate assessment include any type of bruising. The DON stated, Yes. The DON was asked if a bruise was identified during an assessment or an observation of a resident, when should the investigation of how the bruise occurred begin. The DON stated, Immediately. The DON was asked if the bruise was assessed to Resident #1's right cheek, should the licensed nurse have documented it in the medical record. The DON stated, Yes. The DON was asked if staff monitored Resident #1's change of condition (on 7/10/2026). The DON stated, .I expect the nurses to come in and round on the residents.if a change of condition starts to occur.the licensed nurse should document the change of condition immediately. The DON confirmed the nurse should assess and identify the change of condition timely and document their findings, then notify the Physician or Nurse Practitioner (NP) as soon as the change is identified. The DON confirmed she had been involved in discussions about whether or not Resident #1's change in condition was identified timely and if it was documented in the medical record, but she (the DON) had not personally read the documentation. The DON was asked if the facility did not do a timely assessment or document their assessment findings or did not communicate their assessment to the Doctor of Nursing Practice (DNP), or call the DNP for instructions, could this have caused injury or a decline in the outcome of the resident's condition. The DON stated, .it could have caused it. The DON confirmed staff should have called 911 for Resident #1's transfer to the ER on [DATE]. Refer to F600 The Removal Plan was verified and validated onsite by the surveyor on 7/20/2026 through 7/22/2026 through review of the in-service training records and audits, review of the facility's policy, observations, and staff interviews. Identification of Residents Affected or Likely to be Affected: The facility took the following actions to review and identify residents affected or likely to be affected. Resident #1 was discharged to the emergency room on 7/10/26. The DON, ADON, SDC, IP nurse, Unit Managers, Nurse Supervisors, Wound Care Nurse, Medical record nurse, admission Nurse or MDS Coordinators will assess current residents with BIMS of 7 or less for any injuries that are suspicious in nature or of unknown origin and identified will be reported and investigated per state/federal guidelines. This will be completed on 7/18/26. The DON, Social Services Director, Social service assistant, MDS Nurse, ADON will interview current residents with BIMS scores of 8 and above for potential abuse and/or neglect. Any allegations of abuse and/or neglect will be reported/investigated per state/federal guidelines. This will be completed on 7/18/26. Residents who are not interview able with a BIMs score of 7 or below will have a skin assessment to identify any injuries that are suspicious in nature or of unknown origin. The DON, ADON, SDC, IP nurse, Unit Managers, Nurse Supervisors, Social services, Wound care nurse, Medical record nurse, admission nurse or MDS Coordinators will assess for change in condition including vital signs, respiratory assessment, change in mentality and overall change in condition, to identify any change to determine if any current resident has a change in condition with any change in condition being reported to the provider for further instruction. This will be completed on 7/18/26. The RDO/VPO will educate the Administrator and DON on abuse/neglect policy and reporting guidelines on 7/18/26. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. The Administrator and Director of Nursing reviewed the Abuse and Neglect policy and the Notification of Changes policy and no further recommendations on 7/18/26. The DON, ADON, SDC, IP Nurse, Unit managers, Medical record Nurse or Nursing Supervisors will provide education to all current licensed nurses on notification to provider on significant change in medical conditions to include completion of documentation, assessment, notification and use of the emergency services in cases of medical emergencies. No licensed staff will be allowed to work after 7/18/26 until they have completed this training. The facility does not utilize agency staff, and any new hired licensed nurse will be educated during orientation. All current licensed nurses will be given a posttest to validate understanding. All current direct care staff, Nurses, Certified Nursing Assistants and Therapy Staff will be educated on the stop and watch program which is a evidence based program part of the INTERACT program to alert to early warning signs of change in condition and report to nurse via direct communication or the electronic medical record. No direct care staff will be allowed to work after 7/18/26 until they have completed this training. The facility does not utilize agency staff, and any newly hired direct care staff will be educated during orientation. All current direct care staff will be given a posttest to validate understanding. All current staff will be educated on Abuse and neglect policy to include injuries of unknown origin and/or suspicious in nature with a posttest given with each staff member passing with 100% accuracy. Education will be completed by the Administrator, Director of Nursing, Social Services Director, ADON, Unit Manager, Staff Development Coordinator, or Nurse Supervisor. No staff will be allowed to work after 7/18/26 until they have completed this training. The facility does not utilize agency staff, and any newly hired staff will be educated during orientation. The DON, ADON, SDC, IP Nurse, Unit Managers, or Nursing Supervisors will conduct 5 employee questionnaires weekly x 12 weeks to validate understanding of abuse/neglect policy. The DON, ADON, SDC, IP Nurse, Unit Managers, Medical

Based on policy review, medical record review, and interview, the facility failed to notify the Doctor of Nursing Practitioner (DNP) and the resident's legal representative of a change of condition that was identified on 7/10/2026 at approximately 10:56 AM for 1 of 6 (Resident #1) sampled resident reviewed for notification of change. Based on policy review, medical record review, and interview, the facility failed to notify the Doctor of Nursing Practitioner (DNP) and the resident's legal representative of a change of condition that was identified on 7/10/2026 at approximately 10:56 AM for 1 of 6 (Resident #1) sampled residents reviewed for notification of change. The findings include: 1. Review of the facility policy titled, Notification of Changes, dated 8/29/2024, revealed .The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, resident's representative when there is a change requiring notification.Circumstances requiring notification include.Significant change in the resident's physical, mental, or psychological condition such as deterioration in health, mental or psychosocial status. This may include Life- threatening conditions, or Clinical complications. Review of the facility policy titled, Transfer and Discharge (including AMA [Against Medical Advice]), dated 10/30/2023 revealed .Emergency Transfers/ Discharges- initiated by the facility for medical reasons .Notify resident and/or resident representatives . 2. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses including Hypertension, Fracture of Superior Rim of Right Pubis (pelvic fracture), Encounter for Fracture with Routine Healing, Osteoarthritis, and Overactive Bladder. Review of the 5-day Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) assessment was not coded. Review of the facility's Skilled Daily Note for Resident #1 dated 7/10/2026 at 3:33 PM, revealed Resident #1 experienced a change in condition and exhibited decreased consciousness, decreased mobility, and lethargy that began at approximately 10:56 AM, and vital signs were taken at that time. The DNP and RP were not notified of the change in condition when it first occurred. Review of the Nurses' Note for Resident #1 dated 7/10/2026 at 4:00 PM, revealed documentation that Resident #1 experienced a change of condition and an order was received to send the resident out to the emergency room (ER). During a telephone interview on 7/16/2026 at 12:30 PM, Resident #1's Responsible Party (RP) stated he was notified of the Resident's change of condition on 7/10/2026 at 3:30 PM, prior to her being transferred out to the ER. During an interview on 7/20/2026 at 12:40 PM, CNA B confirmed she provided care to Resident #1 on 7/10/2026 and the Resident was different after 10:30 AM. CNA B said she told the charge nurse Resident #1 was hard to awaken and seemed different. During an interview on 7/20/2026 at 4:22 PM, Certified Occupational Therapist Assistant (COTA) E was asked if she cared Resident #1 on the day she was discharged (7/10/2026). COTA E stated, .yes, she participated well before breakfast, she was talking alert and oriented.I split my time with her and was going back later in the day.At 11:00 AM I was trying to arouse her, but she wasn't arousing.the Unit Manager was there and said they were going to send her out. During a phone interview on 7/21/2026 at 12:06 PM, the DNP confirmed she was Resident #1's Primary Care Provider. The DNP said she was notified of Resident #1's change in condition after 3:00 PM on 7/10/2026, but she should have been notified when the change in condition first occurred. During an interview on 7/22/2026 at 1:00 PM, Licensed Practical Nurse (LPN) F was asked if she did a head-to-to-toe assessment on Resident #1. LPN F stated, No, I didn't. LPN F was asked if staff communicated to her a change in condition. LPN F stated, .not sure . LPN F was asked if she should have completed an assessment, documented it in the medical record, and notified the physician. LPN F stated, .I didn't assess the patient and document.but yes, I should have. LPN F confirmed she did not notify the DNP or Resident #1's family when the change of condition began. During an interview on 7/22/2026 at 3:15 PM, the Director of Nursing (DON) confirmed the facility should have notified Resident #1's DNP and her family, as soon as the change of condition started occurring. Refer to F-600 and F-684

Based on interview, record review, facility document and policy review, the facility failed to implement procedures for missing items and grievances for 1 of 1 (Resident #105) resident reviewed for personal property. Findings included: A facility policy titled, Complaint and Grievance Process, revised 01/01/2022, revealed, Purpose: To enable any individual to file a complaint either directly to the Facility (internal complaint) or to the Secretary of Health and Human Services. The policy continued, 5. The Facility will receive and document complaints, but no response is required. 6. Complaints and their disposition will be documented, if any. An Face Sheet revealed the facility admitted Resident #105 on 04/25/2025. According to the Face Sheet, the resident had a medical history that included diagnoses of hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following a cerebral infarction (blockage of blood flow) affecting the left dominant side. A 5-Day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/02/2025, revealed Resident #105 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. A document titled, 24 Hour Report/Change of Condition Report, dated 05/04/2025, revealed Resident #105 was missing light blue top- Lands End, 2 XL [extra-large]. The facility's Record of Concern Log for May 2025 revealed no documented grievances or concerns involving Resident #105. During an interview on 06/19/2026 at 10:23 AM, the Social Service Director (SSD) stated that when a missing item was reported, she made sure it was on the inventory sheet. She completed a grievance, searched the room to make sure it did not get mixed into the roommate's items, and called the family to see if they had the item. If the item was not on the inventory sheet, she gave the family an option to purchase the same item and then reimburse the item. The SSD stated that if a resident had been discharged and reported an item missing, the process was the same. The SSD stated that if a grievance was reported to her or discussed during the morning meetings, she created a grievance. If the item was not found, then the Business Office Manager ordered another item like the missing item and provided a receipt that was attached to the grievance. The SSD reviewed the grievances and stated that she did not have a grievance for Resident #105's missing light blue shirt. During an interview on 06/19/2026 at 11:13 AM, the Business Office Manager (BOM) stated that if an item was reported missing, the social worker was supposed to investigate it. Their process was to pull the inventory sheet to review for replacement or reimbursement. If the item was not on the inventory list, it got replaced most of the time, depending on the cost. If the item was purchased by the resident, family, or representative, the BOM asked for receipts and requested a check from the corporate office. If it was a high-ticket item, it was reviewed by the Administrator for reimbursement. The BOM reviewed the payment systems and did not locate a reimbursement to Resident #105 or their representative in April, May, or June. The BOM reviewed her notes and did not have any notes outlining a discussion of reimbursement with Resident #105 or their representative. During an interview on 06/19/2026 at 12:45 PM, the Administrator stated that he expected grievances related to missing items to be handled through the grievance process.

Based on interview, record review, and facility document review, the facility failed to monitor and provide treatment for constipation for 1 (Resident #108) of 2 residents reviewed for bladder and bowel incontinence. Findings included:During an interview on 06/18/2026 at 10:15 AM, the Director of Nursing (DON) stated there was no bowel management policy available.A facility document titled, Clinical Pathways (Please follow protocols before calling provider), dated 11/04/2019, indicated, After 2 days of constipation, check for impaction first; give milk of magnesia 30 cc [cubic centimeters] po/peg [by mouth or feeding tube] daily prn [pro re nata or as needed] if no renal failure; or give dulcolax 5 mg [milligrams] tablet, 1 tablet po/peg/suppository per rectum daily prn; If milk of magnesia or dulcolax not effective after 4 hours, give fleets enema. Notify provider if not effective within 24 hours.A Face Sheet indicated the facility admitted Resident #108 on 12/09/2025. According to the Face Sheet, the resident had a medical history that included diagnoses of encephalopathy, acute and chronic respiratory failure with hypoxia, sepsis, pneumonia, dysphagia, heart failure, type 2 diabetes mellitus, chronic atrial fibrillation, end stage renal disease, need for assistance with personal care, and dependence on renal dialysis. A 5-day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/16/2025, revealed Resident #108 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS was coded to indicate that the resident was dependent on staff for toileting hygiene and had not attempted toilet transfers (the ability to get on and off a toilet or commode) during the assessment look-back period due to a condition or safety concerns. Per the MDS, the resident was frequently incontinent of bowel and was not on a toileting program to manage bowel incontinence.Resident #108's Care Plan Report, included a focus area initiated on 12/09/2025 that indicated the resident had episodes of bowel/bladder incontinence related to congestive heart failure, diabetes, diuretic use, generalized weakness, impaired mobility, pain, physical limitations, and renal disease. Interventions directed staff to observe for no bowel movement in three days (initiated 12/09/2025). Resident #108's Care Plan Report, included a focus area initiated on 12/09/2025 that indicated the resident was at risk for fluid volume deficit related to diabetes, diuretic use, renal disease, having a feeding tube, receiving nothing by mouth (NPO), dialysis, and recent infections. Interventions directed staff to observe the frequency of bowel movements and to provide medication as ordered (initiated 12/17/2025). Resident #108's Order Recap [recapitulation] Report for the timeframe from 06/01/2025 through 06/30/2026, revealed an ordered started on 12/09/2026 to monitor/document/report to the physician any side effects of pain medication, which included Observe for constipation. The Order Recap Report revealed no medication orders to treat constipation. Resident #108's Documentation Survey Report for the month of December 2025 indicated no bowel movement (BM) on 12/11/2025, 12/13/2025, 12/14/2025, and 12/15/2025; 12/16/2025 small BM at 11:44 AM; 12/17/2025 no BM; small BM on 12/18/2025 at 2:31 PM; large BM on 12/19/2025 at 3:21 AM; 2 medium bowel movements on 12/20/2025 at 1:14 PM and 8:34 PM; no BM on 12/21/2025, 12/22/2025, 12/23/2025, and 12/24/2025; a small bowel movement on 12/25/2025 at 10:26 AM; and no BM on12/26/2025, and 12/27/2025. Resident #108's Medication Administration Record for December 2025 indicated instructions to monitor, document or report to physician any observation of constipation due to using pain medications. There was no documented evidence that Resident #108 received medication for constipation. Resident #108's Progress Notes dated 12/27/2025 at 7:53 AM, indicated that Resident #108 had two episodes of nausea and vomiting, and orders were received from the Nurse Practitioner (NP) for anti-nausea medication and to follow the protocol for nausea and vomiting and constipation. During an interview on 06/18/2026 at 9:40 AM, Certified Nurse Aid (CNA) #5 stated that she documented bowel movements on every resident daily and informed the nurse prior to the end of her shift. She stated that the nurses were able to see the documentation on the computer, but she notified them anyway to remind them if a resident was not having bowel movements. During an interview on 06/18/2026 at 9:51 AM, CNA #6 stated that she documented residents' bowel episodes in the point of care system (electronic charting system) and let the nurse know if there was a change in consistency. She stated generally if there was no BM within two or three days, she notified the nurse. She stated that the protocol in the facility was to notify the nurse if a resident had no BM for two days, but she notified the nurse daily after each shift for all the residents she was assigned to provide care prior to leaving for the day. During an interview on 06/18/2026 at 10:00 AM, Licensed Practical Nurse (LPN) #7 stated that she was unaware of a notification system on the computer alerting her about residents not having a BM. She stated that she went into Point Click Care (the electronic medical record system) for each resident she was assigned to throughout the shift and could see if they were having bowel movements or not. LPN #7 stated that if the CNAs told her then she looked, if the resident informed her, then she verified the information with the staff. She stated that if a resident had no BM in three days, then she notified the NP for orders. She stated that she was not familiar with the bowel protocol nor the standing orders. During an interview on 06/18/2026 at 12:57 PM, Staff Development/Licensed Practical Nurse (SD/LPN) #9 stated that all staff go through online video training. She said CNAs were educated that if a resident did not have a BM that the nurse should be notified at the end of the CNA's shift and the nurse should initiate the bowel protocol. SD/LPN #9 stated that the nurse on every shift was required to follow the bowel protocol.During an interview on 06/18/2026 at 1:37 PM, the Assistant Director of Nursing (ADON) stated that Resident #108 should have had something after three days with no bowel movement but stated that there was nothing documented on Resident 108's Medication Administration Record (MAR). She stated that they did not have any record of Resident #108 populating on the alert system nor being added to a list that was given to the staff for intervention. During an interview on 06/17/2026 at 9:56 AM, the Nurse Practitioner (NP) stated that she did not recall the situation nor being called but stated that there was a protocol that staff would have followed and would not have needed to call her. She stated that the resident had abnormal labs and that she referred them back to the nephrologist due to kidney issues. During an interview on 06/19/2026 at 2:50 PM, the Administrator stated that he would defer all medical questions to the nursing team, as he was not a clinical professional.

Based on record review, observation, interview, and facility document review, the facility failed to ensure staff provided catheter care appropriately for 1 of 2 (Resident #24) residents reviewed for catheter care. Findings included: A facility policy titled, Catheter Care Procedure- Urinary, revised 12/28/2023, indicated, 5. Catheters should be secured to prevent pulling and damage to the urethral meatus. This may be accomplished by: a. Utilizing the appropriate drainage device (leg bag or catheter bag) b. leg strap c. Velcro strap d. Linen/clothing clamp e. Adhesive securing device.An undated facility document titled Peri and Catheter Care, revealed a skills checkoff list for catheter care. Per the document, questions 8 through 10 included a list of tasks to complete for catheter care and an option to document whether the staff member met or did not meet the task requirement. The document revealed the tasks for catheter care included, Stabilize the catheter near the insertion point. Using a new, clean cloth wipe the catheter tubing starting near the insertion point and working downward. Clean at least 4 inches of tubing. If multiple wipes are required to cleanse the tubing grab a new cloth each time, starting from the meatus and working downward. Repeat steps to rinse and dry as indicated. A Face Sheet indicated that the facility admitted Resident #24 on 03/06/2025. According to the Face Sheet, the resident had a medical history that included diagnoses of other neuromuscular dysfunction of the bladder, chronic kidney disease, and presence of urogenital implants. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/12/2026, revealed Resident #24 had a Brief Interview for Mental Status (BIMS) score of 2, which indicated the resident had severe cognitive impairment. The MDS revealed that the resident had an indwelling catheter.Resident #24's Care Plan Report included a focus area initiated on 03/06/2025 that indicated Resident #24 had a need for an indwelling suprapubic catheter related to neurogenic bladder. Interventions directed staff to assist the resident with catheter care as needed (revised 04/22/2025) and to keep the catheter tubing free of kinks and twists (initiated 03/25/2025).Resident #24's physician Order Summary Report for active orders as of 06/17/2026, revealed an order started on 02/04/2026 to cleanse area around the supra pubic catheter site with soap and water, rinse and pat dry then apply split 4x4 gauze daily and as needed.During a catheter care observation on 06/17/2026 at 10:09 AM, Certified Nurse Aide (CNA) #3 opened Resident #24's incontinence brief and used wet wipes to wipe the catheter insertion site. CNA #3, without securing or stabilizing the catheter tubing, then used another wipe and cleaned the catheter away from the resident, tugging on the tubing. The CNA repeated the wiping steps three additional times, then discarded the wipe. During an interview on 06/18/2026 at 10:27 AM, CNA #3 stated that he was supposed to hold the base of the catheter when he cleaned the catheter. During an interview on 06/19/2026 at 12:51 PM, the Director of Nursing stated that it was her expectation that staff provide catheter care according to the skills checklist. During an interview on 06/19/2026 at 2:50 PM, the Administrator stated that he would defer all medical questions to the nursing team, as he was not a clinical professional.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure that 1 of 5 (Resident #24) residents reviewed for respiratory care had oxygen therapy administered at the physician's order rate. Findings included: A facility policy titled, Oxygen Administration, implemented 06/23/2025, indicated, Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. The policy further indicated, Oxygen is administered under the orders of a physician, except in the case of an emergency.A Face Sheet indicated the facility admitted Resident #24 on 03/06/2025. According to the Face Sheet, Resident #24 had a medical history that included diagnoses of atelectasis and dependence on supplemental oxygen. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/12/2026, revealed Resident #24 had a Brief Interview for Mental Status (BIMS) score of 2, which indicated the resident had severe cognitive impairment. The MDS indicated that Resident #24 received oxygen therapy during the assessment's look-back period. Resident #24's Care Plan Report, included a focus area initiated 04/22/2025, that indicated Resident #24 had impaired pulmonary/respiratory status related to respiratory infection, and pneumonia with atelectasis. Interventions directed staff to provide supplemental oxygen as needed when the resident exhibited signs of difficulty breathing. Resident #24's Order Summary Report, with active orders as of 06/17/2026, contained an order dated 04/08/2026 for supplemental oxygen at 3 Liters Per Minute (LPM) via nasal cannula continuously for shortness of breath. An observation on 06/15/2026 at 12:04 PM revealed Resident #24 in bed with supplemental oxygen on. The oxygen concentrator was set to 4.5 LPM. An observation on 06/16/2026 at 3:22 PM revealed Resident #24 in bed with supplemental oxygen on. The oxygen concentrator was set to 4.5 LPM. An observation on 06/18/2026 at 1:29 PM revealed Resident #24 in bed with supplemental oxygen on. The oxygen concentrator was set to 4.5 LPM. During a concurrent observation and interview on 06/18/2026 at 1:39 PM, Licensed Practical Nurse (LPN) #7 stated Resident #24's supplemental oxygen was always on, and she just had to check it to ensure it was running at the correct rate. LPN #7 reviewed Resident #24's physician orders and confirmed the oxygen order was for 3 LPM. LPN #7 then went to Resident #24's room to confirm the oxygen was running at the correct rate. Upon seeing the concentrator, LPN #7 confirmed that the oxygen concentrator had been set too high and corrected it to 3 LPM. During an interview on 06/19/2026 at 11:37 AM, the Administrator stated that if supplemental oxygen had been ordered, his expectation was that nursing should have checked the rate and corrected it if it had been running at the wrong rate. During an interview on 06/19/2026 at 11:50 AM, the Director of Nursing (DON) stated that if a resident had an order for supplemental oxygen, she expected it to be administered at the correct rate. The DON stated that nursing staff should have checked the rate to ensure the rate was correct.

Based on interview and record review, the facility failed to ensure residents were free from significant medication errors, which affected 1 of 1 (Resident #4) resident reviewed for antibiotic use. Findings include:An Face Sheet indicated the facility originally admitted Resident #4 on 04/15/2025 and readmitted the resident on 05/13/2026. According to the Face Sheet, the resident had a medical history that included diagnoses of pressure ulcer of sacral region, stage 4, and osteomyelitis (infection in a bone) of vertebra, sacral, and sacrococcygeal region.A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/09/2025, revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated that Resident #4 had a sacral pressure ulcer.Resident #4's Care Plan Report included a focus area initiated 07/14/2025 and revised on 05/14/2026 that indicated the resident had a sacral wound infection. Interventions directed staff to administer medications and treatments as ordered. Resident #4's After Visit Summary from the hospital, dated 05/13/2026, indicated in the comments section, pt [patient] needs IV [intravenous] ertapenem [an antibiotic] 1gm [gram] q24 [every 24 hours] x 06/22/2026.Resident #4's Order Recap [recapitulation] Report, for the timeframe from 05/01/2026 through 06/01/2026 included an order for ertapenem sodium injection solution 1 gram intravenously one time a day for sacral decubitus infection until 05/22/2026 (start date 05/15/2026). The Order Recap Report also included an order for ertapenem sodium injection solution 1 gram intravenously one time a day for sacral decubitus infection until 06/29/2026 (start date 05/27/2026). Resident #4's May 2026 Medication Administration Record revealed no documented evidence the ertapenem sodium solution 1 gram IV was administered on 05/23/2026, 05/24/2026, 05/25/2026, and 05/26/2026. During an interview on 06/18/2026 at 10:38 AM, the Wound Care Physician (WCP) stated Resident #4 went to the hospital and returned to the facility with a peripherally inserted central catheter (PICC) line and on antibiotic therapy due to a wound infection. During an interview on 06/18/2026 at 5:14 PM, Registered Nurse (RN) #16 confirmed she entered the antibiotic (ABT) order for ertapenem into the computer with a discontinuation date of 05/22/2026. She confirmed that the hospital discharge orders had a discontinuation date of 06/22/2026. RN #16 stated that she received the ABT order verbally from another nurse who no longer worked in the facility. She stated that she did not check the ABT order herself prior to entering the order into the computer system. During an interview on 06/18/2026 at 5:29 PM, the Director or Nursing stated that Resident #4 had missed four doses, and the wound care doctor was contacted and extended the stop date for four additional days. During a follow-up interview on 06/19/2026 at 10:13 AM, the WCP stated that she was made aware that the ABT had been discontinued prematurely. She stated that she gave orders to continue the medication. The WCP stated that with osteomyelitis, there was only a 70% chance of healing with the first course of medication, and the wound was looking good; therefore, it was significant for Resident #4 to receive the medication. During an interview on 06/19/2026 at 2:50 PM, the Administrator stated that he would defer all medical questions to the nursing team, as he was not a clinical professional.

Based on policy review, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions when opened, unlabeled, undated food was in the Kitchen and the dry storage area, black, shiny build-up was on the stove, frying pans, and ovens, a shiny yellow build-up was observed on the vent-a-hood, thick, dark gray dust was observed on the fan in the walk-in-cooler, dark, brown build-up was observed on the tea makers, 9 serving trays were wet-nested, 6 metal pans were wet-nested, and 1 of 6 dietary staff (Dietary Aide #2) used a dirty dish rack to push a clean dish rack out of the ware-washer and failed to perform hand hygiene when she went from the dirty side of the ware-washer to the clean side. The facility had a census of 77 with 73 of those residents receiving a tray from the kitchen. The findings include: Review of the facility's policy titled, .Food Storage: Cold, dated 5/2014, revealed .The Food Service Director/Cooks(s) ensures that all food items are stored properly in covered containers, labeled and dated . Review of the facility's policy titled, .Manual Warewashing, revised on 9/2017, revealed .All serviceware and cookware will be air dried prior to storage . Review of the facility's policy titled, .Environment, revised on 9/2017, revealed .All food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition .The Dining Services Director will ensure that all employees are knowledgeable in the proper procedures for cleaning and sanitizing of all food service equipment and surfaces . Review of the facility's policy titled, .Food Preparation, revised on 9/2017, revealed .All staff will practice proper hand washing techniques and glove use .Dining Services staff will be responsible for food preparation procedures that avoid contamination by potentially harmful physical, biological, and chemical contamination . Review of the facility's policy titled, .Equipment, revised on 9/2017, revealed .All non-food contact equipment will be clean and free of debris . Observation in the in the Kitchen on 6/27/2022 at 9:15 AM, revealed: a. 2 open, undated packages of dry seasoning mix b. 1 open, undated, unsealed bag of confectioner sugar Observation in the in the Kitchen on 6/27/2022 at 9:15 AM and 2:00 PM, and on 6/28/2022 at 8:36 AM, revealed: a. two tea makers with a dark brown substance on the metal area above the tea bag holder b. a shiny black substance on 6 gas stove burners c. a shiny gold accumulation on the stove's vent-a-hood Observation in the walk-in cooler on 6/27/2022 at 9:21 AM and 2:08 PM, revealed a thick, dark gray ball of dust on the exhaust fan. Observation in the dry storage area of the Kitchen on 6/27/2022 at 9:27 AM, revealed: a. an opened, undated bag of toasted oats cereal b. an opened, undated bag of confectioner sugar During an interview on 6/27/2022 at 2:00 PM, the Dietary Manager (DM) observed the stove and stated, .It will always look like that. The stove is 7 years old . Observation in the Dishwashing Area on 6/27/2022 at 2:10 PM, revealed Dietary Aide #2 used a dirty rack of dishes to push a clean rack of dishes out of the ware-washer. Dietary Aide #2 removed her soiled gloves, failed to perform hand hygiene, went to the clean side of the ware-washer, lifted the handle, and opened the ware-washer with soiled hands. Dietary Aide #1 entered the dish room, removed serving trays from a clean rack, dried the trays with a disposable towel, and failed to allow the trays to air dry. Observation in the Dishwashing Area on 6/27/2022 at 2:18 PM, revealed 9 wet-nested serving trays stacked on a shelf. Observation in the Kitchen on 6/28/2022 at 8:36 AM, revealed a black, shiny build-up inside the upper and lower ovens on the base and sides. Observation in the dry storage area in the Kitchen on 6/28/2022 at 8:39 AM, revealed: a. an opened, undated bag of hot dog buns b. an opened, undated package of sliced bread Observation in the Dishwashing Area on 6/28/2022 at 8:43 AM, revealed a black, shiny build-up on the outer surface of a frying pan on a metal shelf. Observation in the Dishwashing Area on 6/28/2022 at 11:25 AM, revealed the following on a metal shelf: a. two wet-nested 6-inch quarter metal pans, b. two wet-nested 4-inch full metal pans, c. two wet-nested 6-inch half metal pans, and d. black, shiny build-up on the outer surface of a frying pan. During an interview on 6/29/2022 at 3:29 PM, the Registered Dietician (RD) confirmed opened foods should be dated and labeled, the stove should not have carbon or grease build-up, the vent-a-hood should not have grease build-up, staff should not use a dirty rack of dishes to push a clean rack of dishes out of the ware-washer, staff should sanitize their hands after removing gloves, staff should not use their soiled hands to lift the handle on the clean side of the ware-washer, tea makers should be clean, all serving trays and metal pans should be air dried and not wet-nested, skillets should be free of carbon build up, the exhaust fan in the walk-in cooler should be free of dust, and the oven should be clean.

Based on policy review, medical record review, and interview, the facility failed to provide education for Advance Directives to residents or residents' responsible parties for 24 of 24 sampled residents (Resident #5, #8, #9, #11, #12, #14, #15, #17, #18, #26, #31, #32, #34, #35, #36, #44, #51, #62, #65, #67, #71, #224, #424, and #425) reviewed for Advanced Directives. The findings include: Review of the facility's policy titled, Residents' Rights Regarding Treatment and Advance Directives, dated 1/1/2022, revealed .It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive .The facility will provide the resident or resident representative information, in the manner that is easy to understand, about the right to refuse medical or surgical treatment and formulate an advance directive .upon admission . Review of the medical record, revealed Resident #5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #5 had severe cognitive impairment. Review of Resident #5's medical record, revealed there was no documentation the resident or their legal guardian were informed or provided written information regarding their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #8 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE], revealed Resident #8 had severe cognitive impairment. Review of Resident #8's medical record, revealed there was no documentation the resident or their legal guardian were informed or provided written information regarding their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #9 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE], revealed Resident #9 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact. Review of Resident #9's medical record, revealed there was no documentation the resident or their legal guardian were informed or provided written information regarding their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #11 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE], revealed Resident #11 was cognitively intact with a BIMS of 15. Review of Resident #11's medical record, revealed there was no documentation the resident or their legal guardian were informed or provided written information regarding their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #12 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS dated [DATE], revealed Resident #12 was cognitively intact with a BIMS of 15. Review of Resident #12's medical record, revealed there was no documentation the resident or their legal guardian were informed or provided written information regarding their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #14 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE], revealed Resident #14 had moderate cognitive impairment with a BIMS of 8. Review of Resident #14's medical record, revealed there was no documentation the resident or their legal guardian were informed or provided written information regarding their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #15 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the significant change MDS assessment dated [DATE], revealed Resident #15 rarely/never understands, and had short and long term memory problems. Review of Resident #15's medical record, revealed there was no documentation the resident or their legal guardian were provided written information or informed of their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #17 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS dated [DATE], revealed Resident #17 had severe cognitive impairment with a BIMS of 3. Review of Resident #17's medical record, revealed there was no documentation the resident or the legal guardian were informed or provided written information regarding their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #18 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS dated [DATE], revealed Resident #18 had severe cognitive impairment with a BIMS of 2. Review of Resident #18's medical record, revealed there was no documentation the resident or their legal guardian were provided written information or informed of their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #26 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual MDS dated [DATE], revealed Resident #26 had severe cognitive impairment. Review of Resident #26's medical record, revealed there was no documentation the resident or their legal guardian were informed or provided written information regarding their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #31 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE], revealed Resident #31 had severe cognitive impairment with a BIMS of 6. Review of Resident #31's medical record, revealed there was no documentation the resident or their legal guardian were provided written information or informed of their right to formulate an Advance Directive upon admission. Review of the medical record, revealed Resident #32 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the quarterly MDS dated [DATE], revealed Resident #32 had severe cognitive impairment. Review of Resident #32's medical record, revealed there was no documentation the resident or their legal guardian were informed or provided written information regarding their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #34 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE], revealed Resident #34 was cognitively intact with a BIMS of 15. Review of Resident #34's medical record, revealed there was no documentation the resident or their legal guardian were provided written information or informed of their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #35 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE], revealed Resident #35 was cognitively intact with a BIMS of 15. Review of Resident #35's medical record, revealed there was no documentation the resident or their legal guardian were informed or provided written information regarding their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #36 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE], revealed Resident #36 had severe cognitive impairment with a BIMS of 3. Review of Resident #36's medical record, revealed there was no documentation the resident or their legal guardian were provided written information or informed of their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #44 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE], revealed Resident #44 had severe cognitive impairment with a BIMS of 3. Review of Resident #44's medical record, revealed there was no documentation the resident or their legal guardian were informed or provided written information regarding their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #51 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE], revealed Resident #51 had severe cognitive impairment with a BIMS of 4. Review of Resident #51's medical record, revealed there was no documentation the resident or their legal guardian were provided written information or informed of their right to formulate an Advance Directive upon admission. Review of the medical record, revealed Resident #62 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS dated [DATE], revealed Resident #62 had moderate cognitive impairment with a BIMS of 11. Review of Resident #62's medical record, revealed there was no documentation the resident or their legal guardian were informed or provided written information regarding their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #65 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual MDS dated [DATE], revealed Resident #65 had severe cognitive impairment with a BIMS of 7. Review of Resident #65's medical record, revealed there was no documentation the resident or their legal guardian were provided written information or informed of their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #67 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE], revealed Resident #67 was cognitively intact with a BIMS of 15. Review of Resident #67's medical record, revealed there was no documentation the resident or their legal guardian were informed or provided written information regarding their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #71 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE], revealed Resident #71 was cognitively intact with a BIMS of 15. Review of Resident #71's medical record, revealed there was no documentation the resident or their legal guardian were provided written information or informed of their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #224 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS dated [DATE], revealed Resident #224 had severe cognitive impairment with a BIMS of 2. Review of Resident #224's medical record, revealed there was no documentation the resident or their legal guardian were informed or provided written information regarding their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #424 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS dated [DATE], revealed Resident #424 had severe cognitive impairment. Review of Resident #424's medical record, revealed there was no documentation the resident or their legal guardian were provided written information or informed of their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #425 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS dated [DATE], revealed Resident #425 was cognitively intact with a BIMS of 15. Review of Resident #425's medical record, revealed there was no documentation the resident or their legal guardian were provided written information or informed of their right to formulate an Advanced Directive upon admission. During an interview on 6/28/2022 at 8:50 AM, the Administrator confirmed the facility did not have the Advanced Directives or documentation that education for Advanced Directives had been provided. The Administrator stated, .All I have is what I showed you [physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on policy review, observation, and interview, the facility failed to maintain a safe, sanitary, and homelike environment for 2 of 45 resident rooms (Room #125 and #222) related to a torn fall mat on the floor and a dirty privacy curtain, and when 5 of 5 Lifts (Hoyer Lift #1, Hoyer Lift #2, Hoyer Lift #3, Stand Lift #1, and Stand Lift #2) had dirty grime build-up. The findings include: Review of the facility's policy titled, Cleaning and Disinfection of Resident-Care Equipment, dated 3/20/2020, revealed .Resident-care equipment can be a source of indirect transmission of pathogens. Reusable resident-care equipment will be cleaned and disinfected in accordance with current CDC (Centers for Disease Control) recommendations in order to break the chain of infection .Multiple-resident use equipment shall be cleaned and disinfected after each use . Review of the facility's undated policy titled, .JOB TO BE DONE .CLEAN CUBICLE CURTAINS, revealed .If curtain is stained, remove immediately .Have spare curtains to replace dirty or torn curtains immediately . Observation in Room #125 on 6/27/2022 at 9:17 AM, 2:39 PM, and 4:44 PM, on 6/28/2022 at 8:35 AM and 11:23 AM, and on 6/29/2022 at 2:42 PM, revealed the fall mat on the floor had torn, ripped areas, and the torn pieces were hanging off of the mat onto the floor. During an interview on 6/29/2022 at 6:40 PM, the Assistant Director of Nursing (ADON) confirmed the fall mat in Room #125 was not in good condition. Observation in Room #222 on 6/27/2022 at 10:19 AM, 1:55 PM, and 4:28 PM, on 6/28/2022 at 8:03 AM, 12:04 PM, and 5:24 PM, and on 6/29/2022 at 7:47 AM, revealed a privacy curtain near the entrance to the room had splatters of a brown substance on the curtain and a privacy curtain in the middle of the room had splatters of a reddish brown substance on the curtain. During an interview on 6/29/2022 at 7:58 AM, the Housekeeping Manager confirmed the privacy curtains in Room #222 were stained and needed to be cleaned. Observation in the 100 Hall on 6/28/2022 at 9:00 AM and 11:25 AM, revealed Stand Lift #1 and Stand Lift #2 had gray and white flaky material covering the base of the stands, and the wheels on both lifts had a build up of dust, grime, and hair. Observation in the Activity Room on 6/29/2022 at 4:30 PM, revealed Stand Lift #1 and Stand Lift #2 had gray and white flaky material covering the base of the stands, and the wheels on both lifts had a build up of dust, grime, and hair. During an interview on 6/29/2022 at 4:30 PM, the Activity Director confirmed Stand Lift #1 and Stand Lift #2 needed to be cleaned. During an observation and interview in the Activity Room and the 100 Hall on 6/30/2022 beginning at 8:15 AM, the ADON confirmed Hoyer Lift #1, Hoyer Lift #2, Hoyer Lift #3, Stand Lift #1 and Stand Lift #2 were dirty and needed to clean.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure Activities of Daily Living (ADL) assistance related to nail care and facial hair was provided for 4 of 18 sampled residents (Resident #14, #17, #18, and #35) reviewed. The findings include: Review of the facility's policy titled, Nail Care, dated 1/1/2021, revealed .for the provision of care to a resident's nails for good grooming and health .Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis .Routine nail care, to include trimming and filing, will be provided on a regular basis .Nails should be kept smooth to avoid skin injury . Review of the facility's policy titled, Activities of Daily Living . dated 1/1/2021, revealed .A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene . Review of the medical record, revealed Resident #14 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #14 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated she had moderately impaired cognition, and required extensive assistance from staff for personal hygiene. Review of the Care Plan dated 4/4/2022 revealed .The resident needs activities of daily living assistance .PERSONAL HYGIENE . Observation in the resident's room on 6/27/2022 at 2:36 PM and 4:45 PM, on 6/28/2022 at 8:38 AM, 11:28 AM, and 2:08 PM, and on 6/29/2022 at 8:50 AM, revealed Resident #14 had long jagged fingernails with a brown substance under the nails and had long whiskers on her chin and upper lip. Review of the medical record, revealed Resident #17 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS dated [DATE], revealed Resident #17 had a BIMS score of 3, which indicated she had severe cognitive impairment, and required extensive assistance from staff for personal hygiene. Review of the Care Plan with a revised date of 5/11/2022, revealed Resident #17 required assistance from staff for personal hygiene. Observation in the resident's room on 6/27/2022 at 10:29 AM, 12:00 PM, and 2:57 PM, on 6/28/2022 at 8:16 AM, on 6/29/2022 at 9:05 AM and 4:12 PM, and on 6/30/2022 at 8:20 AM, revealed Resident #17 had gray and black whiskers on her chin and upper lip. During an interview on 6/30/2022 at 8:22 AM, in Resident #17's room, Licensed Practical Nurse (LPN) #1 confirmed Resident #17 had facial whiskers and needed to be shaved. Review of the medical record, revealed Resident #18 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Care Plan dated 5/20/2022, revealed Resident #18 required assistance with activities of daily living (ADLs). Review of the admission MDS dated [DATE], revealed Resident #18 had a BIMS of 2, which indicated she had severe cognitive impairment, and required extensive assistance from staff for personal hygiene. Observation in the resident's room on 6/27/2022 at 9:17 AM, 2:39 PM, and 4:44 PM, on 6/28/2022 at 8:35 AM, and on 6/29/2022 at 2:42 PM, revealed Resident #18 had long jagged fingernails with a brown substance under the nails and whiskers on her chin and upper lip. During an interview on 6/29/2022 at 2:43 PM, LPN #1 confirmed Resident #18 had whiskers that needed to be shaved and needed to have her nails cleaned and trimmed. Review of the medical record, revealed Resident #35 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual MDS dated [DATE], revealed Resident #35 had a BIMS of 15, which indicated she was cognitively intact, and required extensive assistance from staff for personal hygiene. Review of the Care Plan dated 5/16/2022, revealed Resident #35 required staff assistance for ADLs. Observation in the resident's room on 6/27/2022 at 9:15 AM and 2:35 PM, on 6/28/2022 at 9:33 AM, 12:02 PM, and 5:35 PM, and on 6/29/2022 at 9:02 AM and 2:20 PM, revealed Resident #35 had long fingernails with a brown substance under the nails. During an interview on 6/29/2022 at 2:22 PM, LPN #1 looked at Resident #35's nails and confirmed they needed to be cleaned and trimmed. During an interview on 6/30/2022 at 11:28 AM, the Director of Nursing (DON) confirmed female residents should not have facial hair and their nails should be trimmed and cleaned.

Based on policy review, medical record review, observation, and interview, the facility failed to date and label Percutaneous Gastrostomy (PEG) tube feedings for 1 of 2 sampled residents (Resident #15) reviewed for Peg Tube feedings. The findings include: Review of the facility's policy titled, Feeding Tubes, dated 1/1/2021, revealed .Feeding tubes will be maintained in accordance with current clinical standards of practice, with interventions to prevent complications . Review of the medical record, revealed Resident #15 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the significant change Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #15 rarely/never understands, had short and long term memory problems, and received nutrition through a feeding tube. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .Diabetisource .30ml/hr [milliliters/hour] . Observation in the resident's room on 6/27/2022 at 11:45 AM, 2:10 PM, and 4:35 PM, revealed Resident #15's tube feeding that was being administered was not labeled. There was no resident identifier, room number, rate, start date, or start time. During an interview on 6/30/2022 at 8:37 AM, Licensed Practical Nurse (LPN) #3 confirmed Resident identifiers should be on the peg tube feeding bags when infusing.

Based on policy review, medical record review, observation, and interview, the facility failed to honor dietary preferences for 2 of 6 sampled residents (Resident #9 and #65) reviewed for food preferences. The findings include: Review of the facility's policy titled, Resident Food Preferences, dated 1/1/2021, revealed .Upon the resident's admission Dietary Manager or designee will identify a resident's food preferences .the resident's clinical record .will document the resident's likes or dislikes . Review of the medical record, revealed Resident #9 was admitted to the facility on [DATE] with diagnoses of Diabetes, Dementia, [CONDITION(S)], End Stage Renal Disease, and [CONDITION(S)]. Review of the Resident Profile Details for food preferences dated 3/9/2022, revealed Resident #9 disliked broccoli, shrimp, and cauliflower. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #9 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact. Review of a Dietary Progress Note dated 3/25/2022, revealed .Updated dislike to include broccoli and cauliflower . Review of Resident #9's meal ticket dated 6/29/2022, revealed broccoli florets were on her meal tray. Observation and interview in the resident's room on 6/29/2022 at 5:25 PM, revealed Resident #9's meal tray contained broccoli florets. Resident #9 stated, They always bring me broccoli .I don't like it . During an interview on 6/29/2022 at 5:37 PM, the Registered Dietitian confirmed Resident #9 should not have had broccoli on her meal tray on 6/29/2022. Review of the medical record, revealed Resident #65 was admitted to the facility on [DATE] with diagnoses of Dementia, Diabetes, [CONDITION(S)], and Anxiety. Review of the Resident Profile Details dated 5/31/2021, revealed Resident #65 disliked broccoli and cauliflower. Review of the annual MDS dated [DATE], revealed Resident #65 had a BIMS score of 7, which indicated he had severe cognitive impairment. Observation and interview in the resident's room on 6/29/2022 at 5:38 PM, revealed Resident #65's meal tray contained broccoli florets. Resident #65's responsible party stated, He doesn't eat broccoli . During an interview on 6/30/2022 at 8:18 AM, the Certified Dietary Manager (CDM) confirmed Resident #65 should not have received broccoli on his meal tray on 6/29/2022.

Amended 8/4/2022 Based on review of the Blood Glucose Monitoring System User Instruction Manual (a system used to test the amount of sugar in the blood), policy review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when a multi-use blood glucose meter was not properly disinfected to prevent cross-contamination of bloodborne pathogens (an organism in the blood that can produce a disease) for 1 of 3 sampled residents (Resident #8) observed during medication administration. The findings include: Review of the BLOOD GLUCOSE MONITORING SYSTEM User Instruction Manual revealed, .Cleaning & [symbol for and] Disinfecting Guidelines .We suggest cleaning and disinfecting the meter between patient use .Cleaning and disinfecting can be completed by using a commercially available EPA [Environmental Protection Agency]-registered disinfectant detergent or germicide wipe .To disinfect the meter, dilute 1 ml [milliliter] of household bleach .in 9 ml of water to achieve a 1:10 dilution .The solution can then be used to dampen a paper towel .Then use the dampened paper towel to thoroughly wipe down the meter . Review of the facility's policy titled, Blood Glucose Machine Disinfection, revised 7/15/2020, revealed .Disinfection is a process that eliminates many or all pathogenic microorganisms .on inanimate objects .The facility will ensure blood glucose machines will be cleaned and disinfected after each use and according to manufacturer's instructions for multi-resident use .The blood glucose machine should be disinfected with a wipe pre-saturated with an EPA registered healthcare disinfectant that is effective against [CONDITION(S)] [[CONDITION(S)]], [CONDITION(S)] and [CONDITION(S)] B virus .Blood glucose machines should be cleaned and disinfected after each use and according to manufacturer's instructions regardless of whether they are intended for single resident or multiple resident use . Review of the facility's training sheet titled, PSTG [Private Sector Testing Group] BLOOD GLUCOSE SPECIMEN AND SANITATION-ANNUAL, dated 9/30/2021, revealed .Met .Preparation .obtain supplies .Met .blood glucose machine sanitation .Purple Top [Cleaning cloth with bleach] only for cleaning glucometer .Learners Name .[Named Licensed Practical Nurse (LPN) #1] . Observation at the High 100 Hall Medication Cart #1 on 6/28/2022 at 8:30 AM, revealed LPN #1 knocked and entered Resident #8's room and performed a blood glucose test, using a multi-use blood glucose meter. LPN #1 exited the room, returned to the medication cart, removed a 75 percent (%) alcohol disinfectant wipe from the medication cart, cleaned the multi-use blood glucose meter, and placed it in a plastic cup on top of the medication cart. LPN #1 failed to disinfect the glucose meter with an EPA approved disinfectant wipe. During an interview on 6/28/2022 at 11:55 AM, LPN #2 was asked what should be used to disinfect the blood glucose meters. LPN #2 stated, .we are supposed to use the bleach wipes. During an interview on 6/28/2022 at 11:55 AM, LPN #1 was asked what should be used to disinfect the multi-use blood glucose meter. LPN #1 stated, We are supposed to use the bleach wipes. LPN #1 was asked if that was what was used this morning during the observation of a blood glucose check. LPN #1 stated, No, but I should have .I used what I had. During an interview on 6/28/2022 at 6:14 PM, the DON confirmed the multi-use blood glucose meters should be disinfected with a bleach cleaner. During an interview on 6/30/2022 at 10:53 AM, the DON confirmed staff should use a bleach wipe to disinfect the multi-use blood glucose meters after every use. The DON confirmed that LPN #1 had been instructed and had performed a return demonstration on the proper procedure to disinfect a multi-use blood glucose meter in 10/2021, during the facility's yearly competency check. The DON was asked what instructions were given to staff during the competency check for disinfecting the multi-use blood glucose meters. The DON stated, It says wipe down the machine with an approved cleaning pad, removing visible dirt and blood. Using the sanitizing cloth, wipe down all surfaces of the machine allowing for proper contact time of the product, if necessary wrap the machine in 1 or more sanitizing cloths for the period of time necessary, and over to the side there is a section in our competency that says purple top only for cleaning the glucometer and wet time is 2 minutes, then clean the glucometer with 1 towel, then wrap the glucometer in 2 towels, and you may place it on the medication cart or use a cup, while the glucometer is wrapped .place clean glucometer in the cart and repeat the process after each use. The DON was asked if staff should collect all supplies prior to performing a blood glucose to ensure they had all the supplies needed to complete the process. The DON stated, Yes, I would expect them to ensure they have everything they needed .she just did not make sure she had the purple top . The DON was asked if she expected staff to follow the instructions that were given to them during their competency check and return demonstration for cleaning the multi-use blood glucose meter. The DON stated, I do .

Based on review of the Center for Disease Control and Prevention (CDC) guidance, review of employee time punches, review of employee COVID-19 screening forms, review of in-services, and interview, the facility failed to properly follow COVID-19 policies and procedures to prevent and contain COVID 19 when staff members' COVID-19 screening logs were not complete and accurate for 6 of 10 sampled staff (Certified Nursing Assistant (CNA) #1, #2, #3, #6 and #8, and Licensed Practical Nurse (LPN ) #1) for 8 of 36 days (12/5/2020, 12/12/2020, 12/13/2020, 12/26/2020, 12/27/2020, 1/1/2021, 1/2/2021, and 1/3/2021) of screening logs reviewed. The findings include: Review of the CDC guidance Preparing for COVID-19 in Nursing Homes, updated 11/20/2020, showed, .Screen all HCP (Health Care Providers) at the beginning of their shift for fever and symptoms of COVID-19 . Review of in-service documents provided by the facility showed staff were in-serviced on completing screening forms on 3/25/2020 and 10/22/2020. Review of the facility's Staff-Surveyor/Vendor Vitals /Log, updated 12/16/2020, showed anyone entering the building is required to record their temperature on entrance and answer the following questions: .Have you had a COVID Vaccine (yes/no) .Do you work at another facility (Yes/No) .Do you have any of the following: Fever, new onset cough, new onset shortness of breath or difficulty breathing, Chills, muscle or body aches, headache, sore throat, new loss of taste/smell, repeated shaking with chills, Congestion/runny nose, nausea/vomiting/diarrhea, New production of sputum of Hemoptysis? Y/N (Yes/No) .Community or travel exposure in last 14 days Y/N . Review of CNA #1's time punches and the employee screening logs from 12/3/2020-1/7/2021, showed CNA #1 did not record his temperature or answer screening questions prior to providing care to residents on the following dates: 12/5/2020, 12/12/2020, 12/13/2020, 12/26/2020 and 12/27/2020. The facility was unable to provide documentation of screenings for CNA #1 on these dates. During an interview on 1/8/2021 at 3:46 PM, the Director of Nursing (DON) confirmed CNA #1 did not complete the screening log on 12/5/2020, 12/12/2020, 12/13/2020, 12/26/2020 and 12/27/2020. Review of employee screening logs and time punches from 12/3/2020-1/7/2021, showed staff did not complete screening logs prior to providing care for residents on the following dates: On 1/1/2021, CNA #2 and #3 did not record a temperature or answer screening questions. On 1/2/2021, CNA #6 and LPN #1 did not record a temperature or answer screening questions. On 1/3/2021, CNA #8 did not record a temperature or answer screening questions. The facility was unable to provide documentation of screenings for these employees on these dates. During an interview on 1/8/2021 at 3:46 PM, the DON confirmed staff should take and record their temperature and answer screening questions prior to providing care to residents. During an interview on 1/11/2021 at 3:35 PM, CNA #1 confirmed that employees are to take and record their temperature and answer screening questions prior to providing care to residents. During an interview on 1/11/2021 at 4:02 PM, CNA #2 confirmed that employees are to take and record their temperature and answer screening questions prior to providing care to residents.

Based on policy review, observation and interview the facility failed to ensure food was stored and served in a sanitary manner as evidenced by carbon and grease build-up on the gas stove and in 2 ovens, an ant crawling in a bin of thickener, a dietary aide using a dirty rack to push a clean rack of dishes out of the dishwasher, wet-nesting trays, 3 of 17 (Certified Nursing Assistant (CNA) #1 and 2) staff members failed to perform hand hygiene between serving resident trays, and 1 of 17 (CNA #3) staff members failed to perform hand hygiene between assisting residents during dining. The facility had a census of 80 with 71 of those residents receiving a meal tray from the kitchen. The findings included: 1. The facility's Equipment policy documented, .It is the center policy that all foodservice equipment is clean, sanitary, and in proper working order .The Food Services Director will ensure that all equipment is routinely cleaned and maintained . Observations in the kitchen on 11/13/17 at 9:31 AM and 3:19 PM, 11/14/17 at 12:35 PM, and on 11/15/17 at 1:27 PM, revealed grease and carbon build-up on the gas stove and inside the upper and lower ovens. Interview with the Regional Dietary Manager on 11/15/17 at 1:30 PM, in the kitchen, the Regional Dietary Manager confirmed that there was grease and carbon build-up on the gas stove and inside the upper and lower ovens. The Regional Dietary Manager confirmed that the grease and carbon build-up on the stove and ovens was not acceptable. 2. The facility's Pest Control policy documented, .It is the center policy that there is a program established for the control of insects and rodents for the Dining Services Department . Observations in the kitchen on 11/13/17 at 9:34 AM, revealed an ant crawling in the thickener stored in a white plastic rolling storage bin. Interview with the Dietary Manager on 11/13/17 at 9:36 AM, in the kitchen, the Dietary Manager looked inside the storage bin, and confirmed an ant was crawling in the thickener. 3. The facility's Ware washing policy documented, .The Food Services Director insures that the nutrition service staff is knowledgeable in proper technique for processing dirty dish ware to clean through the dish machine and proper handling of sanitized dish ware .ensures that all dishware is air dried and properly stored . Observations in the kitchen on 11/13/17 at 9:44 AM, and 11/15/17 at 1:27 PM, revealed the dietary aide used a dirty rack of dishes to push a clean rack of dishes out of the dishwasher. Observations in the kitchen on 11/13/17 at 9:46 AM, revealed the Dietary Manager stacking wet trays as she removed them from the dishwasher. Observations in the kitchen on 11/13/17 at 3:22 PM, revealed 43 wet-nested trays on the serving line. Interview with the Dietary Manager on 11/13/17 at 3:25 PM, in the kitchen, the Dietary Manager confirmed the trays were wet-nested and stated it was .not appropriate . Interview with the Regional Dietary Manager on 11/15/17 at 1:31 PM, the Regional Dietary Manager was asked if it was appropriate to use a dirty rack of dishes to push a clean rack of dishes out of the dishwasher. The Regional Dietary Manager stated, No. The person on the clean side should pull the clean dishes out of the washer. Interview with the Regional Dietary Manager on 11/15/17 at 1:34 PM, the Regional Dietary Manager was asked if it was appropriate to wet-nest trays. The Regional Dietary Manager stated, No, they should let them air dry. 4. The facility's Standard Precaution: Hand Hygiene policy documented, .Assume every person is potentially infected or colonized with organisms that could be transmitted in the facility and apply the following infection control practices .Before having direct contacts with residents .After contact with inanimate objects .in the immediate vicinity of the resident . Observations in the 100 Hall on 11/13/17 at 12:20 PM, revealed CNA #1 entered a resident's room and touched the bedside table and placed a meal tray on the table. CNA #1 then obtained another meal tray, entered another resident's room, and placed the tray on the table. CNA #1 obtained the next meal tray, entered another resident's room, set the tray on the bedside table, touched the wheelchair pedals, and adjusted the bedside table. CNA #1 then obtained the next tray, went into another resident's room, and served a meal tray. CNA #1 then obtained the next meal tray and entered another resident's room, placed the meal tray on the bedside table, adjusted the table, touched the resident's arm, and touched the bed linens. CNA #1 then went to the meal cart and pulled up her pants, obtained another meal tray, went into another resident's room and served the meal tray. CNA #1 did not perform hand hygiene at any time during the dining service observations. Observations in the dining room on 11/14/17 between 5:32 PM and 5:35 PM, CNA #2 delivered and set up the trays for 4 residents without performing hand hygiene. Observations in the Private dining room on 11/14/17 at 5:46 PM, CNA #3 sat to assist Resident #113 to eat. CNA #3 then went to straighten the clothing protector of another resident, and brushed food from the clothing protector with her hand. CNA #3 returned to Resident #113 and continued to assist him to eat supper. CNA #3 did not perform hand hygiene before returning to assist Resident #113. Interview with the Director of Nursing (DON) on 11/15/17 at 3:55 PM, in the DON office, the DON was asked how she expected staff to perform hand hygiene during dining service. The DON stated, .wash hands or use hand sanitizer before assisting other residents .

Based on policy review, medical record review, observation, and interview, the facility failed to provide appropriate care and services for [MEDICAL TREATMENT] for 1 of 1 (Resident #196) sampled residents reviewed receiving [MEDICAL TREATMENT]. The findings included: 1. The facility's [MEDICAL TREATMENT] Monitoring policy documented, .If the access (graft or fistula) starts to bleed, apply firm pressure with a pad of 4 x 4's (4 inch by 4 inch gauze pads) for 15 (to) 20 minutes. Notify the attending physician . 2. Medical record review revealed Resident #196 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].[MEDICAL TREATMENT] .Tuesday, Thursday and Saturday at 6:15 am . The interim care plan dated 11/3/17 documented, .Focus .I HAVE LEFT AV (ARTERIOVENOUS) FISTULA SHUNT TO UPPER INNER ARM AND RECEIVES [MEDICAL TREATMENT] 3 (TIMES) A WEEK AND HAS POTENTIAL FOR COMPLICATIONS .Interventions .EMERGENCY KIT AVAILABLE AT BEDSIDE IN CASE OF EMERGENCY BLEEDING .IF BLEEDING NOTED AT SITE, APPLY MINIMUM EFFECTIVE PRESSURE TO BLEEDING SITE . Observations in Resident #196's room on 11/14/17 3:26 PM, revealed Resident #196 had just returned from [MEDICAL TREATMENT] and LPN #1 was assessing the AV fistula to Resident #196's left arm. Interview with LPN #1 on 11/14/17 at 3:32 PM outside Resident #196's room, LPN #1 was asked what she assesses when she checks a [MEDICAL TREATMENT] AV fistula after a resident returns from [MEDICAL TREATMENT]. LPN #1 stated, .for bleeding . LPN #1 was asked what she would do if an AV fistula began to bleed. LPN #1 stated, Take the dressing off . Interview with LPN #2 on 11/14/17 at 3:46 PM, outside Resident #196's room, LPN #2 was asked what she would do if a [MEDICAL TREATMENT] AV fistula began to bleed. LPN #2 stated, I would call the doctor . LPN #2 was asked if there were emergency procedures for a bleeding AV fistula. LPN #2 stated, I really don't know . Observations in Resident #196's room on 11/14/17 at 4:30 PM, revealed LPN #1 and LPN #2 were unable to find the [MEDICAL TREATMENT] emergency kit at the bedside. Interview with the Minimum Data Set (MDS) Coordinator on 11/14/17 at 4:31 PM, near the Club room, the MDS Coordinator was asked how the nurses know how to take care of residents when they are newly admitted to the facility. The MDS Coordinator stated, They are to use the interim plan of care that is in the computer that they have access to. Interview with the Assistant Director of Nursing (ADON) on 11/15/17 at 10:02 AM, near the Station 1 nurses station, the ADON was asked if she expected all the nursing staff to know how to take care of emergency bleeding for [MEDICAL TREATMENT] residents. The ADON stated, Yes .

Based on medical record review, observation, and interview, the facility failed to follow physician orders [REDACTED].#10) of 10 sampled residents. The findings included: Medical record review revealed Resident #10 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of a physician order, dated 7/29/17 documented, .Cleanse right lower leg with wound cleanser, pat dry, apply Silver alginate and cover with Dry dressing (every other day and as needed) - every 48 hours for wound . Review of a Wound Note dated 9/8/17 as a late entry for 9/5/17 documented, .location of wound: right shin. Type of wound: diabetic/ischemic .Wound measurements in centimeters: length: 2.0 width: 3.5 depth: 0.1 . Drainage: moderate serosanguinous. Odor: none. Wound base: granulation. Tunneling (if applicable): none. Peri-wound: [MEDICAL CONDITION] .Progress: no changes noted to the surface area at this time. Wound bed is stable with 100% pink granulation tissue noted. 2+ (plus) [MEDICAL CONDITION] noted to both lower extremities. Will continue to treat area with silver alginate (every other day) . The care plan dated 7/29/17 documented, .The resident has potential/actual impairment to skin integrity (related to) - diabetic ulcer-right chin (shin) .Provide all skin treatment as indicated . Review of the August 2017 Treatment Administration Record (TAR) documented the treatment was scheduled for 8/8/17, 8/10/17, 8/12/17, and 8/20/17; however, there was no documentation to indicate it was done on those days. Review of the September 2017 Treatment Administration Record (TAR) documented the treatment was not performed on 9/1/17, 9/5/17, 9/7/17, and 9/11/17. The treatment was scheduled for 9/3/17 and 9/9/17 as well; however, there was no documentation to indicate it was done on those days. Observations in Resident #10's room on 9/11/17 at 9:57 AM revealed Resident #10 seated on her bed in her room with her legs uncovered. There was a bandage on her right shin above the ankle. The bandage was dated 9/7/17. There were large yellow stains on the bandage and on the sock on her right foot. The resident stated she had a sore on her leg. Interview with the Treatment Nurse on 9/12/17 at 3:05 PM, the Treatment Nurse stated most of the missed treatments were during the weekend and during the week she was off on vacation. The treatment nurse stated Resident #10 does not refuse dressing changes, and she was unaware of a reason the above treatments were missed. On 9/12/17 at 3:10 PM, the Unit Manager (UM) stated the treatment nurses should have completed the wound treatments every other day as ordered, or should document on the TAR a reason for not doing the treatment.

Based on medical record review and interview, the facility failed to ensure complete bowel movement documentation for 1 (Resident #3) of 10 sample residents. The findings included: 1. Medical record review revealed Resident #3 was admitted to the facility on [DATE] Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the August 2017 Resident ADL (Activities of Daily Living) Record revealed numerous shifts without any bowel documentation. The following were shifts that did not have the documentation: a. 8/19/17: day shift b. 8/20/17: night shift and day shift c. 8/22/17: day shift d. 8/23/17: day shift e. 8/24/17: day shift f. 8/25/17: day shift g. 8/28/17: day shift h. 8/29/17: night, day, and evening shifts i. 8/30/17: night shift and day shift j. 8/31/17: day shift Review of the September 2017 resident ADL Record revealed numerous shifts without any bowel documentation. The following were shifts that did not have the documentation: a. 9/1/17: night shift b. 9/2/17: night shift and evening shift c. 9/3/17: night shift and evening shift d. 9/4/17: night shift and evening shift e. 9/6/17: night shift f. 9/7/17: day shift g. 9/9/17: day shift and evening shift h. 9/10/17: day shift and evening shift i. 9/11/17: night shift and day shift 2. Interview with the Clinical Reimbursement Specialist on 9/12/17 at 1:05 PM, the Clinical Reimbursement Specialist stated she expected bowel documentation to be completed every shift. She added the facility did not have an audit process in place to ensure complete documentation, and she would need to do follow up and education with the staff to ensure completion of bowel records every shift.

Based on facility policy review, medical record review, observation and interview, the facility failed to revise the resident care plans for nutrition, pressure ulcers, accidents and non-pressure related skin conditions for 9 of 27 (Resident # 20, 128, 201, 8, 58, 68, 163, 188 and 218) sampled residents reviewed for care plan revision of the 45 residents included in the stage 2 review. Failure to revise the plan of care with nutrition-related interventions to address the serious weight loss resulted in immediate jeopardy (IJ) to Resident #20, 128 and 201. Failure of the facility to revise the plan of care to target the identified concern in maintaining nutritional status for residents with serious and significant weight loss resulted in an IJ to Resident # 20, 128 and 201. Immediate Jeopardy is a situation in which the provider's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Corporate Vice President, the Nurse Consultant, the Interim Administrator, and the Director of Nursing were informed of the Immediate Jeopardy on 9/14/16 at 6:10 PM, in the Club Room. The facility was cited an Immediate Jeopardy at F325-K which is Substandard Quality of Care. An extended survey was completed on 9/14/16. The Immediate Jeopardy is effective March 16 2016, and is ongoing. The findings included: 1. The facility's Care Plans policy documented, .Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change .The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans. 2. Medical record review revealed Resident #20 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the weight records revealed the following: a. On 5/9/16 the resident weighed 104.2 pounds (lbs) b. On 6/10/16 the resident weighed 96.8 lbs c. On 7/13/16 the resident weighed 87 lbs d. On 8/10/16 the resident weighed 85 lbs e. On 9/14/16 the resident weighed 81.8 lbs Resident #20 had a 30 day weight loss of 7.1% and 90 day weight loss of 18.4%. The care plan dated 6/28/16 documented, .Focus .resident has had significant weight loss r/t (related to) recent AKA (above knee amputation) .Sacral wound .7/1/2016 .Weight loss of 7% (percent) x (times) 20 days. 8/12/2016 Significant weight loss of 27.3% x 180 days r/t poor po (by mouth) intake. CBW (current body weight) 85# (pounds) Interventions .Give the resident supplements as ordered . Focus . RESIDENT AT NUTRITIONAL RISK R/T (related to) .REQUIRING A MECHANICALLY ALTERED DIET AND THICKENED LIQUIDS D/T (due to) DIX (diagnoses) OF DYSPHAGIA .Interventions .Monitor and evaluate any weight loss .Determine percentage lost and follow facility protocol for weight loss . The care plan intervention of .Determine percentage lost and follow facility protocol for weight loss .Date Initiated: 07/19/16 . was inappropriate because the facility was unable to provide a written weight loss protocol. Interview with the Director of Nursing (DON) on 9/13/16 11:18 AM, in the Club Room, the DON was asked about the facility's protocol for weight loss as documented on the care plan. The DON stated, .We do not have a facility weight protocol . Interview with the Registered Dietician (RD) on 9/13/16 11:26 AM, in the Club Room, when asked, What do you consider significant weight loss, the RD stated, .5% in 30 days, 7.5% in 90 days and 10% in 180 days. The RD was then asked, If there is a weight loss or significant weight loss should that be addressed on a care plan. The RD stated, Yes. Failure to revise the plan of care with nutrition-related interventions related to serious weight loss resulted in immediate jeopardy to Resident #20. 3. Medical record review revealed Resident #128 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan dated 6/17/16 documented, The resident has triggered a significant weight loss over 180 day r/t Poor food intake, Acute illness .Monitor and evaluate any weight loss. Determine percentage lost and follow facility protocol for weight loss .Date Initiated: 06/28/2016 . Review of the weight records for Resident #128 revealed a weight of 127# (lbs) on 3/3/16, a weight of 4/1/16 of 118# (a significant weight loss of 7% (percent) x 30 days); a weight of 115# on 6/10/16 (a significant weight loss of 9% x 90 days); and a weight of 107.8# on 9/7/16 (a significant weight loss of 15% x 180 days) Interview with the Director of Nursing (DON) on 9/13/16 11:18 AM, in the Club Room, the DON was asked about the facility's protocol for weight loss as documented on the care plan. The DON stated, .We do not have a facility weight protocol . Failure to revise the plan of care with nutrition-related interventions related to serious weight loss resulted in immediate jeopardy to Resident #128. 4. Closed medical record review revealed Resident #201 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the weight records revealed the resident weighed 159 lbs on 5/17/16 and weighed 149.8 lbs on 5/30/16 which is a weight loss of 9.2 lbs or 5.8 % in less than 2 weeks. The care plan dated 6/7/16 documented, .AT RISK FOR ALTERATION IN FLUID BALANCE R/T FAILURE TO THRIVE .OBSERVE FOR SIGNIFICANT WEIGHT CHANGES . The care plan was not revised to reflect the resident's weight loss. Interview with the MDS (Minimum Data Set) Director on 9/13/16 at 8:45 AM, in the hall beside room [ROOM NUMBER], the MDS Coordinator was asked if the care plan should be revised to reflect the significant weight loss. The MDS Coordinator stated, He wasn't here a month. We don't usually revise the care plan for weight loss for less than a month . The MDS Coordinator was asked if the care plan should be revised to reflect the current status of the resident with a significant weight loss. The MDS Coordinator stated, Yes it should . Failure to revise the plan of care with nutrition-related interventions related to serious weight loss resulted in immediate jeopardy to Resident #201. 5. Medical record review revealed Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The comprehensive care plan dated 8/11/16 documented, The resident has potential impairment to skin integrity . The WEEKLY BODY AUDIT form dated 9/11/16 documented, SDTI (suspected deep tissue injury) (purple or maroon localized area of discolored intact skin or blood-filled blister) (L) (left) post (posterior) lower leg . Observations in the resident's room on 9/12/16 at 3:51 PM, revealed left lower extremity had dry, skin peeling at the achilles with a total area approximately 2.5 length (L) x 2.5 width (W) centimeters (cm). There were scattered small darkened areas within the area of dry peeling skin noted. A darkened circular wound with intact skin was noted to be approximately L 2 x W 2 cm on the resident's left heel. The resident had no complaint of pain related to the wounds and tolerated wound care with skin prep without difficulty. Interview with the MDS Coordinator on 9/14/16 at 9:25 AM, when asked for the resident's most recent care plan, stated, You should have it all . and printed the care plan which had not been revised with the SDTI identified on 9/11/16. 6. Medical record review revealed Resident #58 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the comprehensive plan of care dated 7/6/16 revealed the resident was at nutritional risk related to Dementia, Cerebral Infarction and [MEDICAL CONDITION] and at risk for weight changes due to [MEDICAL CONDITION] and diuretic treatment. The care plan documented, .8/12/16: Triggered significant weight loss of 6.5 % x (in) 30 days r/t [MEDICAL CONDITION] and diuretic tx (treatment) .Interventions .8/12/16: Refer to Nutritional progress note r/t nutritional interventions . Review of a Registered Dietitian progress note dated 8/5/16 revealed, with -5.7% wt loss since admit. Resident was admitted with swelling to the right upper extemity with [MEDICATION NAME] 20 mg (milligram) in place and documented, .weight loss expected Diet: Regular diet with 8 oz (ounce) additional beverage @ (at) meals .[MEDICATION NAME] in place for appetite. Po (by mouth) intake noted approximately 75% - 100% .Will recommend start MVI with Minerals and continue to monitor on weekly wts (weights) .8/12/16 CBW (current body weight): 176.8 # (8/10/16) continues with good po intake at meals . Review of the weight record revealed the resident weighed 185.6 pounds on admission and in 30 days weighed 178.2 pounds which was a 5.7% weight loss. Weekly weights continued during August 2016 and revealed the most recent weight, obtained during survey on calibrated scales, was on 9/13/16. The resident's weight had stabilized at 177 lbs. Review of the August Medication Administration Record [REDACTED]. Interview with the Nurse Consultant (NC) on 9/14/16 at 10:34 AM, in the Club Room, when asked if referring to nutritional progress notes was an appropriate care plan intervention, the NC stated, .It could be appropriate if it was clarified . The care plan intervention of .8/12/16: Refer to Nutritional progress note r/t (related to) nutritional interventions . was inappropriate because it was not inform the nursing staff a specific intervention and the RD progress note would eventially be thinned from the paper chart. 7. Medical record review revealed Resident #68 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan dated 7/15/16 documented, .THE RESIDENT HAS TRIGGERED SIGNIFICANT WEIGHT LOSS OF 5.6% x 30 DAYS R/T POOR FOOD INTAKE .Monitor and record food intake at each meal . Review of the resident's meal intake record for June and July 2016 revealed the resident consistently consumed 75% to 100% percent of his meal. The nutrition services progress notes documented, .5/14/16 .Continues on diuretics .6/21/16 .Continues on [MEDICATION NAME] .recommend Prostat 30cc po BID x 30 Days .7/15/16 .Resident triggered (with) -10.1% wt loss .90 Days .5.6# loss x 30 Days .[MEDICAL CONDITION] .Arterial Wounds .Consuming 75 - 100% @ meals per ADLs .Continues Diuretic use .Restart Prostat 30cc po BID x 30 Days .8/12/16 .-11.8% wt loss x 120 Days .(downward) trend noted .Arterial wounds .[MEDICAL CONDITION]. Note continued diuretic use .Recommend (increasing) Glucerna to 1 can po TID to support wt (weight) stability .9/8/16 .New order for weekly weight and [MEDICATION NAME] . Interview with the MDS Director on 9/14/16 at 2:29 PM, in the Club Room, when asked, Would you consider 75 to 100% of meal intake to be poor intake, the MDS Director stated, No. The MDS Director was then asked if the care plan revision which documented poor intake was related to the resident's significant weight loss, the MDS Coordinator reviewed the June and July meal intake reports and the care plan, and stated, Well, based on what I read in the chart, it does not appear that his intake is poor. If he had a weight loss .I don't think it's related to meal intake. 8. Medical record review revealed Resident #163 was admitted to the facility on [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. The care plan dated 4/6/16 documented, .Resident has a SDTI to L ankle. Review of the WEEKLY PRESSURE ULCER RECORD beginning 7/3/16 through 8/26/16 revealed the resident's left ankle pressure ulcer was unstageable (the wound bed cannot be visualized due to slough and/or eschar). Interview with the MDS Director on 9/13/16 at 9:46 AM, in the Club Room, when asked if the care plan should be revised to reflect the current staging of the left ankle wound, the MDS Coordinator stated, .Yes, the care plan should be revised to reflect the current status of the wound . 9. Closed medical record review revealed Resident #188 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].#188 was started on an antibiotic for 7 days for surgical incison infection R (right) hip and thigh . Review of the care plan dated 5/25/16 documented, The resident has potential/actual impairment to skin integrity of the (R) HIP INCISION) r/t (related to) surgical wound . A WEEKLY NO-PRESSURE SKIN CONDITION REPORT dated 5/27/16 documented the resident's right hip surgical wound .remains dehisced (ruptured open) at distal end on incision . Interview with the MDS Coordinator on 9/13/16 at 9:59 AM, in the Club Room, when asked why the care plan did not reflect the current status of the resident's surgical wound, the MDS Coordinator stated, .I dont know why that's like that . When asked if the dehiscense should be on the care plan, the MDS Coordinator stated, Yes. 10. Medical record review revealed Resident #218 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 6/30/16 revealed Resident #218 was at risk for fall related injuries, and had fallen on 7/9/16 and 8/23/16. The care plan had not been updated with new interventions to prevent further accidents following Resident #218's fall on 8/23/16. Interview with the MDS Director on 9/9/16 at 2:30 PM, in the Club Room, when asked if Resident #218's care plan had been updated with new interventions following the fall on 8/23/16, the MDS Director stated, No.

Based on medical record review, observation and interview the facility failed to follow resident care plan interventions related to nutrition, pressure ulcers, and accidents for 8 of 27 (Resident #11, 20, 50, 68, 118, 128, 143, and 218) sampled residents reviewed for care planning of the 45 residents included in the Stage 2 review. The facility's failure to follow nutrition-related care plan interventions related to significant weight loss resulted in immediate jeopardy (IJ) to Resident #20, 50, 128 and 143. Failure of the facility to follow the plan of care interventions targeting the identified concern of maintaining and improving the nutritional status for residents with significant weight loss resulted in an IJ when Resident # 20, 50, 128 and 143 had continued serious and significant weight loss. Immediate Jeopardy is a situation in which the provider's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Corporate Vice President, the Nurse Consultant (NC), the Interim Administrator, and the Director of Nursing (DON) were informed of the Immediate Jeopardy on 9/14/16 at 6:10 PM, in the Club Room. The facility was cited an Immediate Jeopardy at F325-K which is Substandard Quality of Care. An extended survey was completed on 9/14/16. The Immediate Jeopardy is effective March 16 2016, and is ongoing. The findings included: 1. Medical record review revealed Resident #20 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The care plan dated 6/28/16 documented, .Focus .resident has had significant weight loss r/t (related to) recent AKA (above knee amputation) .Sacral wound .7/1/2016 .Weight loss of 7% (percent) x (times) 20 days. 8/12/2016 Significant weight loss of 27.3% x 180 days r/t poor po (by mouth) intake. CBW (current body weight) 85# (pounds) Interventions .Give the resident supplements as ordered . Focus . RESIDENT AT NUTRITIONAL RISK R/T (related to) .REQUIRING A MECHANICALLY ALTERED DIET AND THICKENED LIQUIDS D/T (due to) DIX (diagnoses) OF DYSPHAGIA .Interventions .Monitor and evaluate any weight loss .Determine percentage lost and follow facility protocol for weight loss . Review of the weight records revealed the following: a. On 5/9/16 the resident weighed 104.2 pounds (lbs) b. On 6/10/16 the resident weighed 96.8 lbs c. On 7/13/16 the resident weighed 87 lbs d. On 8/10/16 the resident weighed 85 lbs e. On 9/14/16 the resident weighed 81.8 lbs Resident #20 had a 30 day weight loss of 7.1% and 90 day weight loss of 18.4%. A physician's order dated 5/10/16 documented, .Ensure three times a day GIVE ENSURE ONE CAN BETWEEN MEALS AND HS (bedtime) .Juven two times a day until 06/11/2016 .Prostat two times a day until 06/11/2016 . On 6/1/16 Mighty Shakes with meals was added to the resident's diet. Review of a physician's order dated 6/21/16 revealed the Juven and Prostat were reordered for another 30 days. Review of the Medication Administration Record (MAR) for June 2016 revealed that none of the Mighty Shake with meals had been given. Ensure was not given on 6/2 and 6/3 at 2:00 PM, 6/22 at 9:00 PM, and 6/24 at 10:00 AM and 2:00 PM. The Prostat was not given on 6/22 and 6/23 at 5:00 PM. The Juven was not given on 6/22 and 6/23 at 5:00 PM. The physician's orders dated 7/1/16 documented, .Ensure three times a day GIVE ENSURE ONE CAN BETWEEN MEALS AND HS .Juven two times a day until 07/21/2016 .Mighty Shake with meals .Prostat two times a day until 07/22/2016 . Review of the MAR for July 2016 revealed Ensure was not given on 7/2 and 7/7 at HS, 7/14 and 7/21 at 2:00 PM and 7/22 at 10:00 AM and 2:00 PM. The Mighty Shake was not given on 7/7 and 7/29 at HS, and 7/22 at 8:00 AM and 12:00 PM. Prostat and Juven were not given on 7/10 at 5:00 PM. Review of August and September 2016 physician's orders documented, .Ensure three times a day GIVE ENSURE ONE CAN BETWEEN MEALS AND HS .Magic Cup - two times a day .Mighty Shakes with meals . Review of the MAR for August 2016 revealed Ensure was not given 8/31 at 10:00 AM and 2:00 PM. The Mighty Shake was not given 8/30 and 8/31 at 8:00 AM and 12:00 PM. The Magic Cup was not documented as given 8/14 through 8/31. Review of the September 2016 MAR revealed Magic Cup had not been given 9/1 through 9/9. Interview with the DON on 9/12/16 at 5:18 PM, in the Club Room, the DON was asked what do the empty spaces mean on the MAR. The DON stated, . by looking at that it shows that the nurse's did not document that they gave it. The DON was asked should the supplements be documented that they are given. The DON stated, .yes . The facility's failure to follow the resident's plan of care by providing recommended and ordered nutritional interventions to a resident with serious weight loss resulted in immediate jeopardy to Resident #20. 2. Medical record review revealed Resident #128 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan dated 6/17/16, and revised on 8/13/16 revealed, .at nutritional risk .requires assistance with all meals .ASSISTED DINING TID (three times a day) .triggered a significant weight loss . Interventions .give the resident supplements as ordered .follow facility protocol for weight loss . The weight records revealed the following: a. On 3/3/16 127 pounds (Lbs) b. On 4/1/16 118 Lbs c. On 6/10/16 115 Lbs d. On 9/7/16 107.8 Lbs On 4/1/16 Resident #128 had a 7% weight loss; on 6/10/16 a 9% weight loss in 90 days; on 9/7/16 a 15% weight loss in 180 days. The physician's orders dated 7/7/16 and 8/1/16 documented, .Assisted dining room for all meals . Observations of Resident #128 during the survey revealed the following: a. 9/12/2016 at 5:09 PM Resident #128 was lying in bed on her left side with her eyes closed. Resident #128's meal tray was on the overbed table beside the wall in her room. Interview with Certified Nursing Assistant (CNA) #1 on 9/12/16 at 5:43 PM, CNA #1 was asked about Resident #128's meal tray. CNA #1 stated, I'm fixing to go help her right now. CNA #1 was asked whether Resident #128 needed assistance with eating. CNA #1 stated, We tried, but sometimes she won't eat, so we have to go back and try again. CNA #1 entered Resident #128's room, and uncovered the meal tray which revealed a magic cup, and a mighty shake, all still covered and untouched. CNA #1 covered the meal and left the room, without attempting to feed the resident. b. 9/13/16 at 7:55 AM Resident #128 was lying in bed. At 8:20 AM, CNA #3# took Resident #128's breakfast tray into the room to feed the resident. c. 9/13/16 at 11:30 AM There were 2 meal carts on the hall. On 9/13/16 at 12:05 PM, Resident #128 was lying in bed with her eyes closed, and her roommate was eating lunch. CNA #4 was asked about Resident #128's meal. CNA #4 confirmed Resident #128's tray was not on either cart on the hall. CNA #4 stated, It is in restorative (assisted dining) . d. 9/13/16 at 5:40 PM Resident #128 was lying in bed, alert and smiling. The dinner tray was on the over bed table at bedside. CNA #5(NAME)was asked how much of the meal Resident #128 had consumed. CNA #5 removed the cover and stated, About 50%. CNA #5 was asked when Resident #128 stopped going to the Restorative Dining Room for meals. CNA #5 stated, When she got her wound. CNA #5 was asked how long ago that was. CNA #5 stated, About 3 months ago. Observations during the survey revealed Resident #128 to be very thin, confused, and required assistance for all ADLs. The resident was not assisted to the Assisted Dining Room for meals as ordered. Interview with the DON on 9/14/16 at 9:10 AM, in the Club Room, the DON was asked when Resident #128 stopped going to the Assisted Dining Room for meals. The DON stated, I would have to read the note .I wouldn't know by heart .So she's stopped going? Oh, (Named Resident #128) .we assist her with all meals in her room . The DON was asked whether there should be a physician's order to discontinue taking her to the Assisted Dining Room. The DON stated, Yes, it should be . Interview with the Assistant Director of Nursing (ADON) on 9/14/16 at 9:15 AM, in the Club Room, the ADON was asked why Resident #128 does not go to the Assisted Dining Room for meals. The ADON stated, She does go . The ADON was asked whether she goes every meal as ordered. The ADON stated, Not every meal . The physician's orders documented, .Mighty Shake two times a day .Order Date 6/15/2016 . The June 2016 MAR documented, .Mighty Shake @ (at) HS (bedtime) .6/1/16 . The MAR revealed no documentation Mighty Shakes were given at all on 6/6, 6/7, 6/10, 6/13, 6/15, 6/16, 6/21, 6/22, 6/23, and 6/24. The MAR revealed Mighty Shakes were administered only one time per day at hs on 6/17, 6/18, 6/19, 6/20, 6/25, 6/26, 6/27, 6/28, 6/29, and 6/30. The physician's orders for July 2016 documented, .Mighty Shake two times a day . Review of the July 2016 MAR revealed Mighty Shake was not given on 7/29 at 9:00 PM. Review of a physician order dated 8/1/16 documented, .Prostat 30cc BID (twice daily) x 30 days .Juven 1 pk (pack) BID x 30 days . On 8/15/16 .Ensure Plus two times a day . Review of the MAR for August 2016 revealed there was no documentation that Prostat was administered twice daily as ordered on 8/5, 8/8, 8/10, 8/11, 8/19, 8/20, and 8/28. Juven was not administered twice daily as ordered on 8/8, 8/10, 8/11, and 8/28. Ensure Plus was not administered twice daily as ordered on 8/25, 8/26, 8/29, 8/30, and 8/31. Interview with the DON on 9/12/16 at 2:45 PM, the DON was asked to explain what the blank spaces meant next to the order for Mighty Shakes on the June MAR. The DON stated, It looks like the nurse didn't sign it out. The DON was asked whether she expected the nurses to document supplement administration. The DON stated, Yes . The DON was asked how would she know whether the supplement was offered if there was no documentation. The DON stated, We don't . Interview with the ADON on 9/12/16 at 4:44 PM, in the Club Room, the ADON was asked whether ordered supplements should be given. The ADON stated, .We are strict on that. If it's not documented, it's not done. The ADON was asked if the supplements were documented on the MARs. The ADON stated, It should be. Interview with the NC on 9/14/16 at 10:22 AM, the NC was asked about the missing documentation for Mighty Shakes on the June 2016 MAR. The NC stated, Omissions. The facility's failure to follow the resident's plan of care by providing recommended and ordered nutritional interventions to a resident with serious weight loss resulted in immediate jeopardy to Resident #128. 3. Medical record review revealed Resident #50 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE],revealed Resident #50 was severely impaired cognitively and totally dependent on staff to eat. Review of the weight records revealed the following: a. On 2/8/16 the resident weighed 134.6 lbs b. On 3/16/16 the resident weighed 124.0 lbs c. On 4/6/16 the resident weighed 128.4 lbs d. On 5/4/16 the resident weighed 122 lbs e. On 6/10/16 the resident weighed 125.2 lbs f. On 7/6/16 the resident weighed 124.6 lbs g. On 8/18/16 the resident weighed 111.8 lbs Resident #50 had a 30 day weight loss of 7.8%, 90 day weight loss of 9.3% and 16.9% weight loss in 180 days. The care plan dated 6/28/16 documented, Focus .resident has nutritional problem .Interventions .Provide and serve supplements as ordered . The physician's orders dated 6/1/16 documented, .Ensure two times a day .House Shake .with meals .Juven two times a day . Review of the July 2016 MAR revealed Ensure had not been given two times a day as ordered at any time during the month. The Mighty Shake with meals had not been given 7/5 at 12:00 PM and 7/29 at 4:00 PM. The physician's orders dated 8/1/16 documented, .Ensure two times a day . Review of the August 2016 MAR revealed Ensure had not been given two times a day as ordered at any time during the month. Review of the September 2016 MAR revealed Ensure had not been given 9/1 through 9/13. Interview with the Nurse Consultant (NC) on 9/14/16 at 3:43 PM, in the Club Room, the NC was asked would you expect the physician order's to be followed. The NC stated, Yes. The NC was shown Resident #50 physician's orders and the July, August and September MARs, and confirmed the supplements were not given as ordered. The facility's failure to follow the resident's plan of care by providing recommended and ordered nutritional interventions to a resident with serious weight loss resulted in immediate jeopardy to Resident #50. 4. Medical record review revealed Resident #143 was admitted to the facility on [DATE], and readmitted on [DATE] with [DIAGNOSES REDACTED]. The comprehensive care plan dated 6/17/16, and revised 8/13/16, documented, .resident has triggered significant weight loss .7/15/16: TRIGGERED 7.6% SIGNIFICANT WEIGHT LOSS X 30 DAYS .8/12/16: TRIGGERED significant weight loss of 13.4% x 90 days . Interventions . Give the resident supplements as ordered. Alert nurse/dietician if not consuming on a routine basis .Monitor and evaluate any weight loss. Determine percentage lost and follow facility protocol for weight loss . Review of the weight record revealed the following: form revealed Resident #143 weighed a. On 3/22/16 236.2 lbs b. On 6/6/16 230.4 lbs c. On 9/9/16 197.4 lbs Resident #143 had a 16.4 % weight loss in 90 days. The physician's orders dated 8/19/16 documented, .Ensure after meals . Review of the September 2016 MAR on 9/9/16, revealed no documentation that the Ensure supplement had been ordered or administered. Observations in the Club Room on 9/9/16 at 9:05 AM, revealed CNA #2, Restorative Aide, weighed Resident #143 in the wheelchair designated for weights with a weight result of 197.4#. Observations of Resident #143 revealed he was able to feed himself after tray setup by staff. There were no observations of Ensure supplements being administered to Resident #143 during observations of Resident #143 on 9/6/16 through 9/8/16. Interview with LPN #3 on 9/9/16 at 8:10 AM, at the 200 Hall Nurses' Station, LPN #3 was asked whether Resident #143 was receiving Ensure supplements. LPN #3 stated, Yes, and went to review the MAR. LPN #3 was not able to provide documentation that the supplement was being provided. LPN #3 stated, He was on [MEDICATION NAME] .That was DC'd (discontinued) .Let me look in dietary (progress notes). After review of Resident #143's medical record, LPN #3 stated, .So, Ensure should have been added on the 18th (August). LPN #3 was asked whether the Ensure had been added after it was ordered. LPN #3 stated, Let me see. I can check in the computer and see. LPN #3 went to the computer and stated, I see it (physician's order) here. The order date was 8/19/16. LPN #3 was asked if the Ensure should have been documented. LPN #3 stated, Well if they say for us to document, like the HS (bedtime) snacks, then we document the HS snacks . The LPN's answers were indirect, and LPN #3 did not answer whether the Ensure had been documented. On 9/9/16 LPN #3 was unable to provide documentation that the Ensure had been administered as ordered. Interview with Resident #143 on 9/9/16 at 8:25 AM, in his room, Resident #143 was asked how often he receives Ensure supplements. Resident #143 stated, When I ask for them. Sometimes I forget to ask. I wish somebody would tell them to bring me 1 strawberry and 1 vanilla. Resident #143 confirmed that staff did not bring the supplements regularly, and only brought them if he requested them. Interview with the DON on 9/9/16 at 8:45 AM, in the Club Room the DON was asked if the staff should administer supplements as ordered. The DON stated, Yes. The DON was asked whether the nurses should document administration of the supplements. The DON stated, Yes . The DON was unable to provide documentation that the Ensure supplements were administered to Resident #143 during the month of September as ordered by the physician. The facility's failure to follow the residents plan of care by providing recommended and ordered nutritional interventions to a resident with serious weight loss resulted in immediate jeopardy to Resident #143. 5. Closed medical record review revealed Resident #11 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The care plan dated 7/10/16 documented, .(Named Resident #11) has a STAGE 2 pressure ulcer to left buttock .DIETARY SUPPLEMENTATION AS ORDERED . Review of a physician's order dated 8/26/16 revealed the resident was to be given the protein supplement, Prostat, twice daily. Review of the August 2016 MAR revealed the Prostat was no administered as ordered on 8/26 or 8/27. Interview with the NC on 9/14/16 at 10:39 AM, in the Club Room, NC was asked whether the order for Prostat was documented on the August 2016 MAR. The NC stated, .No I don't see Prostat. 6. Medical record review revealed Resident #68 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was deemed interviewable, was alert and oriented. The care plan dated 6/16/16 and revised on 7/15/16, documented, .RESIDENT HAS TRIGGERED SIGNIFICANT WEIGHT LOSS OF 5.6% X 30 DAYS R/T POOR FOOD INTAKE .Interventions .Give the resident supplements as ordered .Monitor and evaluate any weight loss. Determine percentage lost and follow facility protocol for weight loss . A physician's telephone order dated 4/25/16 documented, .(Increase) Glucerna to 1 can po BID @ 10A (and) 2P . The physician's orders dated 6/1/16 documented, .Glucerna 1.5 one time a day for Weight Stability .Start Date .4/22/2016 . No End Date was documented There was no documentation on the June 2016 MAR that Glucerna was administered during the month of June. The physician's orders for July 2016 documented, .Glucerna 1.5 one time a day for Weight Stability .Prostat two times a day until 07/22/2016 . Review of the July 2016 MAR revealed no documentation that Glucerna was administered on 7/1/16 through 7/17/16, or that Prostat was administered twice daily as ordered on [DATE] or 7/18/16. The physician's orders for August 2016 documented, .Glucerna 1.5 two times a day for Weight Stability . The August 2016 MAR revealed no documentation that the Glucerna was administered twice daily as ordered during the month. Observations made during the survey 9/6/16 through 9/14/16 revealed Resident #68 was independent with eating after tray setup by staff. No supplements were observed in Resident #68's room during the survey observations. Interview with Resident #68 on 9/13/16 at 10:15 AM, in his room, Resident #68 was asked if he ever received any Ensure or Glucerna or milkshake-type drinks or milkshakes. Resident #68 stated, No. Resident #68 was asked whether he likes these type of drinks, and he stated, Well, yes. Interview with the NC on 9/14/16 at 11:42 AM, in the Club Room, the NC was asked about the missing documentation on the July 2016 MAR for Prostat on 7/3/16 and 7/18/16. The NC stated, Omissions. 7. Medical record review revealed Resident #118 was admitted to the facility with an admission date of [DATE] and a readmitted with [DIAGNOSES REDACTED]. The care plan dated 6/9/16 documented, .Focus .POTENTIAL FOR ALTERATION IN NUTRITION LESS THAN BODY REQUIREMENTS . Interventions .RECEIVES SUPPLEMENTS .MVI WITH MINERALS DAILY .ENSURE supplements WITH ALL MEALS . A physician's order dated 7/8/16 documented, .Ensure Clear one time a day for supplement . Review of the July 2016 MAR revealed the Ensure Clear was not administered on 7/8, 7/12, or 7/14. The physician's orders for August 2016 documented, .Ensure Clear one time a day for supplement .Magic Cup with meals .Mighty Shake with meals . Review of the August 2016 MAR revealed the Ensure Clear, Magic Cup and the Mighty Shake were not administered at any time during the month. Interview with the NC on 9/14/16 at 9:48 AM, in the Club Room, the NC was asked if the Ensure Clear was administered as ordered in August. The NC stated, .according to our documentation .no, they were not given . 8. Medical record review revealed Resident #218 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan dated 6/30/16 documented, .At risk for fall related injuries . Fall 07/09/16 LACERATION ON FOREHEAD INTERVENTION: .WHEELCHAIR ALARM . Medical record review revealed no physician's orders were written to discontinue the chair alarm. Observations on 9/6/16 at 11:38 AM and 2:48 PM, in Resident #218's room revealed, Resident #218 seated in his wheelchair watching television with no chair alarm in use. Observations on 9/8/16 at 11:21 AM, revealed Resident #218 propelling himself down the hallway in his wheelchair with no chair alarm in use. Interview with Resident #218, who was alert and oriented, on 9/9/16 at 9:25 AM, in his room, Resident #218 was asked if he had ever had a chair alarm. Resident #218 stated, Yes, for several weeks .when I'd get up it would make a loud noise . Resident #218 was asked when the chair alarm had been removed. Resident #218 stated, I don't know, it was after I'd had therapy and they said I was stronger so they took it away . Interview with the MDS Coordinator on 9/9/16 at 2:30 PM, in the Club Room, the MDS Coordinator was asked based on the current care plan that called for a wheelchair alarm to be in place, should Resident #218's wheelchair still have an alarm. The MDS Coordinator stated, Yes, unless you have a doctor's order to discontinue it. Interview with the ADON on 9/9/16 at 2:37 PM, at Station 2 nurses' station, the ADON was asked if Resident #218 had a chair alarm on his wheelchair. The ADON went into Resident #218's room, looked, and came back to the nurses' station and stated, He doesn't have it on .

Based on The National Pressure Ulcer Advisory Panel .Prevention and treatment of [REDACTED].#11, 20, 50, 128 and 163) sampled residents reviewed of the 13 residents with pressure ulcers. The facility's failure to provide care and services for residents with pressure ulcers resulted in deterioration of the wounds and resulted in immediate jeopardy (IJ) to Resident #50 and 128. Immediate Jeopardy is a situation in which the provider's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Corporate Vice President, the Nurse Consultant (NC), the Interim Administrator, and the Director of Nursing (DON) were informed of the Immediate Jeopardy on 9/14/16 at 6:10 PM, in the Club Room. The facility was cited an Immediate Jeopardy at F314-K which is Substandard Quality of Care. An extended survey was completed on 9/14/16. The Immediate Jeopardy is effective March 16, 2016, and is ongoing. The findings included: 1. The National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and treatment of [REDACTED]. Emily Haesler (ED). Cambridge Media: Osborne Park, Western Australia; 2014 page 12 documented, .INTERNATIONAL NPUAP/EPUAP PRESSURE ULCER CLASSIFICATION SYSTEM .Category/Stage II .Partial Thickness Skin Loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough .intact or open serum filled blister .Category/Stage III .Full thickness tissue loss .Subcutaneous fat may be visible .slough may be present .May include undermining and tunneling ., and page 16 documented, .Document the findings of all comprehensive skin assessments .Ongoing assessment of the skin is necessary to detect early signs of pressure damage, especially over bony prominences . 2. Medical record review revealed Resident #50 was admitted to the facility with an original admission date of [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE], documented Resident #50 was severely impaired for daily cognitive skills and had one stage 4 pressure ulcer on admission with length 2.4 width 0.6 depth 0.1. The care plan dated 4/15/16 and revised on 7/8/16 documented, Focus .resident has stage IV pressure ulcer r/t (related to) Immobility .Interventions .Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate . The NORTON PLUS PRESSURE ULCER SCALE dated 3/7/16 documented score of 7 indication high risk for developing a pressure ulcer. Review of the March 2016 WEEKLY PRESSURE ULCER RECORD of the Stage IV sacral wound revealed the following: a. 3/4/16 2.4 x 0.6 x 0.1 (Length by Width by Depth in centimeters); pink granulated b. 3/11/16 2.0 x 0.6 x 0.1; pink granulated c. 3/18/16 3.2x 2.0 x0.1; pink granulated d. 3/25/16 3.8 x2.0 x 0.2; pink granulated There were no weekly wound assessments provided for the Stage IV sacral wound from 3/25/16 until 4/15/16. The physician's order dated 3/1/16 documented, [MEDICATION NAME] APPLY TO STAGE FOUR SACRAL WOUND DAILY .CLEAN SACRAL WOUND, PAT DRY, APPLY AG++ (silver), CAL- (calcium) ALGINATE, [MEDICATION NAME] 2X2, DSG (dressing), Q (every) 3 DAYS/PRN . There was no documentation that wound care was administered as ordered for the month of March. Review of the April 2016 WEEKLY PRESSURE ULCER RECORD of the Stage IV sacral wound revealed the following: a. 4/15/16 3.2 x2.0 x 0.1; pink granulated b. 4/22/16 3.5 x 3.7 x 0.2; pink granulated There were no weekly wound assessments provided for the Stage IV sacral wound from 4/22/16 until 5/22/16. A physician's order dated 4/1/16 documented, .IF DRSG (dressing) COMES OFF SACRAL WOUND, CLEAN WITH WOUND SPRAY, APPLY WOUND GEL, 4X4 GAUZE, COVER WITH BORDER GAUZE . There was no documentation that wound care was administered as ordered for the month of April. Review of the May 2016 WEEKLY PRESSURE ULCER RECORD of the Stage IV sacral wound revealed the following: a. 5/22/16 3.0 X 2.0; UNSTAGEABLE (full tissue thickness loss in which the base of the ulcer is covered by dead tissue or eschar) b. 5/29/16 3.2 x 2.0; UNSTAGEABLE A physician's order dated 5/1/16 documented, one time a day Cleanse with WD (wound) spray, pat dry, apply silvergel, 4x4 border gauze . There was no documentation that wound care was administered as ordered for the month of May. Review of the June 2016 WEEKLY PRESSURE ULCER RECORD of the Stage IV sacral wound revealed the following: a. 6/3/16 3.2 x 2.8; pink granulation tissue b. 6/10/16 3.0 x 2.6 x 0.2; pink granulation tissue c. 6/17/16 3.7 x 3.3 x 0.3; pink granulation tissue d. 6/24/16 4.0 x 3.9 x 0.4; pink/yellow A physician's order dated 6/1/16 documented, .Cleanse sacral wound with WD spray, pat dry, apply silvergel, 4x4 border gauze . There was no documentation that wound care was administered as ordered for the month of June. Review of the July 2016 WEEKLY PRESSURE ULCER RECORD of the Stage IV sacral wound revealed the following: a. 7/1/16 4.0 x 3.9 x 0.4; pink b. 7/8/16 3.4 x 3.5; pink There were no weekly wound assessments provided for the Stage IV sacral wound from 7/8/16 until 8/5/16. Review of the August 2016 WEEKLY PRESSURE ULCER RECORD of the Stage IV sacral wound revealed the following: a. 8/5/16 3.0 x 2.0 x 0.1; pink b. 8/12/16 3.5 x 2.3 x 0.1; pink c. 8/19/16 4.2 x2.2 x 0.1; pink d. 8/26/16 4.3 x 3.2 x 0.1; pink A physician's order dated 8/1/6 documented, .CLEAN SACRAL WOUND WITH WD .CLEANSER, PAT DRY APPLY NPWT (NEGATIVE PRESSURE WOUND THERAPY) -80MMHG (MILLIMETERS MERCURY) .COVER WITH TRANSPARENT DSG (dressing) CHANGE TWICE A WK (week) .CLEAN SACRAL WOUND WITH WOUND SPRAY PAT DRY APPLY SANTYL, 4X4, BORDERGAUZE, DSG .CHANGE EVERY DAY .CLEAN SACRAL WOUND WITH WOUND SPRAY, PAT DRY, APPLY CALCIUM -ALGINATE, 4X4, COVER WITH BORDERGAUZE CHANGE QOD (every other day)/PRN (as needed) . Review of the Treatment Administration Record (TAR) for August 2016 revealed there was no documentation that the treatments had been performed as ordered. Observations in Resident #50's room, on 9/14/16 at 8:40 PM, revealed Resident #50 lying on her right side. The WCN was asked if she had done Resident #50 wound treatment today. WCN stated, Yes The WCN removed a dressing from Resident #50's sacrum that was initialed and dated 9/13 and revealed a stage 4 pressure ulcer. The WCN was asked what date was on the dressing. The WCN stated, .I must have put the wrong date . Interview with The WCN on 9/14/16 at 5:39 PM, in the cafe, the WCN was asked if there had been concerns with physician's orders not being transcribed on the TAR's. The WCN stated, .it has happened . The WCN was asked if physician orders for wound care should be performed as ordered. The WCN stated, .yes definitely. The WCN was asked where the wound care orders were for Resident #50's stage 4 sacral ulcer for the month of April. The WCN stated, .I don't know . The WCN was asked where the wound care treatments for April 2016 were. The WCN stated .I don't know how they can disappear . The WCN was shown the empty spaces on the TAR for wound care documentation for Resident #50's stage 4 pressure ulcer for the month of May 2016 and was asked should there be initials in the boxes to show that wound care was provided. The WCN stated, Yes there should . The WCN was asked if it was acceptable to have empty spaces. The WCN stated, No. The WCN was asked if she could provide the documentation that shows wound care was provided for Resident #50 for the stage 4 pressure ulcer on her sacral ulcer in May. The WCN stated, .no, I might as well leave with ya'll . The WCN was asked about the two different treatments for the month of June 2016 for Resident #50's pressure ulcer. The WCN stated, .that's crazy . The WCN was asked about the three different treatment orders for Resident's stage 4 pressure ulcer on the physician's August order and was asked if that was correct. The WCN stated, .no that is incorrect .how is the d/c (discontinue) order coming back on the TAR .it printed again. The WCN was asked if she should have have been doing both of these treatments. The WCN, stated, No . Interview with the Regional Consultant (RC) on 9/14/16 at 7:06 PM, in the Administrator office, was shown the August 2016 and was asked about the different wound treatments for Resident #50. The RC stated, .don't know which one is correct .they both should not be there . The RC was asked if the facility cannot provide documentation that wound care treatments are administered as ordered, can the facility prove the treatments were done. The RC stated, .cannot see where care administration had been completed for August. The RC was asked if she could locate the treatments for the stage 4 sacral ulcer on the TAR for the month of March and June 2016. The RC stated, No . The RC was asked if the treatment doesn't get put on the TAR how would the wound care get done. The RC stated, .it would not get done . The RC was shown the physician order for [REDACTED]. The RC stated, .no . The RC was shown the May TAR and the empty spaces for the treatment for [REDACTED]. The RC stated, No . The RC was shown the physician order for [REDACTED]. The RC stated, .it looks like we have . different wound treatments for the same wound . The RC was asked if that was the way it should be. The RC stated, .to my knowledge of wound care we would not have three different treatments for one wound, The RC was shown the August order and was asked if the treatment for [REDACTED]. The RC was asked about Resident #50 not getting wound treatment and was asked if that was acceptable. The RC stated, No . The RC was asked what she thought the problem could be. The RC stated, .I think its layers . The failure of the facility to provide weekly wound assessments and treatments as ordered resulted in immediate jeopardy to Resident #50. 3. Medical record review revealed Resident #128 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual MDS dated [DATE] documented Resident #128 was severely cognitively impaired per staff assessment, required extensive staff assistance for activities of daily living (ADLs), was at risk of developing pressure ulcers, and had no unhealed pressure ulcers. The quarterly MDS dated [DATE] documented Resident #128 was severely cognitively impaired per staff assessment and was totally dependent on staff for ADLs, was at risk for developing pressure ulcers, and had no unhealed pressure ulcers. The care plan dated 6/29/16, documented, .SKIN DISCOMFORT .R/T (related to) SACRAL SKIN IRRITATION .Interventions .7/05/16 Apply skin prep to right ischial/buttock every shift for skin excoriation (excoriation) Date Initiated: 07/06/2016 .PROVIDE TREATMENT AS ORDERED. IF RASH WORSENS OR FAILS TO RESPOND TO TREATMENT, NOTIFY MD/ARNP .resident has potential for skin integrity related: incontinence and immobility .Date Initiated: 07/12/2016 .Interventions .Encourage good nutrition and hydration in order to promote healthier skin .Date Initiated .08/29/2016 .Ulceration or interference with structural integrity of layers of skin .has right buttocks stage 2, caused by prolonged pressure related to: immobility, incontinence .Date Initiated: 08/05/2016 . Interventions .Record amount of supplemental nutrition consumed .resident has infection of the right buttock wound .Date Initiated: 09/02/2016 . The nutrition service progress note documented, .5/11/16 .Mighty Shakes .qd @ (at)dinner .6/14/16 .receives Mighty Shake q (every) day .Will recommend (increase) Mighty Shake to BID (twice daily) .7/15/16 .Resident continues to trigger for wt (weight) loss of -7.9% .90 days . recommend start Ensure Plus 1 can po q Day .7/30/16 .Recommend Prostat 30cc BID x 30 Days and .Juven 1 pk BID x 30 Days .8/18/16 .-5.9% x 30 Days .-8.0% .60 days .and -16.7% .150 days .receives Mighty Shake BID, Juven BID, Prostat 30cc o BID, Ensure Plus q Day .8/26/16 .wound to (right) buttocks .Continues (with) multiple nutritional interventions in place: Ensure Plus BID, Juven BID, Prostat BID .Mighty Shake BID . The nurse's note dated 6/1/16 documented, .New order received for Mighty Shake @ HS (bedtime) . The physician's orders signed on 7/7/16 documented, .Mighty Shake two times a day .Order Date .06/15/2016 .Start Date .06/15/2016 . The Medication Administration Record (MAR) for June 2016 documented, .Mighty Shake @ HS (bedtime) .6/1/16 . There was no documentation that the Mighty Shake was administered on 6/6, 6/7, 6/10, 6/15, 6/16, 6/21, 6/22, 6/23, or 6/24/16. There was no documentation that the Mighty Shake was administered BID as ordered on 6/17, 6/18, 6/19, 6/20, 6/25, 6/26, 6/27, 6/28, 6/29, or 6/30. The physician's order summary report documented, .Ensure Plus two times a day .Order Date .8/15/2016 . Review of the MAR for August 2016 revealed there was no documentation that the Ensure Plus was administered twice daily as ordered on 8/25, 8/26, 8/29, 8/30, and 8/31/16. The MAR for August 2016 documented, .Prostat 30cc BID x 30 days .8/1/16 .Juven 1 pk BID x 30 days .8/1/16 . Review of the MAR for August 2016 revealed there was no documentation that the Prostat was administered twice daily as ordered on 8/5, 8/8, 8/10, 8/11, 8/19, 8/20, and 8/28/16. The MAR for August revealed there was no documentation that the Juven was administered twice daily as ordered on 8/8, 8/10, 8/11, and 8/28/16. Interview with the DON on 9/12/16 at 2:45 PM, the DON was asked to explain what the blank spaces meant next to the order for Mighty Shakes on the June MAR. The DON stated, It looks like the nurse didn't sign it out. The DON was asked whether she expected the nurses to document supplement administration. The DON stated, Yes . The DON was asked how she would know whether the supplement was offered if there was no documentation. The DON stated, We don't . Interview with the Assistant Director of Nursing (ADON) on 9/12/16 at 4:44 PM, in the Club Room, the ADON was asked whether ordered supplements should be given. The ADON stated, .We are strict on that. If it's not documented, it's not done. The ADON was asked if the supplements were documented on the MARs. The ADON stated, It should be. Interview with the NC on 9/14/16 at 10:22 AM, the NC was asked about the missing documentation for Mighty Shakes on the June 2016 MAR. The NC stated, Omissions. The nurses' notes documented, .7/4/16 .dark area (right) buttock .7/14/16 .wound to (right) buttock/ischial .wound has worsen (worsened) .8/5/16 .Rt (right) buttock Stage II wound .has less dark tissue . The WEEKLY PRESSURE ULCER RECORD assessments were reviewed, and documented the following: a. 7/14/16: .DATE OF ONSET: 7/14/16 .SITE/LOCATION: Rt buttock/ischial .STAGE .II .SIZE IN CM (centimeters) .2.0x0.8 .DEPTH (cm) .0.1 .EXUDATE TYPE/AMOUNT .Small serosanguineous .WOUND BED .Fatty tissue . No tunneling was documented. b. 7/26/16: .STAGE .II .SIZE IN CM .2.0x1.8 .DEPTH (cm) .0.3 .EXUDATE TYPE/AMOUNT .Small serosanguineous .WOUND BED .PINK . No tunneling was documented. c. 8/5/16: .STAGE .II .SIZE IN CM .1.5x1.2 .DEPTH (cm) .0.4 .EXUDATE TYPE/AMOUNT .Small serosanguineous .WOUND BED .PINK . No tunneling was documented. d. 8/12/16: .STAGE .II .SIZE IN CM .1.4X1.2 .DEPTH (cm) .0.1 .EXUDATE TYPE/AMOUNT .Small serosanguineous .WOUND BED .Pale . No tunneling was documented. e. 8/19/16: .STAGE .II .SIZE IN CM .1.5x1.0 .DEPTH (cm) .1.0 .EXUDATE TYPE/AMOUNT .Scant .Tunneling (cm) 2 .WOUND BED .PINK .Pale . f. 8/26/16: .STAGE .II .SIZE IN CM .1.0x1.6 .DEPTH (cm) .0.1 .EXUDATE TYPE/AMOUNT .Scant serosanguineous .WOUND BED .PINK . No tunneling was documented. g. 9/13/16: .STAGE .III .SIZE IN CM .2.2x2.3 .DEPTH (cm) .2.8 .EXUDATE TYPE/AMOUNT .Small serosanguineous .Tunneling (cm) 4 .WOUND BED .normal . The weekly body audits were reviewed, and documented the following: a. 7/8/16: .open area noted to (right) buttocks Tx (treatment) in progress. 2 Red area's (areas) noted to (left) buttocks .Tx also in progress . b. 7/15/16: .open area noted to (right) buttocks excoriation noted to (left) Buttocks Tx in progress . c. 7/22/16: .open area noted to (right) buttock .excoriation noted to (left) buttocks Tx in progress . d. 7/29/16: Open area noted to (right) buttocks Tx in progress, excoriation to (left) buttocks Nearly healed . A SKIN ALERT / BODY ALERT dated 9/10/16 revealed a wound to the right buttock area with measurements of 1.3 x 1.2 cm. No depth measurement or stage was documented. A telephone physician's orders dated 7/27/16 documented, .[MEDICATION NAME] .Malnutriiton .unstageable wound . The WOUND CARE SPECIALIST EVALUATION dated 8/16/16 documented, .stage 3 pressure wound of the right ischium of at least 26 days duration .The patient appears to have associated pain evidenced by: grimacing, restless .Malnutrition .WOUND SIZE .1.5 X 1.0 X 1.0 CM .Odor .UNDERMINING .0.5 cm at 3 o' clock .THICK ADHERENT DEVITALIZED NECROTIC TISSUE .20% .DRESSING .Negative Pressure .Three Times per Week .Wound debrided via surgical excision . The WOUND CARE SPECIALIST EVALUATION dated 9/1/16 documented, .stage 3 pressure wound of the right ischium of at least 41 days duration .Malnutrition .WOUND SIZE .1.3 X 1.2 X 1.5 CM .Odor .UNDERMINING .1.5 cm at 3 o' clock .THICK ADHERENT DEVITALIZED NECROTIC TISSUE .75% .WOUND PROGRESS .Deteriorated .Surgical excisional debridement . Observations in Resident #128's room on 9/13/16 at 2:19 PM, revealed the Wound Care Nurse (WCN) removed a clean/dry dressing from Resident #128's right buttock that was dated 9/13, and revealed a deep, open circular wound, approximately 2 cm in diameter. No drainage observed. Measurements were obtained, and the WCN confirmed tunneling in the wound. The WCN was asked what stage the wound was. The WCN stated, Well, it's a 3 now. The WCN was asked when the stage had worsened. The WCN stated, Well, since ya'll have been here. I'll call the doctor. The WCN was asked if Resident #128 had any other wounds, and the WCN stated she did not. Observations in Resident #128's room on 9/13/16 at 3:10 PM, the DON was asked to identify the stage of the wound on Resident #128's right buttock. The DON stated, I'd say a 3, but I'm not supposed to stage them. The wound care nurse does that. The DON was asked whether there was any exposed bone, muscle, or tendon. The DON stated, No. No penlight or flashlight was available for the assessment. Interview with the WCN on 9/12/16 at 2:38 PM, in the Club Room, the WCN was asked whether Resident #128 was receiving Santyl treatments on the right buttock wound. The WCN stated, Yes. The WCN was asked to explain the rationale for using Santyl on the wound since it was documented as a stage 2. The WCN stated, Yes .because she had scratched a scab . The WCN was asked whether the right buttock wound had ever had any tunneling. The WCN, after reviewing the weekly pressure ulcer records, stated, I guess she did .I don't know if we had the Santyl cleaning it up . Interview with the WCN on 9/14/16 at 7:23 PM, in the cafe, the WCN was asked when the right buttock wound was first identified. The WCN stated, 7/14. The WCN was asked about the physician's telephone order documentation on 7/27/16, revealing that the wound was an unstageable wound, and was asked if the right buttock wound was the only wound Resident #128 had. The WCN confirmed the right buttock wound was the only wound. The WCN stated, .I don't know why the doctor wrote that. The WCN was asked if Resident #128 was having problems then? The WCN stated, I don't know. The WCN was asked whether Resident #128 was seeing a wound care specialist. The WCN stated, No, but she will now. The failure of the facility to accurately stage the pressure ulcer, to administer treatments as ordered, and to administer supplements as ordered, resulted in immediate jeopardy to Resident #128. 4. Closed medical record review revealed Resident #11 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment, total dependence on staff for all activities of daily living (ADLs), and one stage 2 pressure ulcer that was present on admission. No other pressure ulcers were documented on the MDS. The care plan documented, .has A STAGE 2 pressure ulcer to left buttock .Date Initiated .7/10/2016 .Revision .8/24/2016 .DIETARY SUPPLEMENTATION AS ORDERED . A telephone physician's order dated 8/26/16 documented, .Prostat 30cc (cubic centimeters) via peg (percutaneous endoscopic gastrostomy) .BID (twice daily) . There was no documentation that the Prostat was administered on the August 2016 MAR. A telephone physician's order dated 8/26/16 documented, .Prostat 30 cc via PEG BID . Interview with the Nurse Consultant (NC) on 9/14/16 at 10:39 AM, in the Club Room, the NC was asked whether the order for Prostat was documented on the August 2016 MAR. The NC stated, .No I don't see Prostat. 5. Medical record review revealed Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE], documented Resident #20 was severely cognitively impaired per staff assessment, was totally dependent on staff for activities of daily living (ADLs) and had one stage 4 pressure ulcer. The care plan dated 5/6/16, and revised on 8/5/16, documented, .Resident has a stage 4 pressure ulcer, caused by prolonged pressure related to Immobility .Interventions .Follow facility protocol/regime for treating breaks in skin integrity/pressure ulcers for STAGE 4 SITE: sacral . Review of the WEEKLY PRESSURE ULCER RECORD revealed an onset date for a stage 4 sacral pressure ulcer of 5/7/16. There were no assessments documented between the dates of 07/8/16 and 8/5/16. Interview with the WCN on 9/14/16 at 5:32 PM, in the Internet Cafe, the WCN was asked how often the wound assessments were done on Resident #20's pressure wound. The WCN stated, Weekly .goes on my weekly assessment form . The Wound Care Nurse was shown Resident #20's weekly pressure ulcer records that revealed no documentation of the stage 4 sacral wound between 7/15/16 and 8/5/16. The WCN was asked if that was acceptable. The WCN stated, .I get interrupted a lot throughout the day . of course not . Interview with the NC on 9/14/16 at 7:00 PM, in the Administrator's office, the NC was asked when they performed weekly skin assessment what should be on the form. The NC stated .each section of that form completed .measurements .stages .treatment . The NC was asked was it ever acceptable to leave an assessment not completely filled out or not done. The NC stated, No. The NC was the shown Resident #20's weekly pressure ulcer assessment for the month of July and confirmed the weekly wound assessments were incomplete. 6. Medical record review revealed Resident #163 was admitted to the facility on [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of the WEEKLY PRESSURE ULCER RECORD revealed no documentation of assessments of the sacral ulcer, left heel ulcer, left lateral leg ulcer or the ankle ulcer for the weeks of 3/1, 3/8, 3/15, and 6/28/16. There was no documentation of assessments of the left lateral leg ulcer or the ankle ulcer for the week of 3/22/16. There was no documentation of assessments for the left lateral leg ulcer for the week of 7/19 and 7/26/16. Interview with the Wound Care Nurse (WCN) on 9/9/16 at 12:42 PM, in the cafe, The WCN was asked about the missing wound assessments. The WCN stated, I can't find them. A WEEKLY PRESSURE ULCER RECORD dated 3/22/16 documented, Lt. (left) lat. (lateral) leg .SIZE IN CM (CENTIMETERS) .1.4 (x) 0.8 .WOUND BED PINK .Lt .heel pos (posterior) .SIZE IN CM .1.7x2.4 .WOUND BED PINK . Medical Doctor (MD) #3's order dated 3/21/16 documented, Left, Lateral lower leg cleanse wound with mild soap and water .Apply .Santyl ointment to wound daily .Cover dressing with dry gauze and wrap with Kerlix .Left Heel .cleanse wound with mild soap and water .Apply .Santyl ointment to wound daily .cover dressing with dry gauze and wrap with Kerlix . MD #1's order dated 3/1/16 documented, CLEAN LEFT LATERAL LEG WOUNDS WITH DAKINS 0.25% SOLUTION, PAT DRY, APPLY SANTYL TO LEFT LOWER LEG WOUND, 4X4, COVER WITH BORDERGAUZE, CHANGE EVERY OTHER DAY AND PRN .CLEAN LEFT HEEL POSTERIOR WOUND WITH WOUND SPRAY, APPLY WOUND GEL, CAL-ALGINATE, 4X4, COVER WITH BORDERGAUZE, CHANGE EVERY OTHER DAY AND PRN . A Wound Care Record for March 2016 documented, .clean Lt (left) .heel (with) wd spray pat dry .apply Santyl .cal (calcium)-alginate .change q day .cover (with) Bordergauze . This wound care was documented as performed on 3/22, 3/23, 3/24, 3/25, and 3/26, 3/27/16. A MAR for March 2016 documented, .CLEAN LEFT HEEL POSTERIOR WOUND WITH WOUND SPRAY, APPLY WOUND GEL, CAL-ALGINATE, 4X4, COVER WITH BORDERGAUZE, CHANGE EVERY OTHER DAY AND PRN . This wound care was documented as performed on 3/23, 3/25, 3/27, 3/29, and 3/31/16. There was no documentation that the facility called the physicians to clarify the wound orders. There was no documentation the wound care was done on 3/28/or 3/30. A Wound Care Record for March 2016 documented, .CLEAN LEFT LATERAL LEG WOUNDS WITH DAKINS 0.25% SOLUTION, PAT DRY APPLY SANTYL TO LEFT LOWER LEG WOUND, 4X4, COVER WITH BORDERGAUZE, CHANGE EVERY OTHER DAY AND PRN . This wound care was documented as performed on 3/23, 3/25, 3/27, 3/29, and 3/31/16. There was no documentation that the facility called the physicians to clarify the wound orders. There was no documentation the wound care was done on 3/28/or 3/30. A WEEKLY PRESSURE ULCER RECORD dated 4/1/16 documented, Lt. (left) lat. (lateral) leg .SIZE IN CM (CENTIMETERS) .1.4 (x) 0.8 .WOUND BED PINK .Lt .heel pos (posterior) .SIZE IN CM .1.7x2.6 .WOUND BED PINK . MD #3's order dated 3/28/16 documented, Left, Lateral lower leg cleanse wound with mild soap and water .Apply .Santyl ointment to wound daily .Cover dressing with dry gauze and wrap with Kerlix .Left Heel .cleanse wound with mild soap and water .Apply .Santyl ointment to wound daily .cover dressing with dry gauze and wrap with Kerlix . MD #1's order dated 4/1/16 documented, CLEAN LEFT LATERAL LEG WOUNDS WITH DAKINS 0.25% SOLUTION, PAT DRY, APPLY SANTYL TO LEFT LOWER LEG WOUND, 4X4, COVER WITH BORDERGAUZE, CHANGE EVERY OTHER DAY AND PRN .CLEAN LEFT HEEL POSTERIOR WOUND WITH WOUND SPRAY, APPLY WOUND GEL, CAL-ALGINATE, 4X4, COVER WITH BORDERGAUZE, CHANGE EVERY OTHER DAY AND PRN . A Wound Care Record for April 2016 documented, .CLEAN LEFT HEEL POSTERIOR WOUND WITH WOUND SPRAY .APPLY WOUND GEL .CAL-ALGINATE .4X4 .COVER WITH BORDERGAUZE, CHANGE EVERY OTHER DAY AND PRN . This wound care was documented as performed 4/4, 4/6, 4/8, 4/10, 4/11, 4/13, 4/15, 4/16, 4/18, 4/19, 4/20, 4/21, 4/23, 4/24, 4/25, 4/26, 4/27, 4/28, and 4/29/16. There was no documentation that the facility called the physicians to clarify the wound orders. A Wound Care Record for April 2016 documented, .CLEAN LEFT LATERAL LEG WITH WOUND SPRAY, APPLY WOUND GEL, 4X4 BORDERGAUZE, CHANGE EVERY OTHER DAY AND PRN . This wound care was documented as performed on 4/1, 4/2, 4/4, 4/6, 4/8, 4/10, 4/12, 4/13, 4/14, 4/15, 4/16, 4/17, 4/18, 4/19, 4/20, 4/21, 4/23, 4/25, 4/26, 4/27, 4/28, and 4/29/16. There was no documentation that the facility called the physicians to clarify the wound orders. A WEEKLY PRESSURE ULCER RECORD dated 4/29/16 documented, Lt. (left) lat. (lateral) leg .SIZE IN CM (CENTIMETERS) .1.3 (x) 1.6 .WOUND BED PINK .Lt .heel .SIZE IN CM .1.2x2.2 .WOUND BED PINK . Physician #3's orders dated 5/1/16 documented, .CLEAN LEFT HEEL POSTERIOR WITH WOUND SPRAY, APLLY SANTYL, 4X4, BODERGAUZE, CHANGE QD/PRN .CLEAN LEFT LAT .LEG WITH WOUND SPRAY, APPLY SANTYL, 4X4, COVER WITH BORDERGAUZE, CHANGE QD/PRN . A May 2016 MAR documented, .Clean Lt. pos (posterior) heel (with) wd spray .apply wound gel cal alginate .4x4 .Bordergauze .change QOD (every other day) . This wound care was documented as performed every day in May. A May 2016 MAR documented, .Clean Lt. lat leg (with) wd spray .apply wd gel 4x4, Bordergauze .change QOD (every other day) . This wound care was documented as performed every day in May. A WEEKLY PRESSURE ULCER RECORD dated 5/27/16 documented, Lt. (left) Lat. (lateral) leg .SIZE IN CM (CENTIMETERS) .1.0 (x) 1.4 .WOUND BED PINK .Lt .heel .SIZE IN CM .2.0 X 1.3 .WOUND BED PINK . Physician #3's orders dated 6/1/16 documented, .CLEAN LEFT HEEL POSTERIOR WITH WOUND SPRAY, APPLY SANTYL, 4X4, BORDERGAUZE, CHANGE QD/PRN .CLEAN LEFT LAT .LEG WITH WOUND SPRAY, APPLY SANTYL, 4X4, COVER WITH BORDERGAUZE, CHANGE QD/PRN . A June 2016 MAR documented, .CLEAN LEFT HEEL POSTERIOR WOUND WITH WOUND SPRAY .APPLY WOUND GEL .CAL-ALGINATE .4X4 .COVER WITH BORDERGAUZE .CHANGE EVERY OTHER DAY AND PRN . This wound care was documented as performed on 6/1, 6/3, 6/5, 6/7, 6/9, 6/11, 6/13, 6/15, 6/17, 6/19, 6/21, 6/23, 6/25,

Based on medical record review, observation and interview, the facility failed to follow physician orders [REDACTED].#20, 50, 68, 73, 79, 118, 128, 143, and 201) sampled residents reviewed for nutrition of the 45 included in the stage 2 review. The failure to provide nutritional interventions resulted in immediate jeopardy (IJ) to Resident #20, 50, 79, 128, 143, and 201, who had significant and serious weight loss. Failure of the facility to implement and/or provide supplements to maintain nutritional status for residents with significant weight loss resulted in an IJ when Resident #20, 50, 79, 128, 143, and 201 had continued weight loss when the facility did not ensure nutritional interventions were provided as ordered. Immediate Jeopardy is a situation in which the provider's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Corporate Vice President, the Nurse Consultant (NC), the Interim Administrator, and the Director of Nursing (DON) were informed of the Immediate Jeopardy on 9/14/16 at 6:10 PM, in the Club Room. The facility was cited an Immediate Jeopardy at F325-K which is Substandard Quality of Care. An extended survey was completed on 9/14/16. The Immediate Jeopardy is effective March 16, 2016, and is ongoing. The findings included: 1. Medical record review revealed Resident #20 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The care plan dated 6/28/16 and revised on 8/13/16 documented, .Focus .resident has had significant weight loss r/t (related to) recent AKA (above knee amputation) .Sacral wound .7/1/2016 .Weight loss of 7% (percent) x (times) 20 days. 8/12/2016 Significant weight loss of 27.3% x 180 days r/t poor po (by mouth) intake. CBW (current body weight) 85# (pounds) Interventions .Give the resident supplements as ordered . The quarterly Minimum Data Set ((MDS) dated [DATE] documented, Resident #20 had a Brief Interview for Mental Status (BIMS) score of 00 indicating Resident #20 was severely cognitively impaired per staff assessment and totally dependent on staff to eat. Review of the weight records revealed the following: a. On 5/9/16 the resident weighed 104.2 pounds (lbs) b. On 6/10/16 the resident weighed 96.8 lbs c. On 7/13/16 the resident weighed 87 lbs d. On 8/10/16 the resident weighed 85 lbs e. On 9/14/16 the resident weighed 81.8 lbs Resident #20 had a 30 day weight loss of 7.1% and 90 day weight loss of 18.4% which was a serious weight loss. Review of the Medical Nutritional Therapy Assessment dated 5/9/16 revealed, .Diet, mech (mechanical) soft .1 can glucerna .meals tid (three times a day) per nursing .CBW =104.2 (Lb) .after AKA .98# . Resident @ (at) nutritional risk .impaired skin break .isolation .fed by staff .Recommend .glucerna .between meals .Juven (a nutritional supplement to support wound healing and to help build lean body mass)1 pk (pack) bid (twice a day) x 30 days .Prostat (a nutritional protein supplement) .bid x 30 days .[MEDICATION NAME] in place to promote appetite . A physician's orders [REDACTED].Ensure three times a day GIVE ENSURE ONE CAN BETWEEN MEALS AND HS (bedtime) .Juven two times a day until 06/11/2016 .Prostat two times a day until 06/11/2016 . On 6/1/16 Mighty Shakes with meals was added to the resident's diet. Review of a physician's orders [REDACTED]. The facility was unable to provide the Medication Administration Record (MAR) for the month of May 2016 to verify if the Ensure, Juven and Prostat had been given as ordered. Review of the MAR for June 2016 revealed that none of the Mighty Shake with meals had been given. Ensure was not given on 6/2 and 6/3 at 2:00 PM, 6/22 at 9:00 PM, and 6/24 at 10:00 AM and 2:00 PM. The Prostat was not given on 6/22 and 6/23 at 5:00 PM. The Juven was not given on 6/22 and 6/23 at 5:00 PM. Review of the Nutrition Services Progress Note dated 6/17/16 revealed, .Resident triggered .7.1% wt (weight) loss x .30 days, -15 (Lb) .8% 90 days and 20.0 (Lb)x 180 days .CBW 96.8 (Lb) .receives regular puree diet .Fortified Foods .mighty shake tid, ensure 1 can tid .Lt(left) AKA healed as of 6/2/16 .recommend Prostat po (by mouth) bid x 30 days .Juven po bid x 30 days .continue to monitor .7/01/16 .CBW = 90.8# Resident 6.0 # (loss) from previous wt 96.8 (6/10/16) Resident 7% (weight loss) x 20 days. Resident discussed in Interdisciplinary (IDT) meeting .continues .multiple interventions in place .new recommendation discussed .assist @ all meal .encourage po intake .magic cup .bid .7/15/16 .CBW received today 87# .Resident triggers - 16.5% (weight loss) x 60 days .Resident started on [MEDICATION NAME] 7/9/16 . The physician's orders [REDACTED].Ensure three times a day GIVE ENSURE ONE CAN BETWEEN MEALS AND HS .Magic Cup - two times a day .Might Shake with meals . A physician's orders [REDACTED].[MEDICATION NAME] Tablet 15 MG (milligram) Give 1 tablet by mouth at bedtime for Appetite Stimulant . Review of the MAR for July 2016 revealed Ensure was not given on 6/2 and 6/7 at HS, 6/14 and 6/21 at 2:00 PM and 6/22 at 10:00 AM and 2:00 PM. The Mighty Shake was not given on 6/7 and 6/29 at HS and 6/22 at 8:00 AM and 12:00 PM. The [MEDICATION NAME] was not given as ordered at any time during July. Review of August 2016 physician's orders [REDACTED]. On 8/17/16 the physician ordered the appetite stimulant, [MEDICATION NAME] 400 mg twice daily for 30 days and wrote an order on 8/24/16 to decrease the dose of [MEDICATION NAME] to 7.5 mg for one week then discontinue the medication. Review of the MAR for August 2016 revealed Ensure was not given 8/31 at 10:00 AM and 2:00 PM. The Mighty Shake was not given 8/30 and 8/31 at 8:00 AM and 12:00 PM. The Magic Cup was not documented as given 8/14 through 8/31. The [MEDICATION NAME] was not given on 8/27 or 8/28. The [MEDICATION NAME] was not given on 8/31 at 9:00 AM. Review of the September 2016 MAR revealed Magic Cup had not been given 9/1 through 9/9. Observations in Resident #20's room on 9/13/16 at 8:05 AM, revealed Certified Nursing Assistant (CNA) #7 delivered the resident's breakfast tray into the room. The Mighty Shake, Magic Cup and fortified foods were on the tray. Interview with Certified Nursing Assistant (CNA) #7 on 9/13/16 at 8:05 AM, in Resident #20's room, when asked if the resident eats good, the CNA stated, .Just depends Some days she does good just eats half .she just wants sweets today she is really enjoying her Mighty Shake .and Magic Cup she wouldn't eat her food .she has been doing that the last two or three days . Observations in Resident #20's room on 9/14/16 at 8:04 AM, revealed the resident was lying in bed with the head of the bed elevated. CNA #7 was at the resident's bedside. Interview with CNA #7 on 9/14/16 at 8:04 AM, when asked about the resident's appetite, the CNA stated, .She isn't eating .Will drink her strawberry shake and milk . Interview with the DON on 9/12/16 at 5:18 PM, in the Club Room, the DON was asked what do the empty spaces mean on the MAR. The DON stated, . by looking at that it shows that the nurse's did not document that they gave it. The DON was asked should the supplements be documented that they are given. The DON stated, .yes . Interview with the DON on 9/13/16 at 10:53 AM, the DON had been asked to bring Resident #20's MAR for the month of May 2016 to show that the supplements had been given. The DON was unable to find documentation for the month of May and stated, .not in proper file .going to keep looking . The documentation was not provided. Interview with the Registered Dietician (RD) on 9/13/16 at 11:26 AM, in the Club Room, the RD was asked what do you consider to be significant weight loss. The RD stated, .5% in 30 days .7.5% in 90 days and 10% in 180 days, we do try to catch it before 30 days obviously . The RD was asked about Resident #20's weight loss. The RD stated, .came back in May with an AKA . The RD was asked what Resident #20 weighed before she left the facility. The RD stated, .105.8 .got back she weighed 104.2 .she did have some [MEDICAL CONDITION]. [MEDICATION NAME] was in place .Multiple Vitamin in place .came in on glucerna at meals .our recommendation was to change it to between meals three times a day .we started Juven and the Prostat .she did trigger 6/17 .7.1% (weight loss) in 30 days .she had fortified meals .was getting Mighty Shakes tid .ensure tid .left AKA had healed .still being treated for [REDACTED].down 6 lbs from previous weight .my recommendations at that time added magic cup bid .resident started [MEDICATION NAME] on 7/9 .on 7/15 .87 lbs on 7/28 .89 lbs .was .restarted on Prostat tid and Juven bid .for weight loss . on 8/5 .88.6 (lbs) continue to monitor for 90 days and 180 (days) for wt loss .diet was liberalized to promote intake .I do feel like we do have everything in place. I would like to keep her on weekly weights . The RD was asked if a resident was not receiving supplements and an appetite stimulant that was ordered could that cause a resident to decline in weight loss. The RD stated, Yes ma'am . The RD was made aware that residents were not getting all their appetite stimulants and supplements. The RD stated, .it has been a concern .have discussed it with the DON and ADON .I have met with them . The RD was asked how did you realize that it wasn't being done. The RD stated, .because of all the interventions in place .and the continued weight loss . Interview with the RD on 9/13/16 at 11:33 AM, in the Club Room, the RD was asked if she was familiar with Resident #20. The RD stated, Yes Ma'am . The RD was asked if you recommend supplements would you expect them to be given. The RD stated, Yes. The facility's failure to provide recommended and ordered nutritional interventions and appetite stimulant medications to a resident with significant and serious weight loss resulted in immediate jeopardy to Resident #20. 2. Medical record review revealed Resident #50 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The annual MDS dated [DATE],revealed Resident #50 was severely impaired cognitively and totally depend on staff to eat. Review of the weight records revealed the following: a. On 2/8/16 the resident weighed 134.6 lbs b. On 3/16/16 the resident weighed 124.0 lbs c. On 4/6/16 the resident weighed 128.4 lbs d. On 5/4/16 the resident weighed 122 lbs e. On 6/10/16 the resident weighed 125.2 lbs f. On 7/6/16 the resident weighed 124.6 lbs g. On 8/18/16 the resident weighed 111.8 lbs Resident #50 had a 30 day weight loss of 7.8%, 90 day weight loss of 9.3% and 16.9% weight loss in 180 days which was a serious weight loss. The physician's orders [REDACTED].MIGHTY SHAKE ALL MEALS .JUVEN 1 PACKET .BID .PROSTAT .BID . Review of the February 2016 MAR revealed Resident #50 was not given Mighty Shakes at any time during the month. The Juven was not given on 2/29 at 5:00 PM. The Prostat was not given on 2/10, 2/17, 2/18 and 2/29 at 5:00 PM. Review of the Nutrition Services Progress Note dated 3/17/16 revealed, .CBW 124 # .7.1 (Lb weight loss) x 30 days .11.8 (Lb weight loss) x 90 days .12.4 (Lb weight loss) x 180 days .significant weight loss x 30/90 days .Vit (Vitamin) C, Juven, Prostat all cont (continue) x 30 days on 2/22/16 .3/22 .Diet Puree, Fortified Foods TID .3/22/16 .Resident noted .significant wt loss .multiple interventions in place .continue prostat .bid .juven .bid .also recommend start ensure plus 1 can bid .to support nutritional needs .8/12/16 CBW 116 # .6.6% (weight) loss x 30 days .resident receives mighty shakes tid, fortified foods .MVI (multivitamin) ensure .bid . The physician's orders [REDACTED].MIGHTY SHAKE ALL MEALS .JUVEN 1 PACKET .BID .PROSTAT .BID . On 3/23/16 the physician ordered Ensure Plus one can po BID at 10:00 AM and 2:00 PM. Review of the March 2016 MAR revealed the Might Shake was not given at any time during the month. The Ensure Plus was not given on 3/31 at 2:00 PM. The physician's orders [REDACTED].MIGHTY SHAKE ALL MEALS .JUVEN 1 PACKET .BID .PROSTAT .BID .ENSURE PLUS ONE CAN BID . Review of the April 2016 MAR revealed the Mighty Shake was not given at any time during the month. The Ensure Plus was not given 4/15 at 5:00 PM. The physician's orders [REDACTED].Ensure two times a day .House Shake .with meals . On 5/16/16 the physician ordered Juven two times a day for 30 days and Prostat two times a day for 30 days. Review of the May 2016 MAR revealed the Ensure and the House Shake were not given at any time during the month. The Juven and the Prostat were not given 5/16/16 through 5/30/16. The physician's orders [REDACTED].Ensure two times a day .House Shake .with meals .Juven two times a day . Review of the June 2016 MAR revealed the Ensure two times a day and House Shakes with meals had not been given as ordered at any time during the month. The Juven was not given on 6/15 at 5:00 PM and 6/16 at 9:00 AM. The care plan dated 6/28/16 documented, Focus .resident has nutritional problem .requires adaptive equipment .and assistance with meals .Interventions .Provide and serve diet as ordered .Provide and serve supplements as ordered . The facility was unable to provide signed physician orders [REDACTED]. Attempts made to contact the physician were unsuccessful, as the physician was out of the country. Review of the July 2016 MAR revealed the Ensure two times a day had not been given as ordered at any time during the month. The Mighty Shake with meals had not been given 7/5 at 12:00 PM and 7/29 at 4:00 PM. The physician's orders [REDACTED].Ensure two times a day . Review of the August 2016 MAR revealed the Ensure two times a day had not been given as ordered at any time during the month. Review of the September 2016 MAR revealed the Ensure ordered in August had not been given 9/1 through 9/13. Interview with the NC on 9/14/16 at 3:43 PM, in the Club Room, the NC was asked would you expect the physician order's to be followed. The NC stated, Yes. The NC was shown Resident #50 physician's orders [REDACTED]. Phone interview with the Doctor of Nursing Practice (DNP) on 9/14/16 at 5:15 PM, the DNP was asked if she had written a statement today concerning Resident #50's weight loss. The DNP stated, Yes. The DNP was then read her written statement and confirmed that was her written statement saying that Resident #50 weight loss is unavoidable due to her multiple chronic medical condition and she did not respond to numerous interventions attempted. The DNP was asked if she had been made aware that Resident #50 had not received all of her nutritional supplements that had been ordered. The DNP stated, I was not aware .if she didn't get them I couldn't say it was unavoidable. The DNP was then asked if she was recanting her written statement. The DNP stated, I agree . The DNP was asked if she had any concerns about weight loss in the facility. The DNP stated, .yes .with concerns about residents not getting there trays and not getting fed .I have called the DON and (Named ADON)) with several concerns about residents not being fed .but the DON and ADON don't have a lot of interaction with the residents and there's not follow up . The facility's failure to provide recommended and ordered nutritional interventions to a resident with serious and significant weight loss resulted in immediate jeopardy to Resident #50. 3. Closed medical record review revealed Resident #79 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of an admission MDS dated [DATE] revealed Resident #79 was able to make himself understood, had a Brief Interview for Mental Status (BIMS) of 12, indicating Resident #79 was moderately impaired cognitively, required extensive assistance for all activities of daily living, ate independently, had a height of 68 inches and a weight of 187 pounds (lbs), and received a mechanically altered, therapeutic diet. The care plan dated 7/8/16 documented, .Focus .THE RESIDENT IS AT NUTRITIONAL RISK AEB (as evidenced by) REQUIRING MECHANICALLY ALTERED DIET .RD to evaluate and make diet change recommendations PRN (as needed) . Review of the weight records revealed the following: a. On 7/7/16 the resident weighed 186.8 lbs b. On 7/14/16 the resident weighed 183.8 lbs c. On 7/21/16 the resident weighed 173 lbs d. On 7/27/16 the resident weighed 164.4 lbs e. On 8/3/16 the resident weighed 163.8 lbs Resident #79 had a 27 day serious weight loss of 12.3%. A nurses note dated 7/17/16 documented, .Resident refusing [MEDICATION NAME] in AM .Refusal of [MEDICATION NAME] noted in DNP book .Ankles + (and) feet [MEDICAL CONDITION] . A Medical Nutritional Therapy Assessment dated 7/15/16 documented, .Diet .Cardiac .Regular texture .CBW .186.8 (Lbs) .Resident @ nutritional risk .pmh (past medical history) .therapeutic diet .[MEDICAL CONDITION] .ST (Speech Therapy)(change) diet to puree texture .recommend start MVI (multivitamin) (with) minerals .started Prostat 30 cc (cubic centimeters) on 7/12/16 . A Medical Nutritional Therapy Assessment dated 7/22/16 documented, .Weight/PAR (Patient At Risk) .Resident triggered .-7.4% wt loss over (approximately) 30 days .CBW 173.0 # .Puree (with) thin liquids .Resident consumes (approximately) 25-50% per staff interview .receives MVI (with) Minerals q (every) day .Prostat 30 cc po .Will recommend start Ensure Plus 1 can po BID (twice a day) to support nutritional needs r/t (related to) variable po intake . A physician's orders [REDACTED].Prostat 30 cc po BID . A physician's orders [REDACTED].Multi-Vitamin/Minerals .Give 1 tablet by mouth one time a day for supplement . A Medical Nutritional Therapy Assessment dated 7/28/16 documented, .CBW .164.4 # .Resident (decreased) 8.6# from last week .total .-22.4%/-12.0% since admit .Current Diet order .Cardiac Puree .Poor po intake noted 25-50% .receives MVI (with) Minerals q day .Ensure Plus 1 can po BID (Start 7/25/16) Prostat 30 cc po BID .Will recommen (recommend) MD (Medical Doctor)eval (evaluation) r/t appetite (decrease) .recommend Magic Cup BID . A Medical Nutritional Therapy Assessment dated 8/5/16 documented, .CBW 163.8# .continues to trigger (with) -12% wt loss x (approximately) 30 Days .PO intake .(approximately) 50-100% .Diet .liberalized puree .Magic Cup BID .Ensure Plus BID .MVI (with) Minerals q day .Prostat 30 cc po BID .recommend start fortified foods TID @ meals . A physician's orders [REDACTED].Ensure Plus two times a day for supplement . A physician's orders [REDACTED].two times a day . Review of the MAR for July 2016 revealed that the Multi-Vitamin/Minerals was not administered on 7/29 and 7/30, Ensure Plus was not administered on 7/29 and 7/30 and Magic Cup was not administered on 7/29 and 7/30. A physician's progress noted dated 8/8/16 documented, .the patient eats well .Weight .186.8 pounds (Admission weight .On 8/3/16 Resident #79 had a weight of 163.8 Lbs. according to the weight record) . The physician's orders [REDACTED].Magic Cup two times a day . Review of the MAR for August 2016 revealed that Magic Cup was not given at any time during the month. Interview with the NC on 9/14/16 at 3:13 PM, in the Club Room, the NC was asked if Resident #79 received the Multi-Vitamin/Minerals on July 29 and July 30. The NC reviewed the July MAR and stated, .looks like 7/29 and 7/30 .no . The NC was asked if Resident #79 received Ensure Plus as ordered in July. The NC reviewed the July MAR and stated, .7/29 at 2 PM and 7/30 at 10 AM, he didn't get it according to the documentation . The NC was asked if Resident #79 received Magic Cup in July. The NC reviewed the July MAR and stated, There's an omission on 7/29 at 4 PM and an omission on 7/30 at 4 PM .not according to the documentation . Phone interview with the DNP on 9/14/16 at 5:15 PM, the DNP was asked if she had any concerns about weight loss in the facility. The DNP stated, .yes .with concerns about residents not getting their trays and not getting fed .I have called the DON and ADON with several concerns about residents not being fed .but the DON and ADON don't have a lot of interaction with the residents and there's not follow up . The facility's failure to provide recommended and ordered nutritional interventions to a resident with serious and significant weight loss resulted immediate jeopardy to Resident #79. 4. Medical record review revealed Resident #128 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual MDS dated [DATE] revealed Resident #128 was severely cognitively impaired per staff assessment and required extensive staff assistance for activities of daily living (ADLs), including eating. The MDS documented no swallowing disorder, a height of 66 inches and a weight of 128# with no weight loss, and received a mechanically altered diet at the facility. No speech therapy was documented. Review of the quarterly MDS dated [DATE] documented Resident #128 was severely cognitively impaired per staff assessment and was totally dependent on staff for ADLs, including eating. The MDS documented no swallowing disorder, a height of 64 inches and a weight of 115 # with a weight loss of 5 % or more in the last month or 10% or more in the last 6 months, and received a mechanically altered diet at the facility. No speech therapy was documented. The care plan dated 6/17/16, and revised on 8/13/16 revealed, .at nutritional risk r/t requiring mechanically altered texture diet and requires assistance with all meals .ASSISTED DINING TID .triggered a significant weight loss . Interventions .give the resident supplements as ordered .follow facility protocol for weight loss . The weight records revealed the following: a. On 2/5/16 130.8 Lbs b. On 5/4/16 119 Lbs c. On 7/6/16 112.6 Lbs d. On 8/5/16 106 Lbs Resident #128 had a 9% weight loss in 3 months and an 18.9% weight loss in 6 months. The nutrition service progress notes documented, .5/11/16 .CBW .119# .(loss of) 9.8#/7% x 180 days. Significant weight loss of 11.8#/9% x 90 Days .(Loss of) 3.2#/2% x 30 Days .Attends Assisted dining for all meals .receives .Mighty Shake @ dinner .6/14/16 .Diet Audit .Recommend to clarify Assisted dining for all meals .continues to trigger for significant wt loss .-12.1% .180 days .CBW=115.2# .receives Mighty Shake q Day .[MEDICATION NAME] which may aid in stimulating Appetite .Will recommend (increase) Mighty Shake to BID .7/15/16 .Resident continues to trigger for wt loss of -7.9% .90 days .CBW=112.6# .decreased 2.6# x 1 month .Resident (with) order for assisted Dining all meals . Receives .Mighty Shake BID .[MEDICATION NAME] in place .Resident consuming .75-100% @ meals per ADLs .8/18/16 .Weight Review: CBW=106# .-5.9% (weight loss) x 30 Days .-8.0% (weight loss) .60 days .and -16.7% (weight loss) .150 days .Resident to attend assisted Dining for all meals .Consuming .50-75% at most meals per ADLs .receives Mighty Shake BID . The telephone physician's orders [REDACTED].[MEDICATION NAME] .Malnutrition .unstageable wound . The WOUND CARE SPECIALIST EVALUATION dated 8/16/16 documented, .stage 3 pressure wound of the right ischium of at least 26 days duration .Malnutrition . The WOUND CARE SPECIALIST EVALUATION dated 9/1/16 documented, .stage 3 pressure wound of the right ischium of at least 41 days duration .Malnutrition . The physician's orders [REDACTED].[MEDICATION NAME] .15 MG (milligrams) Give 1 tablet by mouth at bedtime . On 6/1/16 Mighty Shakes @ HS was ordered and on 6/5/16 the Mighty Shake was increased to BID. Review of the June 2016 MAR revealed no documentation that [MEDICATION NAME] was administered as ordered on 6/15 and 6/22. The Mighty Shakes were not given @ HS on 6/6, 6/7, and 6/10. The Mighty Shakes ordered BID were not given as ordered from 6/15 through 6/30. The physician's orders [REDACTED].[MEDICATION NAME] .15 MG .at bedtime .Mighty Shake two times a day . Review of the July 2016 MAR revealed the [MEDICATION NAME] was not given on 7/2. The Mighty Shake was not given on 7/29 at 9:00 PM. Review of a physician order [REDACTED].Prostat 30cc BID x 30 days .Juven 1 pk BID x 30 days . On 8/15/16 .Ensure Plus two times a day . Review of the MAR for August 2016 revealed there was no documentation that the Prostat was administered twice daily as ordered on 8/5, 8/8, 8/10, 8/11, 8/19, 8/20, and 8/28. The Juven was not administered twice daily as ordered on 8/8, 8/10, 8/11, and 8/28. The Ensure Plus was not administered as ordered on 8/25, 8/26, 8/29, 8/30, and 8/31. Interview with the DON on 9/12/16 at 2:45 PM, the DON was asked to explain what the blank spaces meant next to the order for Mighty Shakes on the June MAR. The DON stated, It looks like the nurse didn't sign it out. The DON was asked whether she expected the nurses to document supplement administration. The DON stated, Yes . The DON was asked how would she know whether the supplement was offered if there was no documentation. The DON stated, We don't . Interview with the ADON on 9/12/16 at 4:44 PM, in the Club Room, the ADON was asked whether ordered supplements should be given. The ADON stated, .We are strict on that. If it's not documented, it's not done. The ADON was asked if the supplements were documented on the MARs. The ADON stated, It should be. Interview with the NC (NC) on 9/14/16 at 10:22 AM, the NC was asked about the missing documentation for Mighty Shakes on the June 2016 MAR. The NC stated, Omissions. The physician's orders [REDACTED].Assisted dining room for all meals . Observations of Resident #128 during the survey revealed the following: a. On 9/6/16 at 12:16 PM Resident #128 was seated in the Restorative Dining Room in a wheelchair and staff was assisting the resident with lunch. b. On 9/12/2016 at 5:09 PM Resident #128 was lying in bed. Resident #128's roommate was eating dinner. Resident #128's meal tray was on the overbed table beside the wall in her room. Interview with CNA #1 on 9/12/16 at 5:43 PM in Resident #128's room CNA #1 was asked about Resident #128's meal tray. CNA #1 stated, I'm fixing to go help her right now. CNA #1 was asked whether Resident #128 needed assistance with eating. CNA #1 stated, We tried, but sometimes she won't eat, so we have to go back and try again. CNA #1 entered Resident #128's room, and uncovered the meal tray that was untouched. CNA #1 covered the meal and left the room without attempting to feed the resident. c. On 9/13/16 at 7:55 AM Resident #128 was lying in bed. Resident #128's roommate was eating breakfast. At 8:10 AM, all the trays had been served. The staff was observed removing the dirty trays from the resident rooms, and placing them back into the meal carts. At 8:15 AM, Licensed Practical Nurse (LPN) #1 was asked to provide Resident #128's meal tray for intake review. LPN #1 stated, Her tray comes out on the Restorative cart because, since she had her little wound, she don't get up and go down there anymore . At 8:20 AM, CNA #3 took Resident #128's breakfast tray into the room to feed the resident. d. On 9/13/16 at 12:05 PM, Resident #128 was lying in bed and her roommate was eating lunch. CNA #4 was asked about Resident #128's meal. CNA #4 confirmed Resident #128's tray was not on either cart on the hall. CNA #4 stated, It is in restorative . e. On 9/13/16 at 5:40 PM Resident #128 was lying in bed. The dinner tray was on the over bed table at bedside. CNA #5 was asked how much of the meal Resident #128 had consumed. CNA #5 removed the cover and stated, About 50%. CNA #5 was asked when Resident #128 stopped going to the Restorative Dining Room for meals. CNA #5 stated, When she got her wound. CNA #5 was asked how long ago that was. CNA #5 stated, About 3 months ago. Observations during the survey revealed Resident #128 to be very thin, confused, and required assistance for all ADLs. The resident was not assisted to the Assisted Dining Room for meals as ordered. Interview with the DON on 9/14/16 at 9:10 AM, in the Club Room, the DON was asked when Resident #128 stopped going to the Assisted Dining Room for meals. The DON stated, I would have to read the note .I wouldn't know by heart .So she's stopped going? Oh, (named Resident #128) .we assist her with all meals in her room . The DON was asked whether there should be a physician's orders [REDACTED]. The DON stated, Yes, it should be . Interview with the ADON on 9/14/16 at 9:15 AM, in the Club Room, the ADON was asked why Resident #128 does not go to the Assisted Dining Room for meals. The ADON stated, She does go . The ADON was asked whether she goes every meal as ordered. The ADON stated, Not every meal . Interview with the NC on 9/14/16 at 2:44 PM, in the Club Room, she stated, I don't know if this will help . The NC presented a typed note dated 9/14/16 that documented, .has unavoidable weight loss due to dysphagia related to advanced dementia .(MD #1's signature) . Interview with Medical Doctor (MD) #2 via telephone on 9/14/16 at 5:15 PM, MD #2 was asked if he could elaborate on his statement that Resident #128's weight loss was unavoidable. The MD stated, .She's pretty advanced Alzheimer's and Failure to Thrive .with her dementia she's obviously getting into dysphagia issues. MD #2 was asked if, considering the dysphagia and his orders to have her up in assisted dining room for every meal, he would expect staff to take her to the assisted dining room for every meal. MD#2 was notified of survey observations of Resident #128 being fed in bed multiple times during the survey, and asked whether that was acceptable. MD #1 stated, They do need to be getting her up. She needs to be up in a chair, fed slow

Based on review of the Administrator's job description, policy review, medical record review, observation, and interview, the facility failed to be administered in a manner that enabled it to use it's resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychological well-being by not administering nutritional supplements and appetite stimulants as ordered by the Physician and Registered Dietician recommendations resulting in continued significant weight loss and failed to follow care plan interventions for the care of residents with weight loss. The failure of the facility to be effectively and efficiently administered placed 6 of 13 (Resident #20, 50, 79, 128, 143, and 201) sampled residents with significant and serious weight loss in immediate jeopardy (IJ). The Administration failed to ensure weekly skin assessments were done timely, treatments were provided as ordered, and failed to ensure staging of a sacral wound was accurate for Resident #50 which resulted in IJ to Resident #50 when staging went back and forth from unstageable to a stage 4 wound. The Administration failed to ensure treatment was provided as ordered, failed to ensure nutritional supplements were provided as ordered and failed to ensure staging was accurate by documenting Resident #128 had a stage 2 wound when identified by the physician in August as a stage 3 wound which resulted in IJ for 2 of 5 (Resident #50 and #128). Immediate Jeopardy is a situation in which the provider's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Corporate Vice President, the Nurse Consultant (NC) , the Interim Administrator, and the Director of Nurses (DON) were informed of the Immediate Jeopardy on 9/14/16 at 6:10 PM, in the Club Room. The facility was cited an Immediate Jeopardy at F-314 and F325-K which is Substandard Quality of Care. An extended survey was completed on 9/14/16. The Immediate Jeopardy is effective March 16 2016, and is ongoing. The findings included: 1. Review of the Administrator's Job Description signed 8/4/15 by the Administrator, documented, .Responsible for the overall management, leadership, growth .of the facility. Plans, develops, directs, monitors, and supports all operational, administrative, clinical, human resources, customer service and fiscal activities for the facility's programs and services so as to facilitated quality and consistency with company standards .Ensures that the quality and appropriateness of patient care meets company and industry standards .Participates in quality improvement activities, which reduce cost and increase efficiency through improved systems and processes . 2. Telephone interview with the former Administrator (last day 9/5/16) on 9/14/16 at 5:05 PM, the Administrator was asked if he was aware of the concern with weight loss at the facility. The Administrator stated, .I was aware .I was party to the PI (Performance Improvement) plan . The Administrator was asked if he had followed up on the plan. The Administrator stated, .I was being told they (the residents with weight loss) were being discussed every week in PAR (Patients at Risk Meeting) .I did see some documentation .I looked at documentation (recommendations) from the RD (Registered Dietician) . The Administrator was asked if he was involved in a meeting or discussion with the RD and the Director of Nursing when the RD discussed the weight loss plan and recommendations for the weight loss to ensure the recommendations were being followed. The Administrator stated, .I don't remember. I'm not gonna say 'No they didn't talk about it'. I tend to deal with issues head on .We did discuss in QAPI (Quality Assessment Performance Improvement) every month, the data was given to me by the DON and the ADON (Assistant Director of Nursing). I remember seeing improvement or I would have dealt with it 3. Administration failed to ensure services were provided to attain or maintain the highest practical physical, mental, and psychosocial well-being in accordance with the plan of care by not revising the care plan for nutritional interventions for weight loss. The failure to revise the care plan for weight loss resulted in IJ to Resident #s20, 128, and 201. Refer to F280 4. Administration failed to ensure staff followed the care plan nutritional interventions for weight loss. The failure to follow the care plan interventions for weight loss resulted in IJ to Resident #s 20, 50, 79, 128, and 143. Refer to F282 5. Administration failed to ensure nurses completed timely weekly skin assessments on residents who had pressure ulcers, failed to ensure nurses followed physician orders [REDACTED].#50. The Administration failed to ensure treatments were provided as ordered, failed to ensure nutritional supplements for wounds were provided as ordered and staging was accurate for a resident with wounds resulted in IJ for Resident #128. Refer to F314 6. Administration failed to ensure residents with continued significant and serious weight loss received nutritional supplements as recommended by the RD and ordered by the Physician and/or Nurse Practitioner. This resulted in immediate jeopardy to Resident #s20, 50, 79, 128, 143, and 201 and placed them in IJ. Refer to F 325. 7. Administration failed to ensure the Medical Director assisted with addressing clinical concerns and provided guidance regarding resident care by failing to ensure there was an effective process that monitored and addressed the potential for adverse consequences related to continued weight loss. The failure of the Medical Director to ensure supplements were provided as recommended by the RD and ordered by the physician resulted in IJ to Resident #s20, 50, 79, 128, 143, and 201 when they suffered significant and serious weight loss. Refer to F325 8. Administration failed to ensure an effective Quality Assurance Committee recognized an ongoing concern with weight loss and failed to ensure recommended and ordered nutritional interventions were provided which resulted in IJ when Resident #s20, 50, 68, 73, 79, 118, 128, 143, and 201 suffered significant and serious weight loss. Refer to F-520

Based on review of the Administrator's job description, medical record review, observation and interview, the governing body failed to ensure the facility had a functional nutritional and weight management policy to ensure resident's with weight loss received the necessary care to prevent further weight loss. The Governing Body failed ensure the facility was being administered in a manner that enabled it to use its resources effectively and efficiently to maintain the highest practible physical well- being by not ensuring nutritional supplements were administered as recommended by the Registered Dietician (RD) and ordered by the Physician were implemented and/or provided to maintain nutritional status for 9 of 13 (Resident #s20, 50, 68, 73, 79, 118, 128, 143, and 201) sampled residents reviewed for nutrition and resulted in immediate jeopardy (IJ) to Resident #s20, 50, 79, 128, 143, and 201 who suffered significant and serious weight loss. Failure of the facility to implement and/or provide supplements to maintain nutritional status for residents with significant weight loss resulted in an IJ when Resident #s20, 50, 79, 128, 143, and 201 had continued weight loss when the facility did not ensure nutritional interventions were provided as ordered. The Governing Body failed to ensure weekly skin assessments were done timely, treatments were provided as ordered, and failed to ensure staging of a sacral wound was accurate for Resident #50 which resulted in IJ to Resident #50 when staging went back and forth from unstageable to a stage 4 wound. The Governing Body failed to ensure treatment was provided as ordered, failed to ensure nutritional supplements were provided as ordered and failed to ensure staging was accurate by documenting Resident #128 had a stage 2 wound when identified by the physician in August as a stage 3 wound which resulted in immediate jeopardy and resulted in IJ for 2 of 5 (Resident #50 and #128). Immediate Jeopardy is a situation in which the provider's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Corporate Vice President, the Nurse Consultant (NC), the Interim Administrator, and the Director of Nurses (DON) were informed of the Immediate Jeopardy on 9/14/16 at 6:10 PM, in the Club Room. The facility was cited an Immediate Jeopardy at F-314 and F325-K which is Substandard Quality of Care. An extended survey was completed on 9/14/16. The Immediate Jeopardy was effective March 16 2016, and is ongoing. The findings included: 1. Review of the Administrator Job Description signed 8/4/15 by the Administrator, documented, .Responsible for the overall management, leadership, growth .of the facility. Plans, develops, directs, monitors, and supports all operational, administrative, clinical, human resources, customer service and fiscal activities for the facility's programs and services so as to facilitated quality and consistency with company standards .Ensures that the quality and appropriateness of patient care meets company and industry standards .Participates in quality improvement activities, which reduce cost and increase efficiency through improved systems and processes . 2. Telephone interview with the former Administrator (last day 9/5/16) on 9/14/16 at 5:05 PM, the Administrator was asked if he was aware of the concern with weight loss at the facility. The Administrator stated, .I was aware .I was party to the PI (Performance Improvement) plan . The Administrator was asked if he had followed up on the plan. The Administrator stated, .I was being told they (the residents with weight loss) were being discussed every week in PAR (Patients at Risk Meeting) .I did see some documentation .I looked at documentation (recommendations) from the RD (Registered Dietician) . The Administrator was asked if he was involved in a meeting or discussion with the RD and the Director of Nursing when the RD discussed the weight loss plan and recommendations for the weight loss to ensure the recommendations were being followed. The Administrator stated, .I don't remember. I'm not gonna say 'No they didn't talk about it'. I tend to deal with issues head on .We did discuss in QAPI (Quality Assessment Performance Improvement) every month, the data was given to me by the DON and the ADON (Assistant Director of Nursing). I remember seeing improvement or I would have dealt with it Refer to F490 3. The governing body failed to ensure that Administration ensured services were provided to attain or maintain the highest practical physical, mental, and psychosocial well-being in accordance with the plan of care by not revising the care plan for nutritional interventions for weight loss. The failure to revise the care plan for weight loss resulted in IJ to Resident #s20, 128, and 201. Refer to F280 4. The governing body failed to ensure that Administration ensured services were provided to maintain the highest practical physical well-being in accordance with the plan of care by not ensuring nutritional intervention recommendations and orders were implemented and provided to residents with continued weight loss. Administration failed to ensure staff followed care plan nutritional interventions for weight loss. The failure to follow the care plan interventions for weight loss resulted in IJ to Resident #s20, 50, 128, and 143. Refer to F282 5. The Governing Body failed to ensure nurses completed timely weekly skin assessments on residents who had pressure ulcers, failed to ensure nurses followed physician orders [REDACTED].#50. The Administration failed to ensure treatments were provided as ordered, failed to ensure nutritional supplements for wounds were provided as ordered and staging was accurate for a resident with wounds which resulted in IJ to Resident #128. Refer to F314 6. The governing body failed to ensure staff provided recommended and ordered nutrtional supplements to residents with identified ongoing weight loss . The failure to ensure nutritional interventions were provided to maintain nutritional status for residents with significant weight loss resulted in an immediate jeopardy (IJ) when Resident #s20, 50, 79, 128, 143, and 201 had continued weight loss when the facility did not ensure nutritional interventions were provided as ordered. Refer to F325 7. The governing body failed to ensure Administration ensured an effective Quality Assurance Committee recognized an ongoing concern with weight loss and failed to ensure nutritional interventions were provided to resolve concerns identified April 2016. The failure to ensure nutritional interventions were provided to maintain nutritional status for residents with significant weight loss resulted in an immediate jeopardy (IJ) when Resident #s20, 50, 79, 128, 143, and 201 had continued weight loss when the facility did not ensure nutritional interventions were provided as ordered. Refer to F520 Interview with the Company Vice President (VP) on 9/14/16 at 9:19 PM, in the hall beside the front lobby, the VP stated, .the Administrator, the DON, and Department Heads, accept for the facility, the policies and procedures sent down through Corporate . Interview with the DON on 9/13/16 at 11:14 AM, in the Club Room, the DON was asked if the facility had a weight loss protocol or policy. The DON stated, We do not have a weight loss protocol . Interview with the NC on 9/14/16 at 5:54 PM, in the Club Room, the NC was asked whether the facility has a weight management policy. The NC stated, We do not. Interview during exit conference on 9/14/16 at 10:45 PM, the Corporate Vice President stated, .We do have a Governing Body at Corporate that develops our policies .

Based on contract review, policy review, medical record review, observation and interview, the facility failed to ensure the Medical Director assisted with addressing clinical concerns and provided guidance regarding resident care by failing to ensure there was an effective process that monitored and addressed the potential for adverse consequences related to weight loss. The failure of the Medical Director to ensure nutritional interventions recommended by the Registered Dietician and ordered by the Physicians were provided to the residents with weight loss. The failure of the Medical Director to ensure nutritional interventions were provided to residents with continued weight loss resulted in immediate jeopardy (IJ) when Resident #s20, 50, 79, 128, 143, and 201 suffered significant and serious weight loss. The Medical Director failed to ensure weekly skin assessments were done timely, treatments were provided as ordered, and failed to ensure staging of a sacral wound was accurate for Resident #50 which resulted in IJ to Resident #50 when staging went back and forth from unstageable to a stage 4 wound. The Medical Director failed to ensure treatment was provided as ordered, failed to ensure nutritional supplements were provided as ordered and failed to ensure staging was accurate by documenting Resident #128 had a stage 2 wound when identified by the physician in August as a stage 3 wound which resulted in IJ for 2 of 5 (Resident #50 and #128). Immediate Jeopardy is a situation in which the provider's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Corporate Vice President, the Nurse Consultant (NC), the Interim Administrator, and the Director of Nurses (DON) were informed of the Immediate Jeopardy on 9/14/16 at 6:10 PM, in the Club Room. The facility was cited an Immediate Jeopardy at F325-K which is Substandard Quality of Care. An extended survey was completed on 9/14/16. The Immediate Jeopardy was effective March 16 2016, and is ongoing. The findings included: 1. The Medical Director (MD) contract signed November 17, 2008 by the MD, documented, .Medical Director shall perform all such duties and responsibilities ( Medical Director Services) in accordance with accepted professional standards, all applicable federal, state, and local laws and regulations, Facility policies .Be responsible for reviewing and evaluating administrative and patient care services .Assist the Administrator and Director of Nurses in clinical program development and act as a consultant to the Director of Nurses in matters relating to patient care services . 2. Attempts were made to interview the Medical Director (Medical Doctor #1)by phone but due to Medical Doctor (MD) #1 being out of the country, in a different time zone, and the late exit from the facility, were unable to contact MD #1. 3. The Medical Director failed to ensure the care plans for nutritional interventions were revised in accordance with the plan of care as recommended and ordered for residents with significant and serious weight loss which resulted in actual harm to Resident #s 20, 128 and 201 and placed them in IJ. Refer to F280 4. The Medical Director failed to ensure nutritional interventions were followed according to the resident's plan of care for weight loss which resulted in significant and serious weight loss which resulted in actual harm and placed Resident #s 20, 50, 128, and 143 in IJ. Refer to F282 5. The Medical Director failed to ensure nurses completed timely weekly skin assessments on residents who had pressure ulcers, failed to ensure nurses followed physician orders [REDACTED].#50. The Medical Director failed to ensure treatments were provided as ordered, failed to ensure nutritional supplements for wounds were provided as ordered and staging was accurate for a resident with wounds which resulted in actual harm for Resident #128. Refer to F-314 The Medical Director failed to ensure residents received recommended and ordered nutritional supplements to residents with weight loss which resulted in significant and serious weight loss which resulted in actual harmand placed Resident #s 20, 50, 79, 128, 143, and 201 in IJ. Refer to F325 6. The Medical Director failed to ensure an effective Quality Assurance Committee recognized an ongoing concern with weight loss and failed to implement effective interventions and monitoring to resolve concerns of continued weight loss identified in April 2016. Residents with continued weight loss were still being identified in August 2016. Survey observations and investigation during the recertification survey 9/6/16 - 9/14/16 revealed ongoing significant and serious weight loss. Refer to 520.

Based on medical record review, and interview, the facility failed to provide and maintain accurate, complete, and available medical records for 8 of 45 (Resident #20, 50, 128, 143, 68, 118, 163, and 233) sampled residents included in the stage 2 review. The failure to provide nutritional interventions resulted in immediate jeopardy (IJ) for Resident #20, 50, 128, and 143, who had significant and serious weight loss. The facility failure to ensure wound assessments and treatments were provided to Resident #50 resulted in IJ when Resident #50's sacral pressure ulcer deteriorated. The facility failed to ensure treatment was provided as ordered and failed to ensure staging was accurate by documenting Resident #128 had a stage 2 wound when identified by the physician in August as a stage 3 wound which resulted in IJ for 1 of 5 (Resident #128). Failure of the facility to implement and/or provide supplements to maintain nutritional status for residents with significant weight loss resulted in an immediate jeopardy (IJ) when Resident #20, 50, 79, 128, 143, and 201 had continued weight loss when the facility did not ensure nutritional interventions were provided as ordered. Immediate Jeopardy is a situation in which the provider's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Corporate Vice President, the Nurse Consultant, the Interim Administrator, and the Director of Nursing were informed of the Immediate Jeopardy on 9/14/16 at 6:10 PM, in the Club Room. The facility was cited an Immediate Jeopardy at F514-K. An extended survey was completed on 9/14/16. The Immediate Jeopardy is effective March 16 2016, and is ongoing. The findings included: 1. Medical record review revealed Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. a. Review of the WEEKLY PRESSURE ULCER RECORD revealed an onset date for a stage 4 sacral pressure ulcer of 5/7/16. There were no assessments documented between the dates of 07/8/16 through 8/5/16. Interview with the Wound Care Nurse (WCN) on 9/14/ 16 at 5:32 PM, in the Internet Cafe, the WCN was asked how often the wound assessments were done on Resident #20's pressure wound. The WCN stated,Weekly .goes on my weekly assessment form . The WCN was shown Resident #20's weekly pressure ulcer records that revealed no documentation of the stage 4 sacral wound between 7/15/16 through 8/5/16. The WCN was asked if that was acceptable. The WCN stated, .I get interrupted a lot throughout the day .of course not . Interview with the Nurse Consultant (NC) on 9/14/16 at 7:00 PM, in the Administrator's office, the NC was asked when they performed weekly skin assessment what should be on the form. The NC stated .each section of that form completed .measurements stages .treatment . The NC was asked if it was acceptable leave an assessment not completely filled out or not done. The NC stated, No. The NC was then shown Resident #20's weekly pressure ulcer assessments for the month of July and confirmed the weekly wound assessments were incomplete. b. A physician's orders [REDACTED].Ensure three times a day GIVE ENSURE ONE CAN BETWEEN MEALS AND HS (bedtime) .Juven (a nutritional supplement to support wound healing and help build lean body mass) two times a day until 06/11/2016 .Prostat (a nutritional protein supplement) two times a day until 06/11/2016 . Review of the weight records revealed the following: a. On 5/9/16 the resident weighed 104.2 pounds (lbs) b. On 6/10/16 the resident weighed 96.8 lbs A physician's orders [REDACTED].Ensure three times a day GIVE ENSURE ONE CAN BETWEEN MEALS AND HS .Juven two times a day until 06/11/2016 .Prostat two times a day until 6/11/2016 . The facility was unable to provide the Medication Administration Record [REDACTED]. Resident #20 had a 7.5 % weight loss during the 30 day period between 5/9/16 and 6/10/16. The facility's failure to provide recommended and ordered nutritional interventions to a resident with significant weight loss resulted in immediate jeopardy to Resident #20. 2. Medical record review revealed Resident #50 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The care plan dated 4/15/16, and revised on 7/8/16, documented, .resident has stage IV (4) pressure ulcer r/t (related to) Immobility .Interventions .Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate . Review of the WEEKLY PRESSURE ULCER RECORD for the sacral wound onset 4/8/15 revealed the following; a. On 4/15 a stage 4 with measurements in centimeters (cm) 3.2 length (L) x 2.0 width (W) x 0.1 depth (D). No year was documented. b. On 4/22 a stage 4 with measurments in cm 3.5 L x 3.7 W x 0.2 D. No year was documented. c. On 5/22 an unstageable with measurements in cm 3.0 L x 2.0 W x 1.6 D. No year was documented. d. On 5/29 an unstageable with measurements in cm 3.2 L x 2.0 W x 1.8 D. No year was documented, the 5/29 wound assessment was on the back of the page,and documented, .exudate .small serosanginous .N (no) odor, yellow .pink wound bed .cushion to w/c (wheelchair) . On 5/29 a stage 4 with measurements in cm 3.2 L x 2.0 W x 1.8 D. No year was documented, the 5/29 wound assessment was the first an only wound assessment on the presssure ulcer record, and documented, .serousangionous exudate .S (slight) odor .pink/yellow wound bed .scoop mattress, w/c cushions . Two documents were presented for the same date for the same wound and contained different assessments of the wound. e. On 6/3/16 a stage 4 with measurements in cm 3.2 L x 2.8 x no D documented. f. On 6/5 an unstageable with measurements in cm 6.0 L x 3.2 W x 1.5 D. No year was documented. g. On 6/10/16 a stage 4 with measurements in cm 3.0 L x 2.6 W x 0.2 D. This document addressed the wound bed as pink and the resident was to have heel boots. On 6/10/16 a stage 4 with measurements in cm 3.0 L x 2.6 W x 0.2 D. Measurements documented on this WEEKLY PRESSURE ULCER RECORD are in different places on the form than the previous 6/10/16 assessment. This document does not address heel boots and describes the wound is pink granulated. Two documents were presented for the same date for the same wound. Two copies of the same document was provided to the surveyors making the surveyors question the authenticity of the document. h. On 6/10/16 a stage 4 with measurements in cm 3.0 L x 2.6 L x 0.2 D. Has a different set of dates on the back of the sheet than the other pressure ulcer records with the date 6/10/16. i. On 6/12 an unstageable with measurements in cm 6.0 L x 3.2 W x 1.5 D. No year was documented and addresses heel boots and the wound is pink. j. On 6/17/16 stage 4 with measurements in cm 3.7 L x 3.3 W x 0.3 D. This assessment does not address heel boots and the wound bed is granulated. On 6/17/16 stage 4 with measurements in cm 3.7 L x 3.5 W x 0.3 D. Measurements documented on this WEEKLY PRESSURE ULCER RECORD were in different place on the form than the previous 6/17/16 assessment. Two documents were presented for the same date for the same wound. Two copies of the same document was provided to the surveyors making the surveyors question the authenticity of the document. k. On 6/19 stage 4 with measurements in cm 5.5 L x 2.2 W x 1.0 D. No year was documented but the document was presented to the surveyor as current wound assessments. On 6/24/16 stage 4 with measurements in cm 4.0 L x 3.9 W x 0.4 D. On 6/26 stage 4 with measurements in cm 6.0 L x 2.5 W x 1.8 D with 1.7 cm undermining documented. No year was documented. No other wound evaluation has undermining documented. The document was presented to the surveyor as current wound assessments, the measurements are inconsistent with the measurements on the documents presented for 6/19 and 6/24. l. On 7/1/16 stage 4 with measurements in cm 4.0 L x 3.9 w x 0.4 D. m. On 7/8/16 stage 4 with measurements in cm 3.9 L x 3.5 W and no D documented. There were no weekly wound evaluations documented for the sacral pressure ulcer between the dates of 12/11/15 through 2/5/16; 3/25/16 through 4/15/16; 4/22/16 through 5/22/16; and 7/8/16 through 8/5/16. The physician's orders [REDACTED].[MEDICATION NAME] APPLY TO STAGE FOUR SACRAL WOUND DAILY .CLEAN SACRAL WOUND, PAT DRY, APPLY WOUND GEL, CALOALGINATE, 2X2, BORDERGAUZE, CHANGE EVERY OTHER DAY AND PRN . The January 2016 TAR, documented, .IF DRSG (dressing) COMES OFF SACRAL WOUND, CLEAN WITH WOUND SPRAY, APPLY WOUND GEL, 4X4 GAUZE, COVER WITH BORDER GAUZE, NURSE TO CHANGE AND NOTIFY WOUND NURSE . There was no documentation that any wound care was completed for the sacral stage 4 pressure ulcer for the month of January as ordered. The physician's orders [REDACTED].[MEDICATION NAME] APPLY TO STAGE FOUR SACRAL WOUND DAILY .CLEAN SACRAL WOUND, PAT DRY, APPLY AG (silver) . CAL (calcium)-ALGINATE, [MEDICATION NAME] 2X2,DSG(dressing), Q3 DAYS/PRN . The February 2016 TAR, documented, .IF DRSG (dressing) COMES OFF SACRAL WOUND, CLEAN WITH WOUND SPRAY, APPLY WOUND GEL, 4X4 GAUZE, COVER WITH BORDER GAUZE, NURSE TO CHANGE AND NOTIFY WOUND NURSE . There was no documentation that any wound care was documented or completed for the sacral stage 4 pressure ulcer for the month of February 2016. The physician's orders [REDACTED].[MEDICATION NAME] APPLY TO STAGE FOUR SACRAL WOUND DAILY .CLEAN SACRAL WOUND, PAT DRY, APPLY AG .CAL-ALGINATE, [MEDICATION NAME] 2X2,DSG, Q3 DAYS/PRN . The March 2016 TAR, documented, .IF DRSGCOMES OFF SACRAL WOUND, CLEAN WITH WOUND SPRAY, APPLY WOUND GEL, 4X4 GAUZE, COVER WITH BORDER GAUZE, NURSE TO CHANGE AND NOTIFY WOUND NURSE . There was no documentation that any wound care was ordered or completed for the sacral stage 4 pressure ulcer for the month of March 2016. The physician's orders [REDACTED].IF DRSG COMES OFF SACRAL WOUND, CLEAN WITH WOUND SPRAY, APPLY WOUND GEL, 4X4 GAUZE, COVER WITH BORDER GAUZE, NURSE TO CHANGE AND NOTIFY WOUND NURSE . The April 2016 TAR documented, .IF DRSG COMES OFF SACRAL WOUND, CLEAN WITH WOUND SPRAY, APPLY WOUND GEL, 4X4 GAUZE, COVER WITH BORDER GAUZE, NURSE TO CHANGE AND NOTIFY WOUND NURSE . There was no documentation that any wound care was ordered or completed for the sacral stage 4 pressure ulcer for the month of April 2016 as ordered. The physician's orders [REDACTED].one time a day Cleanse with WD spray, pat dry, apply slivergel, 4x4 border gauze . Review of the May 2016 TAR, revealed there was no documentation for wound treatment on the stage 4 sacral for the month of May 2016 as ordered. The physician's orders [REDACTED].Cleanse sacral wound with WD (wound) spray, pat dry, apply silvergel, 4x4 border gauze .CLEAN SACRAL WOUND, WITH WOUNDSPRAY, PAT DRY, APPLY CALCIUM-ALGINATE, 4X4, COVER WITH BORDERGAUZE CHANGE QOD PRN . Review of the June 2016 TAR there was no documentation for any wound treatment on the stage 4 sacral wound as ordered. The physician's orders [REDACTED].Start Date 07/01/2016 .CLEAN SACRAL WOUND WITH WD CLEANSER, PAT DRY APPLY NPWT(negative pressure wound treatment)-80MM(millimeter) HG (pressure), GAUZE COVER WITH TRANSPARENT DSG, CHANGE TWICE A WK (week). IF DSG BECOMES SOILED REMOVED, CLEAN WOUND, APPLY WD GEL, 4x4, COVER WITH BORDERGAUZE, CHANGE Q DAY. every 72 hours .CLEAN SACRAL WOUND WITH WOUNDSPRAY PAT DRY APPLY SANTYL, 4X4, BORDERGAUZE,DSG. CHANGE EVERY DAY/PRN one time a day .CLEAN SACRAL WOUND WITH WOUNDSPRAY, PAT DRY, APPLY CALCIUM-ALGINATE, 4X4,COVER WITH BORDERGAUZE CHANGE QOD/PRN . Review of the August 2016 TAR revealed there was no documentation that treatments were provided for the sacral stage 4 pressure ulcer as ordered. The physician's orders [REDACTED].D/C NPWT TO SACRAL (wound), CLEAN SACRAL WOUND WITH WOUNDSPRAY PAT DRY APPLY SANTYL, THEN WOUNDGEL 4X4, BORDERGAUZE,DSG. CHANGE EVERY DAY/PRN .CLEAN SACRAL WOUND WITH WOUNDSPRAY, PAT DRY, APPLY CALCIUM-ALGINATE, 4X4, COVER WITH BORDERGAUZE CHANGE QOD/PRN . Review of the September 2016 TAR, revealed no documentation that treatments were provided as ordered for the sacral stage 4 pressure ulcer on 9/2/16, 9/3/16, 9/4/16, 9/6/16, and 9/8/16. The failure of the facility to provide wound assessments and treatments to Resident #50's sacral pressure ulcer resulted in immediate jeopardy when Resident #50's sacral pressure wound deteriorated. 3. Medical record review revealed Resident #128 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. a. The telephone physician's orders [REDACTED].[MEDICATION NAME] .Malnutrition .unstageable wound (full tissue thickness loss in which the base of the ulcer is covered by dead tissue or eschar) . The nurses' notes documented, .7/4/16 .dark area (right) buttock .7/14/16 .wound to (right) buttock/ischial .wound has worsen (worsened) .8/5/16 .Rt (right) buttock Stage II wound (partial thickness loss of the dermis, a shallow open ulcer with pink wound bed) .has less dark tissue . The Wound Care Specialist evaluations were reviewed, and documented the right ischium wound was a Stage 3 wound (fullness thickness tissue loss may include undermining and tunneling) on 8/16/16 and 9/1/16. The WEEKLY PRESSURE ULCER RECORD assessments documented the right buttock ischial wound was a Stage 2 pressure ulcer on 7/14/16, 7/26/16, 8/5/16, 8/12/16, 8/19/16, and 8/26/16. Observations in Resident #128's room on 9/13/16 at 2:19 PM and 3:10 PM, revealed the right buttock wound was a Stage 3 pressure ulcer, and this was confirmed by the WCN and the DON. b. The August 2016 TAR documented, .Clean right buttocks wound with wound spray. Pat dry. Apply silversorb gel. Cover with 4x4, 2x2. one time a day for wound healing -Order Date- 07/22/2016 . The order was initialed as performed from 8/1/16 through 8/31/16. A second copy of the August 2016 TAR documented, .Clean right buttocks wound with wound spray. Pat dry. Apply silversorb gel. Cover with 4x4, 2x2. one time a day for wound healing -Order Date- 07/22/2016 . The order was initialed as performed from 8/1/16 through 8/31/16. On the second copy, a line was drawn through the initials for the dates of 8/14/16 though 8/31/16, and ERROR was written. The same document was provided to the surveyors for the month of August with differing information making the surveyors question the authenticity of the document. Two copies of the same document was provided to the surveyors making the surveyors question the authenticity of the document. c. The July 2016 TAR documented, .Skin Prep Wipes .Apply to Right Ischial/buttock topically every shift . The order was initialed as performed twice daily from 7/4 through 7/31. A second copy of the July 2016 TAR documented, .Skin Prep Wipes . Apply to Right Ischial/buttock topically every shift . There was no documentation that the treatment was provided on the second shift on 7/10, 7/15, 7/23, 7/24, or 7/30 on this document. d. The July 2016 TAR documented, .APPLY [MEDICATION NAME] DSG TO RT. (right) BUTTOCK ABRASION COVER WITH FOAM DSG, CHANGE QOD / PRN . The TAR documented initials in the treatment administration area on 7/26/16, indicating completion. A second copy of the July 2016 TAR documented, .APPLY [MEDICATION NAME] DSG TO RT. BUTTOCK ABRASION COVER WITH FOAM DSG, CHANGE QOD/PRN . The TAR documented X (not performed) in the treatment administration area on 7/26/16, indicating the treatment was not administered. The failure of the facility to accurately stage the pressure ulcer, to administer treatments as ordered resulted in immediate jeopardy to Resident #128 when the wound deteriorated from a stage 2 to a stage 3. 4. Medical record review revealed Resident #143 was admitted to the facility on [DATE], and readmitted on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].Ensure after meals .Order Date .8/19/2016 . Review of the September 2016 MAR indicated [REDACTED]. Observations of Resident #143 revealed him to be alert and oriented, non-ambulatory, and required staff assistance for ADLs. Resident #143 was able to feed himself after tray setup by staff. There were no observations of Ensure supplements being administered to Resident #143 during observations of Resident #143 and his room on 9/6/16-9/8/16. Interview with Licensed Practical Nurse (LPN) #3 on 9/9/16 at 8:10 AM, at the 200 Hall Nurses' Station, LPN #3 was asked whether Resident #143 was receiving Ensure supplements. LPN #3 stated, Yes, and went to review the MAR. LPN #3 was not able to provide documentation that the supplement was being provided. LPN #3 stated, He was on [MEDICATION NAME] .That was DC'd (discontinued) .Let me look in dietary (progress notes). After review of Resident #143's medical record, LPN #3 stated, .So, Ensure should have been added on the 18th (August). LPN #3 was asked whether the Ensure had been added after it was ordered. LPN #3 stated, Let me see. I can check in the computer and see. LPN #3 went to the computer and stated, I see it (physician's orders [REDACTED]. LPN #3 was asked if the Ensure should have been documented. LPN #3 stated, Well if they say for us to document, like the HS (bedtime) snacks, then we document the HS snacks . The LPN's answers were indirect, and LPN #3 did not answer whether the Ensure had been administered or documented. LPN #3 was unable to provide documentation that the Ensure had been administered as ordered. Interview with Resident #143 on 9/9/16 at 8:25 AM, in his room, Resident #143 was asked how often he receives Ensure supplements. Resident #143 stated, When I ask for them. Sometimes I forget to ask. I wish somebody would tell them to bring me 1 strawberry and 1 vanilla. Resident #143 confirmed that staff did not bring the supplements regularly, and only brought them if he requested them. Resident #143 requested an Ensure at that time. LPN #8 was made aware. Interview with the DON on 9/9/16 at 8:45 AM, in the Clubroom the DON was asked if the staff should administer supplements as ordered. The DON stated, Yes. The DON was asked whether the nurses should document administration of the supplements. The DON stated, Yes . The The DON was unable to provide documentation that the Ensure supplements were administered to Resident #143 during the month of September as ordered by the physician. Interview with the Registered Dietician (RD) on 9/12/16 at 4:26 PM, in the Club Room, the RD was asked whether the supplements come out on the meal trays. The RD stated, .the only ones that come out with the trays are Mighty Shakes and Magic Cups .Ensures should be administered by a nurse. I don't believe in this building that we have anybody that gets it with meals. The documentation from the September MAR indicated [REDACTED]. The September MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The facility was previously unable to provide documentation that Ensure had been transcribed to the September MAR indicated [REDACTED]. During an interview with the DON on 9/14/16 at 8:30 AM, in the Club Room, the DON was asked about the supplement documentation being on the MAR indicated [REDACTED]. The DON stated, I know they were told to do a full audit on all the Ensures. The DON was asked to clarify who was told. The DON stated, The nurses .that was given to them by the Nurse Consultant. The DON was asked whether the nurses were told to put the missing documents on the records if they were not already on there. The DON stated, No, I'm sure they weren't, but I wasn't in there. Interview with LPN #3 on 9/14/16 at 8:49 AM, LPN #3 was asked why she didn't bring the documentation as soon as she found it, as it had been requested 5 days prior. LPN #3 stated, I'm sorry . The failure of the facility to administer supplements as ordered, resulted in immediate jeopardy to Resident #143. 5. Medical record review revealed Resident #68 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. a. The care plan dated 6/16/16 documented, .THE RESIDENT HAS TRIGGERED SIGNIFICANT WEIGHT LOSS OF 5.6% X30DAYS R/T POOR FOOD INTAKE .Interventions .Determine percentage lost and follow facility protocol for weight loss . The nutrition services progress notes documented, .5/14/16 . consuming . 100% . 7/15/16 . Consuming 75-100% @ meals . Meal intakes were reviewed for June 2016 and July 2016, and revealed 100% intake documented for 83out of 90 meals in June 2016, and 100% intake documented for 77 out of 90 meals in July 2016. Interview with the MDS Director on 9/14/16 at 2:29 PM, in the Club Room, the MDS Director was asked whether she would consider a majority of 75-100% meal intake to be poor intake. The MDS Director stated, No. The MDS Director was asked whether the care plan was incorrect related to the documentation that Resident #68 had poor meal intakes. The MDS Coordinator stated, Well, based on what I read in the chart, it does not appear that his intake is poor . b. The nutrition services progress notes documented, .Glucerna (increased) to 1 can BID (10a, 2p) on 4/25/16 .5/14/16 .Arterial Wounds .Receives Glucerna BID 6/21/16 .Glucerna 1.5 BID .Consuming 75 - 100% @ meals per ADLs .receives Glucerna Recommend (increasing) Glucerna to 1 can po TID to support wt (weight) stability . A physician's telephone order dated 4/25/16 documented, .(Increase Glucerna to 1 can po BID @ 10A (and) 2P . The physician's orders [REDACTED].Glucerna 1.5 one time a day for Weight Stability .Start Date .4/22/2016 . No End Date was documented. The MAR indicated [REDACTED]. There was no order to DC the Glucerna BID. There was no clarification order. The dietary notes reflected the order for Glucerna BID as of 4/25/16. c. A verbal physician's orders [REDACTED].SKIN PREP RIGHT 5TH BUNION Q DAY . The wound care record was reviewed for May 2016, and revealed there was no documentation that the skin prep to the right 5th bunion had been completed in May 2016. The physician's orders [REDACTED]. a. .APPLY SKIN PREP TO RIGHT ANKLE one time a day .Start Date .4/21/2016 .End Date .7/05/2016 . b. CLEAN RIGHT ANKLE WITH WOUNDSPRAY, PAT DRY, APPLY SANTYL,4X4 COVER WITH BORDERGAUZE, CHABGE (change) Q (every) DAY/PRN (as needed) .Start Date .4/19/2016 .End Date .7/05/2016 . c. .CLEAN RT (right) HEEL WITH WOUND SPRAY, PAT DRY, APPLY SANTYL, 4X4, COVER WITH BORDERGAUZE, CHANGE QD/PRN .Start Date .4/21/2016 .End Date .7/05/2016 . d. .SKIN PREP LEFT HEEL Q DAY/PRN .Start Date .5/04/2016 .(no end date documented) . e. .SKIN PREP RIGHT 5TH BUNION Q DAY .Start Date .5/10/2016 .End Date .7/05/2016 . The July 2016 TAR revealed no documentation that skin prep had been applied to the right ankle or to the left heel as ordered for the month of July 2016, or that any wound treatments were completed on 7/1/16. The July 2016 TAR revealed the Santyl treatments to the right heel and the right ankle were completed on 7/6/16-7/30/16, and the skin prep was applied to the right 5th bunion on 7/6/16-7/30/16. These orders had a stop date of 7/5/16. The physician's orders [REDACTED].Active orders As Of: 7/31/2016 .Clean Left Heel with wound spray. Pat dry. Apply Silversorb Gel with Coalginate. Cover with 4x4 and border gauze. one time a day every other day for wound healing .Order Date .7/22/2016 .Start Date .7/23/2016 . The August 2016 TAR revealed treatment with Silversorb gel to the left heel was completed on 8/2, 8/3, 8/4, 8/6, 8/8, 8/10, 8/12, 8/14, 8/16, 8/18, 8/20, and 8/21, before the physician's orders [REDACTED]. The physician's orders [REDACTED].Active Orders As Of: 7/31/2016 .Clean right ankle with wound spray. Pat dry. Apply Silversorb Gel with Coalginate. Cover with 4x4 and border gauze. one time a day every other day for wound healing .Order Date .7/22/2016 .Start Date .7/23/2016 . The August 2016 TAR revealed treatment with Silversorb gel to the right ankle was completed on 8/2, 8/3, 8/4, 8/6, 8/8, 8/10, 8/12, 8/14, 8/16, 8/18, 8/20, and 8/21, before the physician's orders [REDACTED]. The physician's orders [REDACTED].Active Orders As Of: 7/31/2016 .Clean right lateral foot with wound cleanser. Pat dry. Apply Silversorb Gel with Coalginate. Cover with 4x4 and border gauze. one time a day every other day for wound healing .Order Date .7/22/2016 .Start Date .7/23/2016 . The August 2016 TAR revealed treatment with Silversorb gel to the right lateral foot had been initialed as completed on 8/2, 8/6, 8/8, 8/10, 8/12, 8/14, 8/16, 8/18, 8/20, 8/22, 8/24, and 8/26. DC was documented and a line was drawn through this documentation, and Error was documented, indicating treatment was not completed on 8/2 through 8/26/16. Interview with the WCN on 9/14/16 at 6:52 PM, in the cafe, the WCN was asked about the TARs documenting that treatments had been carried out without orders, and other orders were not done. The WCN reviewed the orders and the TARs, and stated, .It's like the computer did not drop the discontinued orders, it brought them back over to the TAR. The WCN was asked where the DC orders were for the skin prep treatments that were not documented. The WCN stated, It won't be in this chart, it just went straight into (Named computer program). That's what they told us to do .that's computer error . The WCN was asked about the order for Silversorb gel treatment to the right lateral foot for August. The WCN stated, .That treatment was done. When I wrote error, it meant the DC was errored. The WCN did not provide documentation that wound treatments were completed as ordered for Resident #68. Interview with the DON on 9/14/16 at 7:00 PM, in the Club Room, the DON was asked if any concerns had been identified with wounds. The DON stated, Yes, wounds that are not improving or wounds that are worse .we discuss as a team .discuss prevention . The DON was asked whether there was any follow-up after that. The DON stated, Yes. The WCN is there. She will follow up with (named wound care physician) or the Medical Director .she will tell us in the morning clinical meetings if any changes need to occur . The DON was asked whether the WCN had ever informed her of any problems with documentation. The DON stated, We told her (WCN) when she completed her documentation, she needed to put it straight onto the chart . 6. Closed medical record review revealed Resident #118 was admitted to the facility with an admission date of [DATE] and a readmission date of [DATE] with [DIAGNOSES REDACTED]. Resident #118 was hospitalized from 6/13-30/16 and 7/26-8/3/16 and was readmitted on [MEDICATION NAME] 40 mg daily for [MEDICAL CONDITION]. A physician order [REDACTED].[MEDICATION NAME] 15 mg (milligrams) po q HS . Interview with the DON on 9/13/16 at 6:30 PM, in the Club Room, the DON was asked if the [MEDICATION NAME] 15 mg was given as ordered on 7/18, 7/19, 7/20/16. The DON stated, I don't know .I can't find the MAR for that . 7. Medical record review revealed Resident #163 was admitted to the facility on [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of the WEEKLY PRESSURE ULCER RECORD revealed no documentation of assessments as follows: a. Sacral wound stage 4 - no weekly wound assessments completed from 3/1/16 through 3/21/16. The facility provided 2 documents which included assessment of the sacral wound. One assessment dated [DATE] documented an onset date of 3/22/16. The sacral wound assessment dated [DATE] documented an onset date of 12/15/15. b. Left heel wound stage 3 - no weekly wound assessments completed from 3/1/16 through 3/21/16. On 3/30/16 the stage 3 pressure wound was documented as healed. On 4/15, 4/22, and 4/29/16 the weekly wound assessments documented a Stage 3 pressure ulcer to the left heel. Interview with the WCN on 9/9/16 at 12:42 PM, in the Cafe, the WCN was asked about the missing wound assessments. The WCN stated, I can't find them. 8. Medical record review for Resident #233 revealed resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].

Based on review of the Administrator's job description, review of the Medical Director's Contract, review of the performance improvement plans, medical record review, observation and interview, the facility failed to ensure an effective Quality Assurance (QA) program recognized an ongoing concern with weight loss, identified the root cause of the problems, developed appropriate plans and ensured systems and processes were in place and consistently followed by staff to address quality concerns. The QA committee failed to address concerns to ensure residents at risk for weight loss and residents with significant weight loss were provided recommended and ordered nutritional supplements, that interventions to prevent weight loss were consistently implemented or followed, that the facility was administered in a manner that enabled it to use its resources effectively and efficiently, that the Medical Director assisted the facility with identifying evaluating, and addressing clinical concerns, coordinated the medical care and provided clinical guidance and oversight regarding the implementation of resident care policies and procedures for significant and serious weight loss. Failure of the facility to implement and/or provide supplements to maintain nutritional status for residents with significant and serious weight loss resulted in an immediate jeopardy (IJ) when Resident #s20, 50, 79, 128, 143, and 201 had continued weight loss when the facility did not ensure nutritional interventions were provided as recommended and ordered. The Quality Assurance (QA) committee failed to ensure weekly skin assessments were done timely, treatments were provided as ordered, and failed to ensure staging of a sacral wound was accurate for Resident #50 which resulted in IJ to Resident #50 when staging went back and forth from unstageable to a stage 4 wound. The Governing Body failed to ensure treatment was provided as ordered, failed to ensure nutritional supplements were provided as ordered and failed to ensure staging was accurate by documenting Resident #128 had a stage 2 wound when identified by the physician in August as a stage 3 wound which resulted in IJ for 2 of 5 (Resident #50 and #128). Immediate Jeopardy is a situation in which the provider's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Corporate Vice President, the Nurse Consultant (NC), the Interim Administrator, and the Director of Nurses (DON) were informed of the Immediate Jeopardy on 9/14/16 at 6:10 PM, in the Club Room. The facility was cited an Immediate Jeopardy at F325-K which is Substandard Quality of Care. An extended survey was completed on 9/14/16. The Immediate Jeopardy is effective March 16 2016, and is ongoing. The findings included: 1. Review of the Quality Assurance committee report reviewed with the Director of Nursing documented by the Administrator revealed the following: a. May 2016 .There were 5 residents with weight loss for April, up from 4 residents in March. Of the 5 one was expected due to poor prognosis. Interventions put in place by (Named Registered Dietician (RD) . All weight loss was reviewed by the diet tech (technician), restorative nursing assistant (the one that weighs) and nursing . b. June 2016 .There were 4 residents with weight loss for June down from 5, Of the 4 1 was poor prognosis .3 thirty day weight loss and interventions were put in place by (Named RD) . c. July 2016 .There are 4 residents with weight loss for July static from 4 residents in June. There were 1 30 day, 1 90 day and 2 180 day weight loss. Interventions were put in place by RD. All weight loss was reviewed by the diet technician. Restorative nursing assistant, speech therapist and nursing in PAR (Patient At Risk meeting) .Assistive dining began heavily monitored by the diet technician the nursing assistant and assigned nursing personnel. The process for re weigh has been adjusted as all residents requiring a reweigh will be weighed by a different staff member than the staff member originally weighed by. The reweigh will be validated and entered into (Named Computer Program) by the ADON (Assistant Director of Nursing ). Assigned seating is being used in assisted dining to promote meal intake and consistency with residents .Weight loss identified the last week of April 2016. May 1, 2016 the plan of correction developed and implemented. 2. Interview with the DON on 9/14/16 at 7:00 PM, in the Club Room, the DON was asked who was involved in developing the plan of correction. The DON stated, .The Nurse Consultant, DON and ADON. The consultant was doing her regular visit and put this plan in place . The DON was then asked when she had let the Administrator know about the weight loss. The DON stated, .She (the Nurse Consultant) was here 2 days and she left, exited with the Administrator, DON and ADON. That was in April . The DON was asked what was the process with QA after that meeting. The DON stated, .We had already had QA for April, so not discussed until May in QAPI (Quality Assurance Performance Improvement). We verified weights, did baseline weights on all residents, calibrated scales, had restorative weights verified by random trained Certified Nursing Assistant (CNA), we did education with CNA related to weights like, weigh same time of day, or if you weigh them with brace on today use brace tomorrow, we designated one wheelchair for weights in May 2016. By end of May everybody was weighed. We also did weekly weights x 4 (weeks) . The DON was asked at what point did the RD (Registered Dietician) sit down with you and the ADON. The DON stated, .We discussed all interventions during PAR meeting for all weight loss residents. I designated the Unit Manager to input the Dietary recommendations in to the new computer system. She put them in and wrote them onto the MAR (Medication Administration Record), if required a dietary slip she completed the slip for Dietary,like a magic cup, something that is delivered by dietary. This was during a PAR but I can't remember when exactly. Had to be in June. The ADON was performing random audits . The DON was asked what was the ADON looking at. The DON stated, .She was looking at residents up for meals, assistive dining, random audits to make sure recommendations were actually on the MAR, audits to ensure residents were up and being fed. She had no formal audit tool. She had a tool that she developed. She had where she had to council some CNAs. We discussed this prior to her counseling. The DON was asked how long the ADON had done the audits to ensure the recommendations and orders were on the MAR. The DON stated, BI weekly. She did this until survey began . The DON was asked if the ADON had told her the recommendations and orders were not on the MAR indicated [REDACTED].No she handled it herself . the DON's then asked if the Administrator was aware of the audits and the weight loss. The DON stated, .He was aware of the corrective action plan. The DON was asked if anyone ever questioned with the interventions in place why was weight loss still occurring and did the RD tell you there was still weight loss with appropriate interventions. The DON stated, .She did. She would also make additional recommendations The DON was asked if those new recommendations were implemented right then. The DON stated, Yes on that same day before she left. The recommendations were put in a box, the DON box, the SDC's (Staff Development Coordinator) box, the ADON's box, Unit Manager's box and (Named Administrator's) box . Interview with the DON on 9/14/16 at 7:00 PM, in the Club Room, the DON was asked if the Quality Assurance committee had identified any concerns with wounds. The DON stated, .Yes, wounds that are not improving or wounds that are worse . The DON was asked what happened when this was identified. The DON stated, .We discuss the wounds as a team and talk about is there something we can do to prevent this, does the resident require different treatment, does the Doctor (Dr) need to intervene, we discuss prevention . The DON was then asked if there any follow up to that. The DON stated, Yes the Wound Care Nurse is there, she will follow up with (Named Wound Dr.), or the Medical Director. She (Wound Care Nurse) will tell us in morning clinical meeting if any changes need to occur. The DON was asked if the Wound Care Nurse ever told the committee that she had any problems with documentation. The DON stated, .We told her when she completed her documentation she needs to put it straight onto the chart . 3. The facility's Quality Assurance committee failed to identify, develop and implement appropriate plans of action to ensure care plan interventions were appropriate for residents care with continued signiificant and serious weight loss that resulted in IJ to Residents #20, 128 and 201. Refer to F 280 4. The facility's Quality Assurance committee failed to identify, develop, and implement appropriate plans of actions to ensure care plan interventions were implemented for care of residents with weight loss that resulted in IJ to Resident #s 20, 50, 128, and 143. Refer to F282 5. The QA committee failed to ensure nurses completed timely weekly skin assessments on residents who had pressure ulcers, failed to ensure nurses followed physician orders [REDACTED].#50. The QA committee failed to ensure treatments were provided as ordered, failed to ensure nutritional supplements for wounds were provided as ordered and staging was accurate for a resident with wounds for Resident #128. Refer to F314 6. The facility's Quality Assurance committee failed to identify, develop, and implement appropriate plans of action and to follow up on the implementation of the plan to prevent further weight loss for Resident #s 20, 50, 79, 128, 143, and 201 who suffered IJ. Refer to F325 7. The facility's Quality Assurance committee failed to identify, develop and implement appropriate plans of actions and to follow up on the implementation of the plan to ensure the facility was administered in a manner to use its resources effectively and efficiently to maintain the highest practicable well being of Residents # 20, 50, 79, 128, 143, and 201 and all residents residing in the facility at risk of weight loss. Refer to F490 8. The facility's Quality Assurance committee failed to ensure the Medical Director assisted with identifying, evaluating and addressing clinical concerns, coordinate the medical care and provide clinical guidance and oversight regarding the oversight of the implementation of resident care policies and procedures that reflect the current standards of practice for Resident #s 20, 50, 79, 128, 143, and 201 and all residents residing in the facility at risk have weight loss. Refer to F501