Every finding on record at River Ridge Rehabilitation and Nursing LLC

Based on observation, interview, and record review, the facility failed to maintain sufficient air circulation and ventilation in the main Yellowstone dining room, the hallways of Yellowstone and Rosebud units, and rooms of 5 (#s 12, 13, 19, 20, and 21) of 21 sampled residents.During an interview on 8/10/26 at 9:14 a.m., staff member A stated there were two maintenance staff members currently working, and the former maintenance director was no longer employed at the facility. Staff member A stated the facility had been working on getting job bids from local vendors for the facility's air conditioning system. Staff member A stated several local vendors were unable to provide service to the facility, and they would have to reach out in the [NAME] area for services.During an observation and interview on 8/10/26 at 10:54 a.m., temperature checks of rooms along the Yellowstone hallways were conducted. Staff member B stated fans were kept along each of the halls and had to be repositioned at angles to help with the airflow because they would get moved by staff or borrowed for residents. At 10:56 a.m., resident #21's room temperature was 81.6 F. There was no evaporative air cooler along the length of the hallway from resident #21's room to the nursing station.During an observation and interview on 8/10/26 at 11:04 a.m., temperature checks of rooms along the Rosebud hallways were conducted. At 11:04 a.m., resident #13's room temperature was 82 F. At 11:05 a.m., resident #12's room temperature was 82 F. At 11:05 a.m., resident #19 and #20's room temperature was 83 F, with an evaporative air cooler placed directly outside of it in the hallway. Staff member B stated there were seven evaporative air coolers placed throughout the building to help with cooling and airflow. Staff member B stated the Rosebud hallway would get warm and stay warm due to lack of air conditioning, so fans in the hallway were kept on to help with the air circulation. Staff member B stated the fans in the hallways were kept at an angle. Staff member B stated the fans in angled positions in the halls through the Venturi effect helped with the flow of the air from resident rooms to keep hot air circulating away and out of rooms.During an interview on 8/10/26 at 1:20 p.m., staff member A stated, We thought having the smoke dampers replaced recently from a life safety survey would help with the overall air-cooling issue, but it did not. Staff member A stated there were a limited number of stores in the [NAME] area to get fans and evaporative air coolers from, but he did send his staff out to try to get them for use in the hallways and resident rooms.During an observation and interview on 8/11/26 at 10:09 a.m., the main Yellowstone dining room doors were open, and window blinds along two walls in the dining room were closed. Several temperature checks in different areas of the dining room showed the highest reading of 78 F. There were multiple oscillating fans along the two walls with windows and through the dining room. Staff member B stated the dining room would be closed for some meals when it got too warm, so residents could have meals in the main activities room when that happened. Staff member B stated the facility was looking for a replacement unit in the dining room like the air conditioning unit being used in the kitchen. Staff member B stated the fans were kept on during the day in the dining room to help with the airflow. Staff member B stated the walls of the dining room took in direct sunlight from outside through the day, and the blinds of windows were kept closed to help with the heat. Review of an HVAC (Heating, Ventilation, Air Conditioning) maintenance estimate dated 6/4/26 showed a local company was unable to add a commercial account for the size of the facility's needs.Review of an HVAC estimate dated 6/29/26 showed a local company was unable to bid on the replacement of the facility's large air conditioning system.Review of a facility policy titled, Loss of Heating or Cooling, dated 7/21/26, showed: Policy: It is the policy of this facility to take immediate actions when the facility's heating or cooling systems are inoperable in order to maintain temperatures within the facility at 71-81 F. 1. The Maintenance Director is the contact person for questions or issues related to the facility's heating and cooling systems and is responsible for ensuring routine inspection, testing, and maintenance of these systems. 2. The Administrator is responsible for maintaining service contracts for routine and emergency maintenance of these systems. [sic]

Based on observation, interview, and record review, the facility failed to maintain a comfortable and homelike environment in resident rooms for 13 (#s 8, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, and 21) of 21 sampled residents. The deficient practice exposed residents to temperatures greater than 81 F in rooms that had constant fan use to aid in-room airflow. Findings include: During an observation and interview on 8/10/26 at 10:54 a.m., temperature checks of rooms along the Yellowstone hallways were conducted. Staff member B stated fans were kept along each of the halls and had to be repositioned at angles to help with the airflow because they would get moved by staff or borrowed for residents. At 10:56 a.m., resident #21's room temperature was 81.6 F. There was no evaporative air cooler along the length of the hallway from resident #21's room to the nurses station.During an observation and interview on 8/10/26 at 11:04 a.m., temperature checks of rooms along the Rosebud hallways were conducted. At 11:04 a.m., resident #13's room temperature was 82 F. At 11:05 a.m., resident #12's room temperature was 82 F. At 11:05 a.m., resident #19 and #20's room temperature was 83 F, with an evaporative air cooler placed directly outside of it in the hallway. Staff member B stated there were seven evaporative air coolers placed throughout the building to help with cooling and airflow. Staff member B stated the Rosebud hallway would get warm and stay warm due to lack of air conditioning, so fans in the hallway were kept on to help with the air circulation.During an observation and interview on 8/10/26 at 4:02 p.m., resident #8's door was open. There were two fans in the room blowing air, one pointed towards resident #8's bed and one near the wall by the sink. Resident #8 was wearing a tank top and shorts. The ambient air sensor on the side of a wall showed the room temperature at 82 F. Resident #8 stated the temperature showed 83 F earlier in the day. Resident #8 stated she had to request one of the fans for the room. Resident #8 stated the side of the building her room was on would just bake in the afternoon, so she kept her window blinds closed and her fans running to blow air. Resident #8 stated she tried to drink more ice water through the day due to the hot room temperature. Resident #8 stated she had the door to her room kept open through the day and night to help with the airflow.During an interview on 8/10/26 at 4:26 p.m., NF1 stated several residents had expressed concerns regarding the lack of air conditioning through the building. NF1 stated it caused their rooms to get very hot, even with fans used. NF1 stated the facility used swamp coolers (evaporative air coolers) throughout the building to keep the temperatures down. NF1 stated that with how hot temperatures had been getting in the area during the summer months, residents had asked for something to be done to help the situation.During an observation and interview on 8/11/26 at 9:12 a.m., resident #10 was sitting in a wheelchair in his room with his door open, and an evaporative cooler outside of the door. Resident #10 was wearing a tank top and sweatpants. The ambient air sensor on a wall beside resident #10's bed showed the room temperature at 83 F. Resident #10 stated he would feel very sweaty in his room, even with a fan blowing. Resident #10 stated he wished he could wear shorts, but only had sweatpants for his size to wear because he had a condition that caused him to wear briefs. Resident #10 stated his window had been opened this morning, but it was not usually opened. Resident #10 stated he had to ask a nurse yesterday to point the swamp cooler outside of the doorway into his room to cool the air.During an interview on 8/11/26 at 9:28 a.m., staff member C stated residents in different areas of the building had asked for fans to be brought in to their rooms, and staff would place them for residents when they were requested. Staff member C stated on the Yellowstone side of the building it would get very warm in the hallways and in resident rooms. Staff member C stated it would be helpful for residents and nursing staff as they were aiding residents in their rooms to have cooler and better airflows in the building. During an observation and interview on 8/11/26 at 10:03 a.m., temperature checks of rooms along the Rosebud hallways were conducted, while fans were blowing in the hallways and in resident rooms. At 10:03 a.m., resident #13's room temperature was 82 F. At 10:03 a.m., resident #17 and #18's room temperature was 83.2 F. At 10:05 a.m., resident #11 stated the temperature gun had pointed directly at the fan blowing in the room, so it was not getting an accurate temperature. Upon entry into resident #11 and #16's room, the temperature reading was initially 84 F, and the second check was 83.4 F. At 10:07 a.m., resident #14 and #15's room temperature was 83 F. Staff member B stated the hallway was feeling very warm through that end of the building.Review of a facility policy titled, Loss of Heating or Cooling, dated 7/21/26, showed: Policy: It is the policy of this facility to take immediate actions when the facility's heating or cooling systems are inoperable in order to maintain temperatures within the facility at 71-81 F. 1. The Maintenance Director is the contact person for questions or issues related to the facility's heating and cooling systems and is responsible for ensuring routine inspection, testing, and maintenance of these systems.2. The Administrator is responsible for maintaining service contracts for routine and emergency maintenance of these systems. 6. Procedures for loss of cooling:a. Dress residents in light clothing and limit physical activities.b. Provide fans for comfort. Be aware that fans do not cool, and residents are still at risk for heat-related illnesses.c. Provide additional fluids and foods with high liquid content. [sic]

Based on interview and record review, the facility failed to ensure staff provided care needs timely for a resident requiring assistance with activities of daily living for 1 (#4) of 4 sampled residents. The deficient practice increased resident #4's risk for skin impairment and negative psychosocial outcome. Findings include:Review of a facility reported incident, submitted to the State Survey Agency on 1/23/26, showed a staff member had concerns about NF2's timeliness and completion of daily resident cares for several residents, including resident #4. NF2 was suspended from working for initiation of an investigation of the situation. Resident #4 was assessed for skin and physical condition and psychosocial status.Review of the facility reported incident's investigative findings, submitted to the State Survey Agency on 2/1/26, showed resident #4 was assessed and monitored by staff members after the initial report. Resident #4 had no psychosocial harm or skin breakdown based on staff assessments. The findings showed resident #4 had not been checked by NF2 at the beginning of the shift and when checked on later in the shift by staff was wearing dirty clothing and an unclean brief. The facility determined delivery of care standards were not met by NF2 based on NF2's statement, staff statements, and resident interviews.During an interview on 8/11/26 at 9:21 a.m., staff member C stated resident #4 was someone who did not always ask staff members for help with cares. Staff member C stated resident #4 needed help from staff with hygiene when she was incontinent. Staff member C stated resident #4 should be checked on by staff for hygiene needs throughout a shift.Review of resident #4's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 11/29/25, Section GG - Functional Abilities, showed that GG0130. Self-Care had toileting hygiene coded as a 4. The 4-code referred to resident #4's need for staff supervision or touching assistance during toileting hygiene. The section for lower body dressing and personal hygiene was coded as a 3, which referred to resident #4's need for partial/moderate assistance from staff during those activities. Review of a facility document titled, Termination: Status Change Form, dated 1/26/26, showed NF2 was terminated from the position due to unsatisfactory performance. The document showed, Left resident with legs hanging out of bed and resident was found 6 hours into shift wet and dried BM.Review of a facility policy titled, Activities of Daily Living (ADLs), reviewed 6/19/26, showed: . Care and services will be provided for the following activities of daily living:1. Bathing, dressing, grooming. 3. Toileting.Policy Explanation and Compliance Guidelines:. 3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good . personal and oral hygiene.

Based on observation, interview, and record review, the facility failed to ensure safe food labeling and storage in accordance with professional standards for food service safety, and failed to maintain sanitary and clean conditions including employee hygiene. These deficient practices affected all residents receiving food services from the facility kitchen and dietary staff. Findings include: 1. During an observation of the kitchen on 1/12/26 at 12:40 p.m., the following conditions were present:- The kitchen floor was soiled with white, brown, and black debris resembling crumbs and dirt. It did not appear to have been cleaned for some time. At the edge of the floor, where the floor met the wall, a dark brown substance was present which had not been cleaned.- Underneath the counter tops, against the farthest wall from the kitchen entrance, there were shelves that had white, tan, and brown debris resembling crumbs and dirt, and there were clean containers and work equipment stored on the shelves, although the shelves were not kept clean. - Underneath the workstation, across from two refrigerators, there was white, tan, and black debris resembling crumbs and food particles with a tacky film covering the entire surface.- The gas stove burners were soiled with burnt food pieces and particles. Some of the burnt items were up to approximately one inch in diameter. - Three kitchen employees were preparing and cooking food, and all had facial hair that was not covered. - Plastic packing material was strewn on the floor of the walk-in refrigerator, and it has not been picked up. During an observation on 1/12/26 at 12:40 p.m., the following items had incomplete, missing, or expired dates, which also included items not stored properly in the kitchen and dry storage area: - One 50-pound bag of cane sugar was opened and not dated,- One opened container labeled cornbread and muffin mix, not dated,- One opened container labeled sugar, not dated,- One opened container labeled rice, not dated,- One container labeled flour, not dated,- One container labeled chocolate chips, dated 5/15/25 and 11/15/25,- One container labeled cornmeal, marked, Use by 5/10/25 expires in six months,- One container with a white flaky substance, not labeled or dated,- One container had a brown dried granular substance inside it, and three bread slices inside the container, and it was not labeled or dated,- One package of purple shredded cabbage, not labeled or dated,- Ten pitchers of different colored liquid substances, not labeled or dated,- One barrel, half full of a pink liquid (filled to the eight quart line), not labeled or dated,- One barrel, labeled tea, half full (filled to the eight quart line), marked with preparation date 1/1/26, use by date 1/8/26, - Three containers of vanilla yogurt, expiration date 1/3/26,- One open container of vanilla yogurt, expiration date 1/3/26, no opened date,- One open and unsealed package of sliced pepperoni, not dated,- One open and unsealed package of hot dogs, not dated,- One open package of ground beef, not dated,- One open and unsealed box of cheese tortellini pasta, not dated,- Two open and unsealed bags of frozen patties, not dated,- One open container of mayonnaise, not dated,- Five bags of corn chips, not dated,- One box of open and unsealed disposable Styrofoam food trays,- Five plastic lids were on the floor in the dry storage area,- One box of ketchup packets was located directly on the floor (not on a shelf), and,- One box labeled apple blend liquid was located directly on the floor (not on a shelf).During an interview on 1/12/26 at 1:00 p.m., staff member Q stated he had recently assumed the role of dietary manager. He reported that most kitchen employees were new, and he was in the process of training them on proper procedures. Staff member Q stated that employees on each shift were responsible for labeling, dating, and properly storing food items, and he was unsure why these tasks were not being completed. Staff member Q stated he used a calendar to assign cleaning duties, and once complete, the employee would initial the date on the calendar. Staff member Q stated that over the past three months, many dates on the calendar lacked employee initials, reflecting the assigned work may not have been completed. Staff member Q stated beard nets were not required if the facial hair was shorter than one inch.2. During an observation of the kitchen, on 1/14/26 at 1:47 p.m., the following concerns were still present, which were identified the day prior, showing the areas were not cleaned or addressed the prior day: - Underneath the counter, against the farthest wall from the kitchen entrance, shelves contained debris resembling crumbs and dirt where clean containers and work equipment were still stored.- Underneath the workstation, across from two refrigerators, there was still debris resembling crumbs and food particles with the tacky film covering the entire surface.- The gas stove burners were covered with a large number of black burnt food particles. Some particles were up to approximately one inch in diameter.- One kitchen employee was cooking food without wearing a beard cover, and the employee had facial hair. During an observation on 1/14/26 at 1:47 p.m., the following items had incomplete, missing, or expired food dates, which also included items not stored properly in the kitchen and dry storage area, and some were present on the prior observation: - One container with a brown dried granular substance and three bread slices inside the container, not labeled or dated,- Three containers of vanilla yogurt, expiration date 1/3/26,- One open container of vanilla yogurt, expiration date 1/3/26, no opened date,- One open and unsealed package of sliced pepperoni, not dated,- One open and unsealed box of cheese tortellini pasta, not dated,- Two open and unsealed bags of frozen patties, not dated,- One open container of mayonnaise, not dated,- One opened 32-ounce container of liquid whole eggs, not dated,- One box of open and unsealed disposable Styrofoam food trays, and- Three plastic lids were on the floor in the dry storage area.During an interview on 1/14/26 at 2:00 p.m., staff member Q stated he instructed an employee on the evening of 1/13/26 to clean out the walk-in refrigerator. Staff member Q stated the employee may have misunderstood the instructions, as outdated and expired food items remained in the refrigerator. Staff member Q stated all employees with facial hair who work in the kitchen should wear beard nets. Staff member Q stated one staff member with facial hair was not wearing a beard net, and he would remind him again (to wear a beard net).A review of a facility policy titled Food Safety Requirements, dated 4/11/25, showed: Policy: . Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety.Policy Explanation and Compliance Guidelines:. b. Storage of food in a manner that helps prevent deterioration or contamination of the food, including growth from microorganisms.3. Facility staff shall inspect all food, food products, and beverages for safe transport and quality upon delivery/receipt and ensure timely and proper storage.b. Dry food storage- keep foods/beverages in a clean, dry area off the floor. iv. Labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by date, or frozen (where applicable)/discarded; andv. Keeping foods covered or in tight containers.7. Staff shall adhere to safe hygienic practices to prevent contamination of foods from hands or physical objects.d. Dietary staff must wear hair restraints (e.g., hairnet, hat, and/or beard restraint) to prevent hair from contacting food. [sic]

Based on interview and record review, the facility failed to maintain documentation of staff COVID-19 vaccine status and ensure staff were provided information on obtaining the COVID-19 vaccine. Findings include:During an interview on 1/15/26 at 10:19 a.m., staff member H stated she and staff member B divided up the Infection Preventionist duties. Staff member H stated staff member B was responsible for the COVID-19 vaccination status of staff at the facility.During an interview on 1/15/26 at 12:22 p.m., staff member B stated the facility did not maintain documentation of the staff COVID-19 vaccine status. Staff member B stated when new employees went through the onboarding process they were asked to provide documentation of their COVID-19 vaccine status. New employees were verbally told the facility did not offer the COVID-19 vaccine and if they wanted it, they could go to a pharmacy to get it. Staff member B stated she did not maintain a comprehensive list of the COVID-19 vaccine status of employees or document whether or not the staff member had received it or not. The facility had just begun requiring annual COVID-19 education for staff. The facility's online education portal (Relias) had a COVID-19 module which was new for this year. A verbal request was made for documentation of the COVID-19 vaccine status of staff. No documentation was provided prior to the end of the survey.

Based on observation, interview, and record review, the facility failed to ensure effective social services were provided to a resident needing assistance in accessing social security disability benefits for 1 (#79) of 29 sampled residents. The failure resulted in prolonged financial stress for the resident in excess of one year's time, and multiple staff were aware of the resident's need for assistance, but failed to intervene, showing a pattern of not addressing the resident's need for help. Findings include:During an observation and interview on 1/13/26 at 2:12 p.m., resident #79 was observed sitting in a wheelchair in her room. Resident #79's right hand was missing four fingers and was severely contracted at the thumb and wrist. Resident #79's speech was slightly muffled, with a delayed speech pattern. Resident #79 stated she had been at the facility approximately 14 months, and stated she was at the facility due to drug abuse, Parkinson's disease, and was unable to care for herself. Resident #79 stated she had been trying for a long time to obtain access to her social security disability benefit and had spoken with five different staff members over the last six or seven months about getting the disability income without success. Resident #79 stated she could not use her Social Security Direct Express payment card, as Social Security had informed her of the need to verify her identity and address before she could be granted access to the funds in her account. Her previous state-issued identification card was lost. She had been collecting donations from friends within the facility to help her purchase a new identification card. Resident #79 stated she was hoping to obtain just a little money for necessities, and stated the facility was receiving her disability payments. Resident #79 stated, I was hoping the facility could get a little more money from disability since I lost my fingers in August (2025), and maybe there could be a little left over for me to buy a few things.During an interview with staff members A and P on 1/13/25 at 2:30 p.m., staff member A stated resident #79 did not have disability benefits and therefore was not entitled to a monthly stipend. Staff member P stated, It's a cruel system, but there is nothing we can do . She only has Medicaid.During an interview on 1/13/26 at 4:03 p.m., resident #79 stated she had talked to multiple individuals in business services, social services, and the local ombudsman to help her, .try to get just a little money from my disability payment for things like a new pair of sneakers or some toiletries; just a few necessities.During an interview on 1/14/26 at 11:22 a.m., staff member C stated she had been in her position since August of 2025. There were two individuals previously in her role within the past year. Staff member C stated she did not have information or notes from the previous two individuals regarding resident #79. Staff member C stated resident #79 came to her approximately two months earlier and had asked her (staff member C) to help obtain a birth certificate, so she could obtain a new state identification card. Staff member C stated she filed the paperwork, with the understanding the birth certificate could take one to two months to arrive. Staff member C stated she did not know, and did not ask, why resident #79 needed the new identification card. Staff member C stated resident #79 had asked her if the facility could receive more money from Social Security disability benefits due to her recent right hand impairment. Staff member C stated she told resident #79 she did not know anything about her disability income, and referred her to staff member P.During an interview on 1/14/26 at 11:55 a.m., staff member P stated resident #79 came to her to ask if the facility could get more disability funding for her due to her right-hand disability. Staff member P stated she referred her back to staff member C.During a phone interview on 1/15/26 at 9:57 a.m., NF1 stated she was aware of resident #79's desire to obtain a new birth certificate and state-issued identification card. NF1 stated she last heard an update regarding resident #79's situation before Christmas, when the facility had submitted the request for the birth certificate. NF1 stated she also addressed resident #79's disability income concerns to staff member P at the same visit.Review of a document provided by resident #79, titled, Supplemental Security Income Notice of Change in Payment, dated 11/26/23, showed, We plan to increase your monthly Supplemental Security Income (SSI) payment from $914.00 to $943.00 beginning January 2024 . Your bank or other financial institution will receive your monthly payment of $943.00 around January 1, 2024, and on the first of each month after that.Review of resident #79's telehealth psychiatric progress note, dated 1/6/25, showed, Telehealth coordinator (NF5) reports: 'she lost or (was) stolen her social security card that her money comes in on.' 'she's also been reapplying for medicaid'. [sic]Review of resident #79's psychiatric provider note, dated 4/2/25 showed, Upon interview today, she reports having stress related to financial problems. She is future oriented in regard to obtain(in)g a birth certificate so she can apply for SSI. [sic]Review of resident #79's social service note, dated 7/21/25, showed, Resident filled out application for vital statistics NV to obtain birth certificate. Next to get funds for copy and mail application. [sic]Review of resident #79's social service quarterly note, dated 11/26/25, showed, Advanced Directives: DNR Cognitive Status: Cognitively intact with a BIMS of 14. [Resident #79] is friendly and interactive. She is able to make all needs known. Mood/Behaviors: No behaviors noted this last quarter. PASRR status: Level 1, Level 2 submitted no response, will check with DEAP Wandering/elopement/LOA: No risk Smoking/Substance Use: Yes Specialty Referrals: None at this time. Discharge Plan: Staying long time. [sic]No additional social service notes were located in resident #79's electronic health record from admission through the end of the survey period. Interviews and record reviews showed resident #79 had reached out to multiple individuals and staff members seeking assistance with her Social Security disability payment for over one year without resolution.

Based on interview and record review, the facility failed to complete the written transfer notice for a resident sent to the hospital showing the need for the transfer, for 1 (#44) of 29 sampled residents. Findings include:During an interview on 1/13/26 at 11:35 a.m., resident #44 stated he remembered being hospitalized a couple of times in 2025. Resident #44 stated he did not remember getting any paperwork prior to being transferred to the hospital.Review of resident #44's Notice of Discharge/Transfer, dated 7/22/25, failed to show the reason for the transfer. The form showed the resident's name at the top, with his signature and date on the bottom. The line for Need that cannot be met: was blank.During an interview on 1/15/26 at 10:45 a.m., staff member E stated she was working on the day resident #44 was transferred to the hospital (7/22/25) for care. Staff member E stated she signed and dated the form but could not explain why the reason for the transfer was not completed.Review of the facility policy titled Transfer and Discharge (including AMA), dated 4/11/25, showed the facility's transfer/discharge notice was to be provided to the resident and the resident's representative. The policy also showed, The notice will include all of the following at the time it is provided: a. The specific reason and basis for transfer or discharge.

Based on observation, interview, and record review, the facility failed to accurately complete the MDS assessments for 2 (#s 6 and 67) of 29 sampled residents. Findings include:1. During an observation on 1/13/26 at 8:45 a.m., resident #6 was wheeled into the dining room for breakfast. Resident #6 was assisted with set up of her breakfast items and was able to feed herself independently. Review of resident #6's weight measurement, dated 11/17/25, showed she weighed 235 pounds at the time she was admitted to the facility. Review of resident #6's weight measurement, dated 12/1/25, showed the resident weighed 222 pounds. The 13-pound decrease calculated to 5.5% of her total weight. Review of resident #6's 5-day MDS Assessment, with an ARD of 12/1/25, failed to trigger unplanned weight loss. During an interview on 1/15/26 at 12:28 p.m., staff member D stated she completed the 5-day MDS Assessment (ARD 12/1/25) for resident #6. Staff member D stated she calculated the resident's percentage of weight loss incorrectly and therefore failed to trigger unplanned weight loss. Staff member D stated she would submit an MDS correction. 2. During an observation and interview on 1/14/26 at 10:24 a.m., resident #67 was lying in his bed, awake. Resident #67 was noted to have no natural teeth and no dentures in place during the interview. Resident #67 stated, I have some dentures there in the drawer, but I don't wear them . the bottom teeth are supposed to snap in place, but they don't fit right . they are loose and uncomfortable, so I don't wear them . I have a full set; upper and lower. During an interview on 1/14/26 at 11:55 a.m., staff member C stated resident #67 did not usually wear his dentures, and lost them for a brief time, but they were located and returned during the survey. Staff member C stated resident #67 described his lower denture as having one missing tooth and told her they did not fit correctly. During an interview on 1/15/26 at 9:45 a.m., staff member D was unable to recall if resident #67 had dentures. During the interview, staff member D reviewed resident #67's MDS admission assessment and stated she believed it was correctly coded to show he does not have loose fitting or broken dentures. Staff member D stated the MDS assessments were completed using record review, resident interview, and physical assessment. Review of resident #67's Nutrition/Dietary note, dated 6/17/25, showed, [Resident #67] also says he is edentulous, he has dentures but doesn't wear them. Review of resident #67's admission MDS Assessment, with an ARD of 6/16/25, showed the following information in Section L Oral/Dental Status: L0200. Dental . A. Broken or loosely fitting full or partial denture (chipped, cracked, uncleanable, or loose). Facility response showed No, to show resident #67 did not have broken or loose fitting full or partial denture (chipped, cracked, uncleanable, or loose). As the resident stated he had dentures which did not fit, the answer should have been Yes.L0200. Dental . B. No natural teeth or tooth fragment(s) (edentulous). Facility response showed No, to show resident #67 did not have natural teeth or tooth fragment(s) (edentulous). As the resident stated he did not have any natural teeth, the answer should have been Yes.

Based on observation, interview, and record review, the facility failed to revise a care plan to reflect a resident's current care needs after an elopement for 1 (#67) of 29 sampled residents. The failure placed the resident at elevated risk for additional elopements. Findings include:Review of the facility's investigation of a Facility-Reported Incident, submitted to the State Survey Agency on 9/27/25, showed resident #67 eloped from the facility without staff knowledge.During an interview on 1/13/26 at 11:03 a.m., staff member A stated resident #67 exited the facility through an alarmed door that had been deactivated by a facility vendor. Staff member A stated resident #67's care plan was updated after the Interdisciplinary Team meeting to include the elopement risk, and interventions to prevent similar events in the future.During an observation and interview on 1/13/26 at 1:22 p.m., resident #67 was lying in bed, looking out the window. Resident #67 stated he did not recall the elopement incident, but stated, I would like to go outside.During an interview on 1/14/26 at 11:22 a.m., staff member C stated care plans are updated by the nurses, herself, or staff members D or E. Staff member C pointed to a stack of papers on her desk, and stated, These are care plans here I am going through. I review them and confirm any care issues with the nurses and then update them as needed.During an interview on 1/15/26 at 9:45 a.m., staff member D stated the care plan updates would occur after an event by herself or staff member E. Staff member D stated care plans could also be updated on an as-needed basis by any of the staff nurses.Review of a facility incident investigation document titled, Reportable Incident - 9/27/25, undated, showed, Findings/Final Determination . Care plan updated to reflect resident's need for closer monitoring and supervision when approaching facility exits.Review of resident #67's care plan showed the following entry dated 9/27/25: . 9/27/25- Resident added to elopement binder and educated that he cannot leave facility without assistance and educated to use the enclosed patio to enjoy the outdoors when desired.Engage Resident in purposeful activity; Identify if there are triggers for wandering / eloping; Identify wandering / elopement de-escalation behaviors; Provide care in a calm and reassuring manner . [sic]The care plan failed to specify the need for closer supervision and monitoring when approaching facility exits, as identified in the facility's Reportable Incident - 9/27/25 incident summary document.Review of a facility policy titled, Elopements and Wandering Residents, latest revision date 4/30/25, showed, . 4. c. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff.

Based on the interview and record review, the facility failed to ensure staff responded to resident needs timely for a resident requiring assistance with activities of daily living for 1 (#99) of 29 sampled residents. The deficient practice increased the risk for skin integrity issues. Findings include:Review of a Facility-Reported Incident, dated 6/5/25 at 8:40 a.m., showed staff member O found resident #99 lying in his bed in urine-soaked clothing and a soiled brief. This was discovered by staff members O and L after shift change report was completed with NF3, who was a night shift staff member responsible for resident #99's care.During an interview on 1/15/26 at 12:18 p.m., staff member L stated she was one of the day shift staff members who started providing morning cares for assigned residents on 6/5/25, which included resident #99. Staff member L stated NF3, an off going night shift staff member, provided information in report. Staff member L stated before she left, NF3 did not mention resident #99 needed to have his brief and clothes changed. Staff member L stated she did not know how long resident #99 waited for a staff member to assist him with changing his brief. Staff member L stated if she had been told by NF3 that resident #99 needed his brief changed, she would have gone right away to resident #99. Staff member L stated she did not know why NF3 did not change resident #99's brief, but it was not the normal routine to leave a resident with a soiled brief or clothes.Review of resident #99's Minimum Data Set with a Quarterly assessment reference date of 5/14/25, Section GG - Functional Abilities, showed that GG0130, Self-Care, was coded as 3, for lower body dressing and toileting hygiene (the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement). The 3 code reflected resident #99 required partial/moderate assistance with a staff member to help lift, hold, or support the trunk or limbs, in completing the activities. Section H - Bladder and Bowel, showed that resident #99 had was coded as a 2, as frequently having urinary and bowel incontinence.Review of resident #99's comprehensive care plan showed a problem initiated 3/24/25 for ADL self-care performance deficit . Interventions . INCONTINENCE CARE: Staff should check resident regularly for incontinence episodes and provide prompt peri-care after incontinence episodes . An initial request was made to the facility on 1/12/26 at 12:29 p.m. for documentation of investigation notes to include interviews and findings for the facility reported incident of 6/5/25. The facility provided a pertinent investigation finding of the facility's interdisciplinary team, which included a lapse in care by NF3 for resident #99.

Based on observation, interview, and record review, the facility failed to recognize a documented weight severe weight loss and address the weight change, for 1 (#6) of 29 sampled residents, which placed the resident at risk for adverse health consequences. The MDS was not correctly completed to reflect the weight, and the weight loss was suspected to be due to an error, not an actual loss of weight, as reflected in the medical record. Findings include:During an observation on 1/13/26 at 8:45 a.m., resident #6 was wheeled into the dining room for breakfast. Resident #6 was assisted with the set-up of her breakfast items and was able to feed herself independently.Review of resident #6's weights since admission showed the following:- 11/17/25, weight 235 pounds,- 12/1/25, weight 222 pounds, and- 12/16/25, weight 211.5 pounds.The weight loss of 13 pounds from 11/17/25 to 12/1/25 calculated to a 5.5% severe weight loss in 14 days. The total weight lost between 11/17/25 and 12/16/25 calculated to a 10% severe weight loss in one month. During an interview on 1/15/26 at 10:00 a.m., staff member G was asked if he had been notified of resident #6's severe weight loss since admission. Staff member G stated he could not say for sure he was notified of the resident's weight loss. He stated he received a lot of resident notifications and would have to look at the resident's chart to refresh his knowledge of the resident's care. During an interview on 1/15/26 at 12:28 p.m., staff member D stated she completed the 5-day MDS Assessment (ARD 12/1/25) for resident #6. Staff member D stated she calculated the resident's percentage of weight loss incorrectly and therefore failed to trigger the unplanned severe weight loss.During a follow-up interview on 1/15/26 at 1:00 p.m., staff member G stated he reviewed resident #6's chart and believed the weight loss issue was with the accuracy of the resident's admission weight. Staff member G stated it was not realistic to lose the amount of weight documented from 11/17/25 to 12/16/25. Staff member G could not explain why the change in weight was not identified by facility staff or addressed. Staff member G stated the resident's weight had been fairly stable since the middle of December and was not a problem.Review of resident #6's EHR since admission on [DATE] failed to show any nursing or dietician notes which identified a significant change in resident #6's weight since her admission on [DATE]. A written request for dietician notes for resident #6 was made on 1/14/26. None were received prior to the end of the survey.

Based on observation, interview, and record review, the staff member administering medications failed to follow proper processes, and this contributed to the facility's failure to prevent a total medication error rate of five percent or less during medication administration observations for 2 (#s 25 and 74) of 4 sampled residents for medications. This deficient practice increased the risk of residents #25 and #74 experiencing negative physical and psychosocial outcomes related to medication errors. Findings include:The facility's medication error rate was 7.69%, with three errors observed in 39 opportunities.1. During an observation and interview on 1/14/26 at 8:28 a.m., staff member J administered resident #74's ordered morning medications. Staff member J administered resident #74 his oral medications and then administered an eye drop into each eye. Staff member J was asked what the label read on the white eye drop bottle she used to administer the eye drops. The eye drop bottle had a different resident's name on the label, with the medication labeled Artificial Tears. The drops were not meant for resident #74. Review of resident #74's Medication Administration Record (MAR), dated January 2026, showed resident #74 had an order dated 1/2/26 for, .Carboxymethylcellulose Sodium Ophthalmic Solution 0.5 % . Instill 1 drop in both eyes three times a day for dry eyes . The eye drops given to resident #74 were considered to be a medication error. 2. During an observation and interview on 1/14/26 at 9:16 a.m., staff member K was observed taking resident #25's blood pressure. Resident #25's blood pressure reading on the electronic monitor displayed 100/72. Staff member K was observed administering resident #25's scheduled morning medications, which included Amlodipine and Lisinopril (antihypertensives). When asked about holding Amlodipine and Lisinopril if the systolic blood pressure was less than 110, staff member K stated she did not always hold the medications.Review of resident #25's Medication Administration Record, dated January 2026, showed resident #25 had a pertinent diagnosis of essential (primary) hypertension and had orders for two antihypertensives to be administered once a day. The orders showed:- Amlodipine besylate 10 mg was ordered on 12/1/25 for, .1 tablet by mouth one time a day for HTN. Hold for SBP <110 .- Lisinopril oral tablet was ordered on 12/15/25 for, .Give 20 mg by mouth one time a day for HTN Hold for SBP <110 .During an interview on 1/15/26 at 11:56 a.m., staff member I stated that a nurse administering medications should follow the resident's written order found in the MAR. Staff member I stated morning medications sometimes have to be held for vital sign readings, depending on pulse or blood pressure. Staff member I stated that when a resident's ordered blood pressure medication had hold information, the nurse administering the scheduled medication should hold it. Staff member I stated if a resident was taking two blood pressure medications, it would be important to hold the medications if a resident's vital signs were outside of the identified parameters. Review of a facility policy titled, Medication Errors, dated 4/11/25, showed: . 'Medication error rate' is determined by calculating the percentage of errors observed during a medication administration observation. The numerator is the total number of errors that is observed. The denominator consists of the total number of observations or 'opportunities of error' and includes all the doses observed being administered. The facility must ensure that it is free of medication error rates of 5% or greater.7. To prevent medication errors and ensure safe medication administration, nurses should verify the following information:a. Right medication, dose, route, and time of administration;b. Right resident and right documentation.Review of a facility policy titled, Medication Administration, dated 4/11/25, showed: . Policy Explanation and Compliance Guidelines:. 10. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters . 14. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time.

Based on observation, interview, and record review, the facility failed to initiate and provide rehabilitation therapy ordered by a physician for 1 (#34) of 29 sampled residents, which increased the risk of a decline for the resident related to the areas therapy should have been treating. Findings include:During an observation and interview on 1/12/26 at 2:12 p.m., resident #34 was sitting up in a motorized wheelchair in his room. When asked how things were going, resident #34 said they would be a lot better if he was getting therapy. Resident #34 said he was not sure why he had not been getting therapy, but he thought maybe it had something to do with his Medicaid application (which was pending).During an interview on 1/14/26 at 10:18 a.m., staff member F stated she did not know anything about resident #34's therapy until she received a request to evaluate him on 1/13/26. Staff member F stated she did the therapy evaluation at 8:00 p.m. on 1/13/26. Staff member F stated she did not know why the evaluation was not completed sooner. Staff member F stated a therapy evaluation could be done, even when Medicaid was pending. Staff member F stated that when Medicaid was pending, one option would be to evaluate the resident and provide up to five therapy visits. The purpose of this would be to determine the resident's level of commitment and participation in the program. If there was still no payer source after five therapy visits, the resident could be placed on a restorative services program until the financial matters were settled. Staff member F stated the usual procedure for new therapy orders would include a confirmation by the nurse of the physician order, followed by printing two copies of the physician order: one for the DON and one for the therapy department. Staff member F stated she did not receive any paperwork for resident #34 until 1/13/26.During an interview on 1/14/26 at 3:44 p.m., staff member M stated she was responsible for inputting some of the admission orders into the electronic health record when a resident was initially admitted to the facility. Staff member M stated she entered the diet order and all medication orders. When questioned on who put in all the other physician orders, she stated that staff member D or the floor nurse would put in the rest of the physician orders.During an interview on 1/15/26 at 7:35 a.m., staff member D said that she received the admission orders from the hospital discharge note. When questioned why there was no therapy order entered when the resident was initially admitted , she stated she did not know why the therapy order was not entered into the facility's EHR system. Staff member D stated that when resident #34 was initially admitted , he was supposed to be a long-term resident. Staff member D stated that when there was a question about what services were to be provided, she would follow up with staff member A. Staff member D did not remember discussing resident #34's therapy with staff member A.During an interview on 1/15/26 at 7:46 a.m., staff member A stated that new admissions were discussed by the IDT in the daily morning meetings. Staff member A produced the notes generated on 11/7/25 when resident #34 was supposed to be admitted . The notes did not include any information about therapy for resident #34. Staff member A was not able to explain why the therapy evaluation, ordered on 12/4/25, was not completed until 1/13/26.Review of resident #34's admission orders from the hospital discharge note, dated 11/7/25, showed the order, Ambulation per PT/OT recommendations. Review of resident #34's admission orders entered by facility staff, dated 11/7/25, failed to show any therapy orders.During an interview on 1/15/26 at 10:00 a.m., staff member G stated he entered a therapy order for resident #34 on 12/4/25 based on a communication with the consulting rehabilitation physician. Staff member G was not aware resident #34 had not been receiving therapy per the physician order dated 12/4/25.During an interview on 1/15/26 at 10:55 a.m., resident #34 stated he spoke with staff member A at least twice regarding therapy services. Review of resident #34's therapy order, dated 12/4/25, showed an order for therapy for neck pain to be done. Although the order was entered into the facility's EHR system on 12/5/25, the therapy department was not notified of the need to do an evaluation for resident #34 until 1/13/26.Review of resident #34's EHR failed to show any therapy involvement until 1/13/26. There was no documentation of therapy services being provided between 11/7/25 and 1/12/26.

Based on interview and record review, the facility failed to ensure comprehensive investigations of facility reported incidents were completed for 2 (#s 67 and 99) and failed to ensure post-incident interventions were implemented to prevent additional similar incidents for 1 (#67) of 29 sampled residents. These deficient practices increased the risk of an adverse outcomes for the residents involved in the facility reported incidents. Findings include: 1. Review of a Facility-Reported Incident, submitted to the State Survey Agency on 9/27/25, showed resident #67 exited the building through an alarmed door, which a facility vendor had opened. Resident #67 remained outside of the facility until another family member reported the concern to a staff member. Staff were unaware that resident #67 was not in the building. During an interview on 1/13/26 at 11:03 a.m., staff member A stated their video surveillance showed resident #67 exited the facility through an alarmed entrance door, in his wheelchair, by a vendor who was at the facility. Therefore, the alarm was not triggered on the door. Staff member A stated he estimated resident #67 was outside unsupervised for approximately 15 minutes. During an interview on 1/13/26 at 1:22 p.m., resident #67 was unable to recall the incident, but stated, I would like to go outside. Review of resident #67's Quarterly MDS, with an ARD of 12/17/25, showed resident #67 had a BIMS of 11, which was moderate cognitive impairment. Review of the facility's investigation for the resident leaving the facility showed staff were educated on responding to door alarms and instructed to go outside when a door alarm sounded to ensure no resident had left the building. Review of resident #67's IDT event note, dated 10/3/25, showed, Risk Factors and Root Cause Identification: Impaired memory, Confused, Wanting to smoke . New interventions: Resident added to the elopement binder, Resident educated he cannot leave the facility without assistance, Encouraged to use the enclosed patio to enjoy outdoors when desired. [sic] The facility failed to accurately identify the root cause of the elopement to address it, specifically that the resident was being assisted through a door by a non-employee vendor, and the alarm was not triggered. The post-incident education focused on listening for and acting on door alarms, although no door alarm triggered for this incident. The facility failed to investigate or employ interventions post-incident that were specific to the resident's exiting the facility, which placed resident #67 at a continued risk of elopement. 2. Review of a Facility-Reported Incident, dated 6/5/25 at 8:40 a.m., showed staff member O found resident #99 lying in his bed in urine-soaked clothing and a soiled brief. This was discovered by staff members O and L after shift change was completed with NF3, who had been a staff member responsible for resident #99's care on the night shift. Staff member O reported the information about resident #99 to staff member J, who then reported the neglect of care to staff member B, and in turn to staff member A. During an interview on 1/15/26 at 8:36 a.m., staff member A stated he did not have any further documentation to provide for the facility reported incident involving resident #99 on 6/5/25. Staff member A stated he could not show resident #99's responsible party or provider were contacted regarding the incident. Staff member A stated, If it isn't documented, it didn't happen. Staff member A stated there were no risk management or event form templates with information about the incident involving resident #99. An initial request was made to the facility on 1/12/26 at 12:29 p.m. for documentation of any investigation notes, to include interviews and or findings for the facility reported incident with resident #99 on 6/5/25. The facility provided the following incident findings, with no date of submission: - Interviews were conducted by staff member A with residents who resided on resident #99's hallway, with no concerns related to NF3's care or care from other CNAs. - Security camera footage was reviewed and found inconclusive since there was no clear view of resident #99's room entrance. - NF3 resigned her employment prior to the facility completing its findings of the incident. - The facility's interdisciplinary team found there was a lapse in care by NF3 to resident #99, and her employment would have been terminated had she not voluntarily resigned. - Interdisciplinary team findings concluded this was an isolated incident with resident #99, with no evidence of a broader pattern of neglect involving other staff members or residents. A second request was made to the facility on 1/14/26 at 5:10 p.m., for any documentation of interdisciplinary team notes, the event review, staff education or training following the event, and or evidence of the notification of resident #99's provider and responsible party. The facility did not provide additional documentation by the end of the survey. Review of a facility policy titled Abuse, Neglect and Exploitation, implemented 4/11/25, showed: . V. Investigation of Alleged Abuse, Neglect and Exploitation . B. Written procedures for investigations include: . 6. Providing complete and thorough documentation of the investigation. VII. Reporting/Response. B. The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies.

Based on observation, interview, and record review, the facility failed to ensure dietary staff followed safe and sanitary conditions by donning hair coverings and beard nets while preparing resident meals in the facility kitchen. This failure put all residents receiving meals at risk for sanitation issues related to the uncovered hair if it were to get into food. Findings include: During an observation on 3/24/25 at 4:38 p.m., staff member I was in the facility kitchen, not wearing a hair covering or beard net. Staff member I was working at the kitchen grill and preparing food on a serving area. During an observation on 3/25/25 at 7:50 a.m., staff member I was in the facility kitchen, not wearing a hair covering or beard net. Staff member I was dishing food from a pan, onto a plate, preparing breakfast for residents. During an interview on 3/25/25 at 2:15 p.m., staff member D stated dietary staff working in the kitchen are expected to wear hair coverings and a beard net if they have facial hair. Staff member D stated staff member I moved into the cooking role recently and did not always wear a beard net. Staff member D stated staff member I is aware he needed to wear a beard net, he had been told to wear a beard net working in his new role as a cook. Staff member D stated audits by observations were completed to show compliance with facility dining room, kitchen, and food test tray policies. Staff member D stated the dietitian conducted audits on Tuesdays, and on Thursdays she completed the audits. During an interview on 3/26/25 at 1:48 p.m., staff member I stated, It's 50/50 (the time) that I remember to wear a hair or beard net. I forget a lot. I get busy, and I'm new to doing the cook position. Staff member I stated he trimmed hair towards the back of his head the other day for his hair to be shorter. Staff member I stated he needed to do better to remember to wear hair and beard coverings when working in the kitchen. Review of a facility policy titled, Work Clothing and Attire, undated, showed: . Employees engaged in work that places them in a position where they meet the public or provide patient care are expected to present a neat, professional appearance. This means good grooming habits and the proper attire representative of their position .

Based on observation, interview, and record review, the facility failed to implement a system to ensure an interdisciplinary team was involved in determining if a resident was safe to self-administer medication and failed to implement a system to ensure an as needed medication was secured in a resident's room for 1 (#6) of 9 sampled residents. This deficient practiced caused resident #6 a temporary burning sensation under her right arm. Findings include: During an observation and interview on 3/25/25 at 4:10 p.m., resident #6 was in her room sitting in a wheelchair. Resident #6 stated she had limited mobility in her extremities because of multiple health conditions and required assistance with daily care. Resident #6 was observed to have minimal movement in her hands and was unable to lift her arms. Resident #6 stated in late January 2025, staff member E spoke to her about a medication called Blu Emu cream for muscle soreness. Resident #6 stated a nurse left a sample of the Blu Emu cream in a 30cc plastic medication cup on her bedside table and told her to use it when she needed it. Resident #6 stated she did not recall the name of the nurse who left the cream on her bedside table. Resident #6 stated facility staff did not provide a locked container in her room to store the medication. Resident #6 stated she never needed to use the Blu Emu cream, and it sat on top of her bedside table. Resident #6 stated staff member K came into her room on the evening of 1/29/25 and administered her oral nighttime medication but left a white cream in a 30cc medication cup on her bedside table the medical provider ordered to be applied to her underarms due to skin irritation. Resident #6 stated she had stayed up late watching a movie and was sitting in her wheelchair and staff member K wanted staff member J to apply the cream to her underarms when she was ready for bed. Resident #6 stated staff member J helped her prepare for bed around 11:30 p.m. on 1/29/25. Resident #6 stated staff member J mixed up the two creams on her bedside table and applied the blue (Blu Emu) cream instead of the white cream to her underarm. Resident #6 stated she experienced a burning sensation to her underarm after staff member J applied the cream. Resident #6 stated staff member J washed her underarms with soap and warm water which provided resident #6 relief from the burning sensation. During an observation and interview on 3/24/25 at 3:50 p.m., staff member E stated she did not recall completing a medication self-administration assessment on resident #6 for Blue Emu cream. Staff member E stated she did not know why a medication self-administration assessment would be completed for resident #6 because the resident would not be able to apply the cream. Staff member E reviewed resident #6's electronic medical record and was able to locate the medication self-administration assessment completed on 1/23/25. Staff member E stated she completed the assessment but documented on the assessment resident #6, Is able to direct staff to apply medications; resident knows how often and had agreed to supply the medication. Staff member E stated when she documented staff applying the medication, she was indicating licensed staff only. Staff member E denied dispensing Blu Emu cream to resident #6. Review of resident #6's physician order, dated 1/23/25, showed an order for Blue-Emu cream to be applied to the affected areas topically every 12 hours as needed. Resident #6 may have at bedside. Resident will supply this medication. Review of resident #6's Medication Self-Administration Safety Screen, dated 1/23/25, showed medication to be self-administered, Blu Emu cream, to be stored at bedside with resident #6. Resident #6 requires assistance to correctly read label and or identify medication and to open medication package or container. Staff member K documented under the interdisciplinary summary, Resident is able to direct staff to apply medications; she (resident #6) knows how often; she (resident #6) has agreed to supply this medication. Review of resident #6's electronic medical record failed to show the resident's medication self-administration assessment, dated 1/23/25, was reviewed by the facility's interdisciplinary team. Review of the facility's policy titled, Self-Administration of Medications, revised December 2012, showed the following: Policy Statement Residents in the facility who wish to self-administer their medications may do so, if it is determined that they are capable of doing so. Policy Interpretation and Implementation - 1. If a resident expresses a desire to self-administer medications, the staff and practitioner will assess the resident's mental and physical abilities to determine whether a resident is capable of self-administering medications, including (but not limited to) the resident's; a. Ability to read and understand medication labels; b. Comprehension of the purpose and proper dosage and administration time for his or her medications; c. Ability to remove medications from a container and to ingest and swallow (or otherwise administer) them; and d. Ability to recognize risks and major adverse consequences of his or her medication . - 6. Self-administration medication must be stored in a safe secure place, which is not accessible by other residents. If safe storage is not possible in the resident's room, the medications of the residents permitted to self-administer will be stored on a central medication cart or in the medication room. Nursing will transfer the unopened medication to the resident when the resident requests them . [sic]

Based on interview and record review, the facility nursing staff failed to meet professional standards of practice by not providing safe administration of a scheduled topical medication for 1 (#6) of 9 sampled residents. This deficient practice caused resident #6 a temporary burning sensation under her right arm. Findings include: During an interview on 3/25/25 at 4:10 p.m., resident #6 stated on 1/29/25 staff member K brought a plastic 30cc medication cup into her room. Resident #6 stated the medication cup contained a white cream the medical provider had ordered for her due to skin irritation under her left and right underarms. Resident #6 stated staff member K administered her oral medication but left the cream on her bedside table for the certified nursing assistant to apply to the affected area when she went to bed for the evening. Resident #6 stated staff member J helped her prepare for bed around 11:30 p.m. on 1/29/25. Resident #6 requested staff member J apply the cream under her arms. Resident #6 stated after staff member J applied the cream to her right underarm she started to feel a burning sensation. Staff member J then applied a cold cloth to her underarm, which did not relieve the burning sensation. Resident #6 asked staff member J to go and get the nurse. Resident #6 stated she asked staff member J if he had applied the white cream, and he responded, No, it was blue. Staff member J then washed resident #6's underarms with soap and warm water which provided her relief from the burning sensation she had experienced. Resident #6 stated, Then I had the CNA apply the white cream to my underarms. Resident #6 stated the blue cream was in a clear 30cc medication cup and was left at her bedside by a nurse days prior to try out for muscle soreness, and to use it when she needed it. Resident #6 stated she could not recall what staff member gave her the blue cream, but said she was allowed to keep it at her bedside. Resident #6 stated she had not needed to use the blue cream, and it had remained on her bedside table. During an interview on 3/27/25 at 12:06 p.m., staff member K stated she received an order from the medical provider for Triamcinolone Acetonide external cream 0.1% topically to be applied under resident #6's right and left underarms on 1/29/25. Staff member K stated she recalled being in the resident's room around 8:00 p.m. on 1/29/25. Staff member K stated resident #6 was still awake sitting in her wheelchair. Staff member K stated she administered the resident's oral medication around 8:00 p.m. on 1/29/25, and placed Triamcinolone Acetonide cream in a clear 30cc medication cup, on the resident's bedside table. Staff member K stated she was planning to return to the resident's room to apply the cream when resident #6 was ready for bed. Staff member K stated she was new to her position and had worked in the past in different states which allowed certified nursing assistants to apply topical creams. Staff member K stated she could not say why she left the Triamcinolone Acetonide cream on the resident's bedside table. Staff member K denied dispensing a blue cream to resident #6. Review of resident #6's medication administration record showed Triamcinolone Acetonide external cream 0.1% was administered topically under resident #6's right and left underarms on 1/29/25 at 7:38 p.m. by staff member K. Staff member K failed to ensure safe administration of a scheduled topical medication by leaving the medication unsupervised on resident #6's bedside table.

Based on interview and record review, the facility failed to ensure staff members followed appropriate protocols for the safe transfer of residents while using a Hoyer lift for 1 (#6) of 9 sampled residents. Findings include: Review of a facility grievance, dated 1/29/25, showed resident #6 reported staff member J used a Hoyer lift, without assistance from another staff member, to transfer her to bed from her wheelchair, when providing care at night. During an interview on 3/26/25 at 9:05 a.m., staff member B stated newly hired nursing staff received education on lifts. Staff member B stated the facility requires two staff when using lifts for resident transfers. Staff member B stated there was a nursing in-service meeting in September 2024, which included lift training. Staff member B stated staff member P provided education on appropriate lift protocols for resident transfers to staff member J. During an interview on 3/27/25 at 9:19 a.m., staff member J stated the facility was strict about having two staff transfer a resident with lifts. Staff member J stated the facility required two staff members when using Hoyer lifts and EZ stand lifts. Staff member J stated he transferred resident #6 during the night of 1/29/25, on his own, and stated it was because, I believe I couldn't find anyone available to assist. Review of a facility document titled, Inservice 9/19/24, showed, Lifts- all lifts in the facility require 2 person for transfers. If your resident requires a lift please ensure care is provided and sling under resident and w/c or bed is prepared for resident. once all care has been given and resident is ready for transfer then have 2nd staff member join you for safe transfer process . [sic] Review of a facility document titled, Staff Education, undated, showed staff member J was educated by staff member P on training for proper safety when using a Hoyer and sit to stand lift, and proper care procedures. Review of a facility document titled, Certified Nursing Assistant Competency Checklist, undated, showed staff member J completed training and was signed off on 1/7/25 for, Equipment: Use of sit-to-stand lift, and on 1/8/25 for, Equipment: Use of Hoyer lift.

Based on interview and record review, the facility failed to provide pharmaceutical services to ensure safe administration of a scheduled topical medication for 1 (#6) of 9 sampled residents. This deficient practice caused resident #6 a temporary burning sensation under her right arm. Findings include: During an interview on 3/25/25 at 4:10 p.m., resident #6 stated on 1/29/25 at approximately 11:30 p.m., staff member J helped her prepare for bed. Resident #6 requested staff member J apply a cream under her arms due to irritation she had been experiencing the last two days. Resident #6 stated after staff member J applied the cream to her right underarm she started to feel a burning sensation. Staff member J then applied a cold cloth to her underarm, but she had no relief. Resident #6 said she asked staff member J to go and get the nurse and also asked him if he had applied the white cream, and he responded, No, it was blue. Resident #6 stated staff member J then washed her underarms with soap and warm water which provided relief from the burning sensation. Resident #6 stated staff member J then applied a white cream to her underarms which had been placed on her bedside table in a clear 30cc medication cup by the nurse earlier in the evening. Resident #6 stated the blue cream was placed in a clear 30cc medication cup and was left at her bedside by a nurse days prior to try out for muscle soreness, and to use it when she needed it. Resident #6 stated she had not needed to use the blue cream, and it had remained on her bedside table. During an interview on 3/27/25 at 9:14 a.m., staff member J stated on 1/29/25 at some time between 11:00 p.m. and 11:30 p.m., he assisted resident #6 to bed. Staff member J stated the nurse entered resident #6's room while he was assisting the resident and placed two 30cc medication cups on the resident's bedside table. One cup contained white cream and the other contained blue cream. The cups were unlabeled. Staff member J stated the nurse did not provide any instructions prior to leaving the room. Staff member J stated resident #6 requested he apply cream under her right underarm, and he applied the blue cream. Staff member J stated the resident started to complain of a burning sensation. Staff member J stated he then applied a cold cloth under the resident's right under arm which did not relieve the resident's burning sensation. Staff member J stated the resident requested to see the nurse and find out what was in the white cream. Staff member J stated to resident #6, I applied the blue cream. Staff member J stated he then washed the blue cream from resident #6's right underarm with soap and warm water. Staff member J stated resident #6's burning sensation stopped, and he then applied the white cream to her underarms, at her request. Staff member J stated he reported the incident to staff member K, and she had followed up with the resident. Staff member J stated resident #6 voiced no complaints of pain or discomfort for the remainder of his shift. During an interview on 3/27/25 at 12:06 p.m., staff member K stated she received an order from the medical provider for Triamcinolone Acetonide external cream 0.1% topically to be applied under resident #6's right and left underarms on 1/29/25. Staff member K stated she recalled being in the resident's room around 8:00 p.m. on 1/29/25. Staff member K stated resident #6 was still awake sitting in her wheelchair. Staff member K stated she administered the resident's oral medication around 8:00 p.m. on 1/29/25 and placed Triamcinolone Acetonide cream in a clear 30cc medication cup on the resident's bedside table. Staff member K stated she was going to return to the resident's room to apply the cream when resident #6 was ready for bed. Staff member K stated she was new to her position and had worked in the past in different states which allow for certified nursing assistants to apply topical cream. Staff member K stated she could not say why she left the Triamcinolone Acetonide cream on the resident's bedside table. Staff member K denied dispensing a blue cream to resident #6. Review of resident #6's medication administration record showed: Triamcinolone Acetonide external cream 0.1% was administered topically under resident #6's right and left underarm on 1/29/25 at 7:38 p.m. by staff member K. Review of resident #6's medical provider orders showed: - Order date 1/23/25 . Blue-Emu Super Strength External Cream (Liniments & Rubs) Apply to affected areas topically every 12 hours as needed. May have at bedside. Resident will supply this medication. - Order date 1/29/25 Triamcinolone Acetonide External Cream 0.1 % (Triamcinolone Acetonide (Topical)) Apply to bilateral axilla topically two times a day for rash for five days. Review of the facility document titled, Administering Medication, last revised December 2012, showed: Policy Statement Medication shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation - 1. Only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so. - . 7. The individual administering the medication must verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication . [sic]

Based on observation, interview, and record review, the facility failed to ensure enhanced barrier precaution practices were utilized by staff while performing high-contact resident care during a transfer, for 1 (#5) of 9 sampled residents. Findings include: During an observation on 3/25/25 at 3:32 p.m., staff member N and staff member L transferred resident #5 in his room from the bed to his wheelchair. Staff member N and staff member L had gloves on before they started to transfer resident #5 with the sit-to-stand lift. Staff member N and staff member L did not don gowns prior to the transfer. Staff member N and staff member L's uniforms had direct contact with resident #5's upper and lower body during his transfer with the sit-to-stand lift. During an interview on 3/25/25 at 3:44 p.m., resident #5 stated nursing staff wear gowns and gloves when they perform his catheter care, but not when he is transferred with the sit-to-stand lift. During an interview on 3/26/25 at 9:15 a.m., staff member B stated she was the infection preventionist for the facility, and she provided education to nursing staff on the use of enhanced barrier precautions. Staff member B stated all nursing staff are educated on what to use when a resident is on enhanced barrier precautions. Staff member B stated when two staff members are transferring a resident who is on enhanced barrier precautions, staff are required to don gowns and gloves. During an interview on 3/26/25 at 11:31 a.m., staff member N stated when she transferred resident #5 the day prior, with staff member L, It was busy. I usually wear a gown when transferring a resident and have contact, but I didn't during the transfer for [#5]. Review of a facility policy titled, Enhanced Barrier Precautions, revised 4/1/24, showed: . 1. In addition to Standard Precautions, implement Enhanced Barrier Precautions for an individual documented or suspected to be at increased risk of carrying a resistant organism . This includes anyone with . indwelling medical devices (e.g. urinary catheter .) 5. In addition the use of standard precautions, staff should wear gloves and a gown during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. Examples of high-contact resident are activities include: . c. Transferring . [sic]

Based on interviews and record review, the facility failed to keep residents free from neglect for 2 (#s 1 and 15) of 17 sampled residents. This deficient practice of neglect contributed to skin breakdown and psychosocial harm and pain for 1 (#15) and psychosocial harm to 1 (#1) of the 17 sampled. Findings include: 1. During an interview on 7/31/24 at 9:47 a.m., resident #15 stated staff member F refused to change his brief. Resident #15 stated NF4 came in during the evening and was very upset he had not been changed. Resident #15 stated he needed frequent brief changes due to medications he had been given for constipation. Resident #15 stated staff member F told him, I'm not changing your diaper again until shift change, when he asked to be changed for the second time after breakfast. Resident #15 stated, It's an awful feeling to go in a diaper and sit in it all day. It happened at breakfast, and I was not changed until [NF4] came in the evening. Resident #15 stated he was also left in his wheelchair, in the dining room, for six hours after he got up for the morning until the afternoon. Resident #15 stated he was worried about getting pressure sores, and his back was hurting because he had been in the chair too long. NF4 complained to the staff about care provided by staff member F. During an interview on 7/31/24 at 11:12 a.m., NF4 stated she was taking resident #15 down to lunch and stopped at the nurse's station to request resident #15 be given his lunch medications. NF4 stated his medications must be given with lunch due to a medical condition and metabolization. She was told the nurse was not available now, and they went on to the dining room. After lunch, NF4 stated she again stopped at the nurse's station and requested resident #15's medications. NF4 stated staff member F was on her cell phone and yelled, We are right in the middle of a crisis, we don't have time for that. NF4 stated she continued to push resident #15 to his room and he was complaining of back pain. NF4 stated resident #15 informed her he had been in his chair since he woke up, and staff member F refused to change his brief since he got up. NF4 pressed the call button, and staff member F came to the room. NF4 stated he needed to be put in bed and have his brief changed. NF4 stated staff member F told her, I'm not changing him again, I'm not changing him until he is empty. NF4 stated staff member F was complaining about needing a two person lift to get resident #15 back in bed and left the room to find a second person. NF4 stated she left to go home, under the impression staff member F would take care of resident #15's brief change, and allow him to lay down. NF4 stated she returned to the facility at 7:00 p.m., to find resident #15's brief had not been changed, and no one had come in after she left to provide toileting or assistance. NF4 stated she pressed the call light, and after waiting until 8:00 p.m., she changed him herself. NF4 stated resident #15 had feces dried all the way up his back and around his groin, and his brief was overflowing with feces. NF4 stated it took her an hour to clean resident #15 up, and no one answered the call light until she was nearly done cleaning him up. NF4 stated a new CNA entered and when she told the new CNA what happened, the CNA went to get a nurse. The night nurse came into the room, and NF4 told the nurse that staff member F was no longer allowed in resident #15's room, and she wanted to talk to the administrator immediately. NF4 stated resident #15 had a diaper rash, and is now worried he will offend someone if he must have a bowel movement. NF4 stated resident #15 was holding bowel movements in as long as possible to try and avoid upsetting the CNAs. NF4 stated this behavior was .not helping his constipation issues and resident #15 shouldn't have to worry about upsetting CNAs. NF4 stated resident #15 had a traumatic brain injury and a sudden need for total assistance for basic needs so he should not be dealing with people who do not care. During an interview on 7/31/24 at 9:17 a.m., staff member C stated she reported resident #15's grievance to staff member A immediately in a text message on 7/28/24 at 6:40 a.m. Staff member C stated the incident with the CNA had occurred on 7/27/24, but she was not working. Staff member C stated she was told about the grievance in morning report from the night shift nurse. During an interview on 7/31/24 at 2:11 p.m., staff member F stated she changed resident #15 when she came on shift in the morning. Staff member F stated resident #15 was a Hoyer and required two people to transfer him in the Hoyer lift. Staff member F stated she told resident #15 she could not get him on the toilet because it was too messy but would give him a bed pan to use on the bed. Staff member F stated, It was about then that the ambulance came for another resident, and I had to step out to go do vitals on that resident. Then it was four o'clock, so I started getting people up for dinner, showers, and weights. Then my co-worker asked to change jobs because she didn't want to go to the dining room, so she took over my hall, and I went to the dining room. When I came back, it was time to give report and leave. Staff member F stated, I put him down (#15), I didn't go back and check on him because things were just crazy that day. During an interview on 7/31/24 at 7:10 a.m., staff member A stated he did know about the complaint of neglect for resident #15, and had a scheduled a meeting with NF4 for Thursday. Staff member A stated he had not filed a report with the State Survey Agency because he was waiting to meet with NF4. Staff member A stated staff member F had continued to work with residents after the complaint was made on 7/27/24. During an interview on 8/1/24 at 8:50 a.m., staff member O stated, [Staff member A] did not follow proper protocol and was doing it backwards, trying to meet with family and investigate before reporting. Training on more in depth record keeping and keeping folder and interviews for each incident is needed. 2. During an interview on 7/30/24 at 3:30 p.m., NF2 reported resident #1 was not treated with dignity and respect during her stay at the facility beginning 5/2/24. NF2 stated resident #1's call lights were not answered on multiple occasions during the weekend and she was left in her hospital gown for five days. NF2 reported when she arrived on 5/6/24, resident #1 was crying and depressed. NF2 stated she and NF3 requested immediate discharge from the facility, due to the poor care provided. NF2 stated she reported her concerns to the nurse on duty and filed a grievance with the facility. NF2 stated she never received a response from the facility regarding her grievance. NF2 stated she contacted the ombudsman to get a response from the facility. Review of the facility's call light report for resident #1's room [ROOM NUMBER], dated 5/2/24-5/7/24, reflected: - 5/4/24: call light was on for 32 minutes at 10:42 a.m. - 5/4/24: call light was on for 1 hour, and 33 minutes at 6:17 p.m. - 5/5/24: call light was on for 38 minutes at 7:10 p.m. During an interview on 7/21/24 at 7:10 a.m., staff member A stated he was aware of NF2's concerns. Staff member A stated he did not report the neglect to the State Survey Agency. Staff member A stated he was new as an administrator, and only recently learned he should be reporting neglect. He thought he was only reporting abuse and misappropriation of funds. Review of a facility policy, Abuse Policy, revised 6/11/24, reflected: - . Neglect: The failure to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish or emotional distress. - . Abuse Identification and Reporting - The facility will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown origin and misappropriation of resident property are reported immediately, but no later than 2 hours, after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and Adult Protective Services where state law provides jurisdiction in long term care facilities and office of long-term care ombudsman) in accordance with State law through established procedures. - All employees of this facility must immediately report any suspected, observed or reported incidents of resident abuse, neglect, misappropriation of resident property, whether by staff members, family members or any other persons to the Administrator or Administrator's designee. The Administrator serves as the abuse coordinator of the facility. - The Administrator or designee shall interview any staff members, residents, family members or any others who may have knowledge of the incident and document a summary of interviews completed. - The Administrator or designee shall report the results of all investigations to the State Survey Agency within 5 working days of the incident . - When an employee of the facility abuses or is suspected of abuse of a resident, the employee will be placed on immediate suspension and directly escorted by a staff member out of the facility and not permitted to return while the investigation is completed .

Based on observation, interview, and record review, the facility failed to monitor and follow interventions for a severe weight loss for 1 (#6) of 1 sampled resident. Findings include: During an observation and interview on 10/24/23 at 9:08 a.m., resident #6 was sitting in bed, alone with the door to her room closed, and her breakfast tray in front of her. The plate was full of food she was pushing around with her fork. She stated today's breakfast was one of the better ones because the staff usually dropped her tray off while she was asleep, and it would be cold when she woke up to eat. During an observation on 10/25/23 at 8:37 a.m., resident #6 used her call light to notify the CNA that she was done with her tray. Her plate remained full of food. The aide did not ask the resident if she wanted an alternative or a snack. Review of resident #6's Quarterly MDS, with an ARD of 7/20/23, showed she was marked as needing supervision for eating. Review of resident #6's care plan, revision date 7/16/23, showed: Focus: The resident has unplanned/unexpected weight loss r/t [related to] dislike for many foods provided by LTC [long term care], resident statement of difficulty when swallowing . Interventions: - Monitor/document/report any s/sx [signs and symptoms] of dysphagia . - Offer a sandwich in replacement if resident refuses to eat meal being served that day . - Monitor intake and record q [every] meal. Review of resident #6's recorded meal intakes, dated August 2023 to October 2023, showed: - Breakfast intake was blank 13 days in August, five days in September, and 10 days in October, 2023. - Lunch intake was blank 14 days in August, five days in September, and 13 days in October, 2023. - Dinner intake was never documented in August, documented one day in September, and documented once in October, 2023. Review of resident #6's weight summary, dates April 2023 - October 2023, showed: - 4/25/23 122 lbs - 5/18/23 122 lbs - 6/20/23 113.6 lbs - 7/11/23 107.2 lbs - 8/8/23 111.6 lbs - The resident's weight was not documented/monitored in the month of September 2023 - 10/18/23 102.6 lbs This trend represented a 15.9% severe weight loss over six months. During an interview on 10/26/23 at 8:02 a.m., staff member B stated resident #6 would refuse to be weighed, however there was no documentation of any refusals for the resident or weight attempts for the month of September 2023.

Based on observation, interview, and record review, the facility failed to prevent the development of an Unstageable pressure injury for 1 (#38) of 2 sampled residents with wounds Findings include: During an interview and observation on 10/23/23 at 2:40 p.m., resident #38 stated she had gotten a new bed because she had a blister on her heel. She stated it did hurt if she tried to walk. She had bed slippers on her feet, which were on the floor, with no pressure reduction in place for the left heel During an observation on 10/24/23 at 10:41 a.m., resident #38 was lying in bed with no pillow or pressure relieving boots for her left heel. During an observation and interview, on 10/24/23, at 2:43 p.m., staff member B removed the boot, and took the sock off resident #38's left foot. There was a dressing in place on the heel, which was stuck to the resident's sock. Removal of the dressing showed drainage from the pressure injury. Staff member B stated the injury could not be left open to air because of the drainage, and the pressure injury was currently Unstageable. It was the first time the pressure relieving boot was observed on resident #38's left foot. Review of resident #38's treatment record, dated 10/2023, showed four treatments for the resident's left heel wound were not completed on 10/20/23, 10/21/23, 10/22/23, and 10/25/23. During an interview on 10/24/23 at 3:30 p.m., staff member K stated he was overwhelmed, and did not think he could get resident #38's treatment to the heel completed.

Based on interview and record review, the facility failed to maintain the skin integrity of a resident resulting in a Stage II pressure ulcer for 1 (#43) of 1 sampled resident; and the facility failed to assess and document three newly identified pressure ulcers, failed to prevent an eight day delay in the implementation of appropriate wound care for each of the pressure ulcers identified, and failed to consistently perform wound care dressing changes as ordered for each of the three pressure ulcers for 1 (#31) of 1 sampled resident. Findings include: 1. During an interview on 1/4/23 at 2:33 p.m., NF2 stated resident #31 had an ace wrap on her broken left leg for 10 days after her surgical repair of the fracture. NF2 stated when the facility took the ace wrap off they found several areas of skin breakdown on the resident's left calf, ankle, heel, and the top of her foot. Multiple attempts to interview resident #31 between 1/3/23 at 12:45 p.m. and 1/5/23 at 11:00 a.m. were made. Resident #31 was resting in her bed with her eyes closed and was left undisturbed. Review of resident #31's Progress Note - Message Center, dated 9/19/22, showed the facility notified the provider of the skin breakdown identified when the ace wrap was removed, and the areas were being left open to air with offloading of the areas of pressure. The message also showed resident #31's next appointment was in eight days (9/27/22). Review of resident #31's EMR, accessed on 1/4/23, failed to show an assessment of the appearance of the wounds identified on 9/19/22 until 9/29/22 when the resident was seen at the wound care clinic. Review of resident #31's provider order, dated 9/27/22, showed an order for wound care daily for the wound on the resident's left heel. No orders for the wounds on the plantar and dorsal surfaces of the resident's left foot were found until 9/29/22. Review of resident #31's wound care orders, dated between 9/29/22 and 12/15/22, showed the following: a. Dorsal surface of left foot: - started on 9/30/22, stopped 10/20/22, dressing change every other day, and - started on 10/20/22, stopped on 12/15/22, dressing change three times per week. b. Left heel: - started on 9/30/22, stopped on 11/5/22, dressing change every other day, and - started on 11/5/22, stopped on 12/15/22, dressing change three times per week. c. Plantar surface of left foot: - started on 9/30/22, stopped on 10/20/22, dressing change every other day, and - started on 10/20/22, stopped on 12/15/22, dressing change three times per week, Review of resident #31's treatment record, dated 9/2022, failed to show documentation of wound care between 9/19/22 (date wounds under ace wrap were identified and message was sent to a provider) and 9/27/22. The only documentation of a dressing change during September was on 9/28/22, and involved the resident's left heel. Review of resident #31's treatment record, dated 10/2022 and 11/2022, showed the following: - dressing changes to the dorsal surface of the left foot were completed 16 out of 26 opportunities, with 10 dressing changes missed, - dressing changes to the left heel were completed 14 out of 22 opportunities, with eight dressing changes missed, and - dressing changes to the plantar surface of the left foot were completed 16 out of 25 opportunities, with nine dressing changes missed. 40068 2. During an interview on 1/4/23 at 2:43 p.m., staff member E stated resident #43 had a Stage II pressure ulcer on her coccyx. Staff member E stated the pressure ulcer was facility acquired. Staff member E stated, It doesn't take much for skin to open. I don't think it has anything to do with lack of care, it just happens. Staff member E stated in mid-December the skin on resident #43 was not blanchable on her coccyx, but she was being repositioned every couple of hours. Staff member E stated the wound opened just a few days ago and the facility received orders from the doctor for wound care and repositioning. Staff member E stated the facility did not have a specific wound care nurse. Staff member E stated she had not received specific wound care training at this facility. Staff member E stated knowing how to stage pressure ulcers and perform wound care was not something that nurses needed to be trained on. During an interview on 1/5/23 at 8:57 a.m., staff member D stated the facility needed to do training on wound care. Staff member D stated each nurse was expected to do wound care and staging pressure ulcers for the residents they were assigned to, and the facility had not provided any training specifically on how to do this. Staff member D stated, We all just help each other out. Staff member D stated resident #43 did have a pressure ulcer on her gluteal fold from moisture due to incontinence. Review of resident #43's nursing progress notes, dated 12/13/22, showed, CNA reported to this nurse a new skin issue. [Resident #43] has a 2cm x 0.2 cm, reddened, non-blanching area on her coccyx. Review of resident #43's nursing progress notes, dated 12/31/22, showed, Open area noted in gluteal fold on and L buttock. Area cleansed with gentle cleanser and cover with optifoam for protection. Resident turned to side to offload pressure. Will continue to reposition every two hours. [sic] Review of resident #43's nursing progress notes, dated 1/1/23, showed, Open area to left gluteal fold and intergluteal cleft assessed this shift. Open area to left gluteal fold is a stage two pressure injury at this time, measuring 2cm x 2cm. Fissure to intergluteal cleft is measuring 3 cm. Optifoam applied to open area, [NAME] cream applied to peri-wound and surrounding buttocks. Resident offloaded to left side with pillow, tolerating well at this time. Voicemail left with Dr. office to notify of skin breakdown and request further orders. [sic] Review of resident #43's doctor's orders, dated 1/2/23, showed, Reposition pt at least q2h. Wound care orders read, Wound care orders for left gluteal pressure ulcer; Cleanse with NS, apply hydrocolloid dressing q3days and PRN. Apply barrior cream to surrounding skin. During an interview on 1/5/23 at 10:55 a.m., staff member L stated the order for repositioning resident #43 was put in wrong, and therefore did not carry over to the MAR for the nurses to check off as completed. The order for repositioning in the CNA charting was wrong. Staff member L stated it was put in as PRN which was incorrect. It should have been done every two hours, it was fixed. Documentation for resident #43's repositioning every two hours was requested on 1/5/23 at 8:23 a.m., and was not provided by the end of survey.

Based on interview and record review, the facility failed to ensure residents are protected from involuntary discharges and failed to allow residents to return to the facility while a discharge appeal was pending, for 1 (#1) of 6 sampled residents. This deficient practice had the potential to result in a severe adverse outcome as the resident did not have a safe disposition. Findings include: During an interview on 12/21/20 at 11:12 a.m., NF1 stated she was notified resident #1 had left the facility AMA. NF1 stated she had advocated for resident #1 and obtained a judge's order to cease interference with the resident's attempts to return to the facility. NF1 stated she notified staff member A of a resident's right to remain in the facility while an appeal is pending. NF1 stated staff member A did not acknowledge the regulations related to a resident's right to return to the facility and remain in the facility while an appeal is pending. During an interview on 12/21/20 at 11:52 a.m., NF1 stated resident #1 was currently hospitalized at (facility name) on a ventilator. During an interview on 12/21/20 at 1:07 p.m., staff member G stated he did not recall any specific discussions about resident #1's AMA discharge, or any problems with resident #1's care on 10/16/20. Staff member G stated his experience with AMA discharges was mainly in the hospital setting, not long-term care. Staff member G stated he did not consider a resident leaving the facility for a medical appointment as an AMA situation, or a reason not to allow the resident to return to the facility. Staff member G stated he was notified resident #1 had left the facility AMA and was not involved in any discussions prior to her discharge. During an interview on 12/21/20 at 1:20 p.m., staff member B stated she did not speak to resident #1 or her family regarding the resident's desire to leave the facility in order to see a doctor of her choosing. Staff member B stated she notified staff member G of resident #1's AMA discharge and received a discharge order. Staff member B stated the facility had concerns with resident #1's safety while being with her family because her family had snuck contraband (narcotics and a vaping pen) into the facility. Staff member B stated there were discussions about a restraining order against someone in resident #1's family and concerns with the risks of exposure to COVID-19. Staff member B stated the facility was trying to discourage resident #1 from leaving the facility. During an interview on 12/21/20 at 1:32 p.m., staff member A stated he was out of town when the incident with resident #1 had occurred. He stated he received a call from staff member B indicating resident #1 wanted to leave the facility and was not willing to wait for treatment of [REDACTED]. Staff member A stated after resident #1 was discharged AMA, she could not return without a valid provider admission order. Staff member A stated NF1 had notified him of the judge's emergency order to cease interference with resident #1's desire to return to the facility, but said he never received the order in written form. During an interview on 12/21/20 at 2:00 p.m., NF2 stated she picked up resident #1 on 10/16/20 to take her to see a doctor about her RA pain. NF2 stated she took her to a walk-in clinic and got a prescription for [MEDICATION NAME]. NF2 stated resident #1 had asked her to take her because the facility said they could not take her to see a doctor. After the appointment was completed, NF2 took resident #1 to get something to eat and called the facility to let them know they would be returning soon. NF2 said the staff member who answered the phone told her resident #1 had left the facility without permission and had been discharged . NF2 stated resident #1 believed she would be allowed to return after the appointment. During an interview on 12/21/20 at 2:18 p.m., staff member D stated she tried to get resident #1 to stay at the facility. Staff member D stated she had called a rheumatologist regarding her pain and was waiting for a response. Staff member D stated her biggest concern with resident #1 leaving the facility with a family member was safety. Staff member D stated resident #1 had a recent overdose and had been being sneaky all day. Staff member D stated resident #1 told her she was going to an appointment. However, staff member D stated she believed resident #1 was, going for other things. Staff member D stated she, wouldn't have thought twice about her (resident #1) leaving the facility if it was not for the recent overdose by resident #1. Staff member D stated she was concerned resident #1 was going to use drugs while out of the facility. During an interview on 12/22/20 at 10:19 a.m., staff member B stated she was new to the facility and was not aware if there was a formal process or policy for handling AMA discharges. Staff member B stated she did not investigate the circumstances surrounding the AMA discharge of resident #1. During an interview on 12/22/20 at 11:20 a.m., staff member C stated resident #1 had reported an increase in her pain. Staff member C stated resident #1 was not willing to wait for orders from the rheumatologist and called her daughter to take her (resident #1) to see a doctor about her RA pain. Staff member C stated when resident #1 attempted to return, the travel nurse working the night shift was unaware of resident #1's situation and told the resident she had been removed from the computer and would not be allowed to return to the facility. Staff member C stated she never heard resident #1 express a desire to leave the facility permanently and did not believe the resident intended to leave permanently. During an interview on 12/22/20 at 3:58 p.m., staff member A stated he was not aware resident #1 did not have a place to go when she was not allowed to return to the facility on [DATE]. Staff member A stated he received a text from staff member B stating resident #1 wanted to leave the facility and go to the ER. Staff member A stated he responded, Just let her leave. Regarding not allowing resident #1 to return to the facility, staff member A stated he did not remember being notified of the resident's desire to return. Staff member A stated he was not aware a medical provider was not involved in the resident's AMA discharge as required by facility policy. Staff member A stated he believed the resident's refusal to remain in the facility pending medication orders from the rheumatologist was considered against medical advice, and therefore made the AMA discharge valid. A review of resident #1's general nursing progress note, dated 9/8/20, showed a 30-day discharge notice was provided because resident was caught vaping, twice. A review of resident #1's Multidisciplinary IDT assessment note, dated 10/13/20, showed she had nowhere safe to go. The note showed the facility was working on placement in an assisted living facility. A review of resident #1's Behavioral progress note, dated 10/16/20, showed resident #1 was visibly agitated and reported she was leaving with her caregiver to go to the ER so she could have her pain managed since, .we (facility) are not doing anything about it. The note also showed staff were concerned about her safety. Resident #1 persisted and left the facility with her walker. A review of resident #1's General nursing progress noted, dated 10/16/20, showed staff member B notified staff member G about resident #1 leaving the facility with her family, and, Provider stated to D/C resident AMA. A review of resident #1's provider order, dated 10/16/20, showed, Discharge Resident Now. She has left AMA with family. A review of resident #1's Family Contact progress note, dated 10/16/20, showed NF2 had called the facility to let them know she was dropping resident #1 off. The nurse told her resident #1 had been discharged , .out of the system. The note also showed NF2 was not able to have resident #1 stay with her and wondered if she should take her to the women's shelter. A review of resident #1's Alert Note, date 10/16/20, showed when resident #1 was back from the doctor, she was informed she was no longer under the care of the facility, and her belongings were boxed up and placed at the front of the facility. A review of the facility's policy titled Discharging Against Medical Advice (AMA), dated March 2019, showed, If it is the expressed desire of the resident to leave the facility permanently and the physician will not approve discharge orders, the following is to occur: . 2. Call physician and indicate resident's desire to leave. If physician disagrees with the resident leaving the facility, explain to the resident or representative that they will do so Against Medical Advice.

Based on observation, interview, and record review, the facility failed to identify and implement interventions to prevent a severe weight loss for 1 (#19), and a significant weight loss for 1 (#46), of 27 sampled residents. Findings include: 1. Resident # 19 was admitted with [DIAGNOSES REDACTED]. Review of resident #19's Initial MDS, with an ARD date of 8/24/17, showed the resident was cognitively intact with a BIMS of 14. Review of resident #19's weights showed the following: - On 10/14/17 the resident weighed 95 lbs, - On 11/1/17 the resident weighed 82 lbs, - On 1/3/18 the resident weighed 81 lbs. This was a severe weight loss of 13% in one month, with a severe weight loss of 14% in three months. A document request was presented to the facility on [DATE] at 10:00 a.m., requesting Nutrition Assessments on resident #19 from 10/1/17 to current. Documentation was provided from 12/8/17 and 2/6/18. Review of resident #19's Nutrition Assessments, showed the dietician did not complete an RD Nutrition Assessment on the resident until 12/8/17. Review of resident #19's RD Nutrition Follow-up dated 12/8/17, showed: c. Current Weight Changes: showed variable trends d. Current Diet: Regular e. Supplements/Rationale/Intake: NA Accepting HS snack f. Percent of Intake of Food at Meals: 75 - 100 % w. Chewing/Swallowing Status: Meds crushed in pudding due to swallowing concerns. z. Additional Comments: Resident HOH, stated her appetite poor due to not feeling well. a3. Nutrition Intervention: Agreeable to ORS to support weight: Send 120 ml Boost TID at meals. Encourage resident to consume hydration between meals. Goals: a4. Maintain PO 75% of most meals 7 days a week. a7. Resident will maintain weight +/- 5% by next review. Review of resident #19's RD Nutrition Follow-up dated 2/6/18, showed: c. Current Weight Changes: 12.5 % weight loss in 6 months, significant d. Current Diet: Regular e. Supplements/Rationale/Intake: 12/8: 120 ml Boost TID ordered due to weight loss. Resident stated she was not receiving. f. Percent of Intake of Food at Meals: 50 - 100 % of most meals: fair appetite. w. Chewing/Swallowing Status: Meds crushed in pudding due to swallowing concerns. z. Additional Comments: Resident HOH, continues to report poor appetite. Poor historian, and not able to provide weight history 'PTA' (sic). She indicated she was eating well 'PTA' (sic), but admit weight was 89 pounds. a3. Nutrition Intervention: Supplements: updated meal tracker with supplement request. Monitor, weight has been stable for 3 months. Goals: a4. Maintain PO 50-100% of most meals. a7. Maintain current weight +/- 5%. a15. Weight stable x 3 months, with significant change in the past 6 months and this was previously addressed in December. H/P on admit indicated resident was losing weight 'PTA' at home, she is not able to verbalize a weight history today. Supplements in place, and reviewed with resident who indicated she did not believe she was receiving these. Updated meal tracker order. During an interview on 2/5/18 at 4:41 p.m., resident #19 stated she was not getting what was ordered on the menu, she was also supposed to receive a Boost with her meals and did not always get one. She stated she had lost a lot of weight since being admitted to the facility and was worried. She said the facility did not seem to be worried. During an interview on 2/6/18 at 8:22 a.m., staff member J stated she was conducting a quality review in the dining room to check if the residents were receiving the correct diet, supplements, and menu items. She stated this was the first day of conducting the quality review. She said she had met with the regional dietician in December to discuss concerns at that time, and had planned on completing the quality review earlier, but did not have time with her other duties to complete the quality review until that day. The staff member noted resident #19 did not receive her Boost with her meal as ordered. Staff member J stated she was aware of resident #19's weight loss. During an interview on 2/6/18 at 1:51 p.m., staff member J stated she was aware of resident #19's weight loss, she stated the resident had been provided a Boost supplement for the weight loss. The staff member stated the resident triggered in December for weight loss. She stated she was not notified by the nursing staff of changes in the residents' weights until she ran a weight from PCC in December. She stated she was not aware of the weight loss sooner. She stated she would run a report on all residents when she was in the facility to identify any weight changes. She said she would strike out any weight in the system which seemed out of range and asked the nursing staff to re-weigh the resident. But the resident was not always re-weighed on the same day as the weight which was struck out of the record. Staff member J stated she usually would first start a resident on a Boost supplement, and recheck the weight depending on if the weekly weights were feasible. Otherwise she would check every 2-3 weeks on a resident's weight. The staff member stated resident #19 had an unknown reason for weight loss. She said she had discussed the resident's weight loss with her in December, but no sooner. During an interview on 2/7/18 at 11:00 a.m., staff member H stated it was the expectation of the nursing staff to notify the dietitian of any weight changes on a resident. She stated the nurses may not always be notified by the CNA of any weight changes. During an interview on 2/7/18 at 11:10 a.m., staff member Y stated she would re-weigh a resident if the weight seemed wrong, and would notify the nurse of any weight differences. During an interview on 2/8/18 at 8:11 a.m., staff member B stated it was the expectation of the staff to weigh the resident as per the order. When a weight change was identified, the aides were to notify the nurse or the DON promptly. The staff member stated the dietitian was to report to the DON on any weight changes as well. Staff member B said, It is a process which needed improvement. A review of the facility's policy and procedure titled, Weight Assessment, showed, The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. 1. The nursing staff will measure resident weights on admission, the next day, and weekly for two weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter . 3. Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietician in writing. Verbal notification must be confirmed in writing. 4. The Dietician will respond within 24 hours of receipt of written notification. 5. The Dietician will review the unit Weight Record by the 15th of the month to follow individual weight trend over time. Negative trends will be evaluated by the treatment team whether or not the criteria for significant weight change has been met . Analysis: 1. Assessment information shall be analyzed by the multidisciplinary team and conclusions shall be made regarding the: .b. Approximate calorie, protein, and other nutrient needs compared with the resident's current intake; c. The relationship between current medical condition or clinical situation and recent fluctuations in weight; and d. Whether and to what extent weight stabilization or improvement can be anticipated . 2. The physician and the multidisciplinary team will identify conditions and medication that may be causing anorexia, weight loss or increasing the risk of weight loss. Significant Weight Loss: 2. Resident #46 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of resident #46's care plan showed the resident was independent with eating, did not wear his dentures, needed help cutting meat, needed assistance in picking out menu items, and liked to have peanut butter and jelly sandwiches on occasion. A review of resident #46's dietician's progress note, dated 9/18/17, showed BOOST was ordered at bedtime for weight loss. A review of resident #46's dietician progress note, dated 10/17/17, showed BOOST TID was ordered for weight loss. A review of resident #46's dietician progress note, dated 11/25/17, showed double portions for meals were ordered due to continued weight loss. The weight loss was documented as 16% loss in five months. The dietician noted to continue to monitor. A review of resident #46's dietician progress note, on 12/27/17, showed staff member J documented BOOST q PM: question of receiving: increased BOOST TID at meal on 10 - 31: Order was not entered into PCC. Confirmed with the kitchen to ensure he is receiving at all meals. Staff member J also documented an 11% weight loss in six months and to monitor weights. The physician was not notified of the weight loss and no new interventions were put in place. A review of resident #46's dietitian's progress note, on 1/12/18, showed staff member J documented, continued questioning if receiving BOOST TID and at pm. Staff member J documented a 13% weight loss in six months, requested a reweigh of the resident and to continue current interventions. There were no new interventions were put in place. A review of resident #46's dietitian progress note, on 2/6/18, showed staff member J documented resident #46's weight is stabilizing at 115 - 118 lbs since October after experiencing a weight loss of 13% from July. Staff member J documented the RD to continue to monitor, no new interventions were put in place. A review of resident #46's weight record showed the following: on 7/31/17 at 133 lbs, 9/13/17 at 120.5 lbs, 9/17/17 at 125.8 lbs, 9/15/17 at 127.2 lbs, 9/15/17 at 124 lbs, 10/4/17 at 118 lbs, 10/5/17 at 118 lbs, 11/1/17 at 115 lbs, 12/4/17 at 119.4 lbs, 12/6/17 at 115 lbs, and 12/7/17 at 122.8 lbs. Review of resident #46's Quarterly MDS dated [DATE], did not show a weight loss or gain in section K0300 or K0310. Resident #46 had a weight of 122 documented in section K0200. Review of resident #46's Quarterly MDS dated [DATE], did not show a weight loss or gain in section K0300 or K0310. Resident #46 had a weight of 127 documented in section K0200. Review of resident #46's 30-day MDS on 7/14/17, did not show a weight loss or gain in section K0300 or K0310. Resident #46 had a weight of 138 documented in section K0200. Review of resident #46's 14-day MDS on 6/28/17, did not show a weight loss or gain in section K0300 or K0310. Resident #46 had a weight of 138 documented in section K0200. Review of the facility meal intake report for December 2017 showed that of the 42 meals, when the percentage eaten was documented, resident #46 ate 26 - 50% at two meals, and 51- 75% for 10 meals. There was no documentation provided for an alternate meal or supplement given later. Review of the facility meal intake report for January 2018 showed that of 45 meals, when the percentage was documented, resident #46 ate 0 -25% at one meal, 26 -50% at six meals, and 51 -75% at seven meals. During an interview with staff member Q on 2/6/18 at 3:10 p.m. he stated that he had not served resident #46 double portions. During an interview with staff member Z on 2/7/18 at 10:32 a.m., she stated that if there is a five pound weight difference the staff are to check the scale and reweigh the resident. During an interview on 2/7/18 at 3:15 p.m. staff member J stated she documented that day that resident #46 did not want double portions and would like peanut butter and jelly sandwiches very often. She stated she had spoken to resident #46 prior to when she first ordered the double portions, but he had told her he did not want double portions, and she had forgotten to document that until today. Staff member N was interviewed on 2/7/18 at 2:00 p.m. regarding resident #46 weight loss. Staff member N stated that resident #46's dementia was worsening and could be the cause of the weight loss. He further stated he does not remember any notification on the weight loss and does not remember speaking about this with staff recently. Staff member N stated he and the staff did speak of the weight loss for resident #46 that morning. Staff member N stated he was at the facility weekly, and his NP (Nurse Practioner)was at the facility every day. During an interview with staff member B on 2/6/18 at 3:45 p.m., she stated the Dietitian brings any weight concerns to nursing, they then have a weight meeting to discuss changes for those residents and discuss skin issues as well. Resident #46 continued to lose weight. The facility failed to follow up with the weight loss, to introduce new interventions since 10/17/17, and to notify the physician of the continued weight loss.

Based on record review, interview, and observation, the facility failed to notify the physician, for a severe weight loss for 2 (#s 19 and 46) of 27 sampled residents which resulted in harm. Findings include: 1. Resident #46 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of resident #46's care plan showed the resident was independent with eating, did not wear his dentures, needed help cutting meat, needed assistance in picking out menu items, and liked to have peanut butter and jelly sandwiches on occasion. A review of resident #46's dietician's progress note, dated 9/18/17, showed BOOST (nutritional supplement) was ordered at bedtime for weight loss. No physician notification was made regarding the weight loss. A review of resident #46's dietician's progress note, dated 10/17/17, showed BOOST TID was ordered for weight loss. No physician notification was made regarding the continued weight loss. A review of resident #46's dietician's progress note, dated 11/25/17, showed double portions for meals were ordered due to continued weight loss. The weight loss was documented as 16% loss in five months. The dietician noted to continue to monitor. The physician was not notified of the weight loss. A review of resident #46's dietician's progress note, on 12/27/17, showed staff member J documented BOOST q PM: question of receiving: increased BOOST TID at meal on 10 - 31: Order was not been entered (sic) into PCC. Confirmed with the kitchen to ensure he is receiving at all meals. Staff member J also documented an 11% weight loss in six months and to monitor weights. The physician was not notified of the weight loss and no new interventions were put in place. A review of resident #46's dietician's progress note, on 1/12/18, showed staff member J documented, continued questioning if receiving BOOST TID and at pm. Staff member J documented a 13% weight loss in six months, requested a reweigh of the resident, and to continue current interventions. The physician was not notified of the weight loss and no new interventions were put in place. A review of resident #46's dietician's progress note, on 2/6/18, showed staff member J documented resident #46's weight is stabilizing at 115 - 118 lbs since October after experiencing a weight loss of 13% from July. Staff member J documented the RD to continue to monitor, no new interventions were put in place. A review of resident #46's weight record showed the following: on 7/31/17 at 133 lbs, 9/13/17 at 120.5 lbs, 9/17/17 at 125.8 lbs, 9/15/17 at 127.2 lbs, 9/15/17 at 124 lbs, 10/4/17 at 118 lbs, 10/5/17 at 118 lbs, 11/1/17 at 115 lbs, 12/4/17 at 119.4 lbs, 12/6/17 at 115 lbs, and 12/7/17 at 122.8 lbs. During an interview on 2/6/18 at 3:45 p.m., staff member B stated the Dietician brings any weight concerns to nursing, they then have a weight meeting to discuss changes for those residents, and discuss skin issues as well. During an interview on 2/7/18 at 2:00 p.m., staff member N stated that resident #46's dementia was worsening and could be the cause of the weight loss. Staff member N also stated he does not remember any notification on the weight loss for resident #46. Staff member N does not remember speaking about the weight loss with staff recently. Staff member N stated the weight group would bring issues regarding weights to the QAPI meeting. Staff member N stated he and the staff had discussed the weight loss for resident #46 that morning. Staff member N stated he was at the facility weekly and his NP (Nurse Practioner) was at the facility every day. 2. Resident #19 was admitted with [DIAGNOSES REDACTED]. Review of resident #19's Initial MDS, with an ARD of 8/24/17, showed the resident had a BIMS of 14 meaning he was cognitively intact. Review of resident #19's weights showed the following: - On 10/14/17 the resident weighed 95 lbs, - On 11/1/17 the resident weighed 82 lbs, - On 1/3/18 the resident weighed 81 lbs. This was a severe weight loss of 13% in one month, with a severe loss of weight of 14% in three months. A document request was presented to the facility on [DATE] at 10:00 a.m., for physician notification of the severe weight change for resident #19. This documentation was not provided. During an interview on 2/6/18 at 1:51 p.m., staff member J stated she was aware of resident #19's weight loss. She stated the resident had been provided a Boost supplement for the weight loss. Staff member J stated she became aware of the resident's weight loss in December of 2017. She stated she was not notified by the nursing staff of changes in the resident's weights, and she was not sure if the physician had been notified of the weight change. She stated it was the expectation to notify the physician of weight change in a resident. During an interview on 2/7/18 at 11:00 a.m., staff member H stated if any resident had weight changes she would notify the dietician, family, and the provider. During an interview on 2/8/18 at 8:11 a.m., staff member B stated when a weight change was identified, the aides were to notify the nurse or the DON promptly. The dietician was to report to the DON on any weight changes, as well as notify the physician. Staff member B stated, it was a process which needed improvement. A review of the facility's policy and procedure titled, Weight Assessment, showed, The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. 2. The physician and the multidisciplinary team will identify conditions and medication that may be causing anorexia, weight loss or increasing the risk of weight loss.

Based on interview and record review, the facility failed to ensure the resident was free of a significant medication error. Specifically, 1 (#9) resident experienced adverse consequences due to not receiving a medication for her anxiety symptoms out of 19 sampled residents. Findings include: Resident #9 was admitted with [DIAGNOSES REDACTED]. During a meal time observation on 10/17/16 at 12:30 p.m., resident #9 reported a concern that her anxiety medication was not available last night and still not on this day. During an interview on 10/17/16 at 3:20 p.m., staff member AA stated resident #9 asked for her [MEDICATION NAME] for her anxiety and there was none available. She stated she called the pharmacy as the medication was not stocked in the emergency medication kit. She stated the pharmacy told her it would be sent in the next tote in the afternoon. Staff member AA stated the medication did not arrive in the next tote, so she called the pharmacy and was told a new written prescription was needed. She stated the pharmacy did not inform her they needed a new written prescription the first time she made the request. She stated she went to the physician assistant and requested a written prescription. She stated once that was completed the pharmacy would deliver the medication by courier. Staff member AA stated their was a history with not receiving medications in a timely manner from the pharmacy after requests were made. She stated most times she called she talked with a different pharmacy person. She gave an example of another resident who did not receive her [MEDICAL TREATMENT] renal medication for 5-6 days due to the pharmacy not following through. Review of the resident's narcotic sign-out sheet reflected the last dose of [MEDICATION NAME] given was on 10/15/16 at 8:10 p.m. The card count reflected that was the last two pills in the bubble pack. Review of the resident's Medication Administration Record [REDACTED]. The resident's order was increased on 10/10/16 to 0.25 mg-0.50 mg BID. During an interview on 10/19/16 at 3:15 p.m., staff member C stated the nurse that administered the dose on October 15th should have reordered the medication. She stated if the medication was unavailable staff are told to call, and if it continues to be a problem they are to notify the physician. She stated the facility would be changing the way medications were ordered. During an interview on 10/19/16 at 2:15 p.m., resident #9 stated she was ready to go through the roof without her [MEDICATION NAME]. The resident stated she had gone without her [MEDICATION NAME] this week for 40 hours because she was told it wasn't available. She stated she was picking at her fingers and was shaky. She stated she asked for it and was told there wasn't any. She stated, I stayed in my room. My whole insides were shaking and I was feeling helpless and hopeless. It made my pain worse because my muscles got tight.

Based on observation, interview and record review, the facility failed to provide services to prevent the development of an infected pressure ulcer; treated with no physician orders for which required immediate surgery after a wound clinic appointment one (#9), and failed to prevent the emergence of a stage four pressure ulcer for one (#5) of 17 sampled residents. IMMEDIATE JEOPARDY The facility failed to provide adequate services to prevent the development of a stage three pressure ulcer and then failed to prevent that pressure ulcer from progressing to a stage four pressure ulcer for resident #9. The facility failed to develop a plan of care based on the resident's stage three pressure ulcer. The facility failed to prevent a nurse from administering treatment to the pressure ulcers without a physician's order. The facility failed to notify and document the notification to the physician or physician's assistant in a timely manner. The facility failed to address a resident's pain prior to treatment of [REDACTED]. On 12/17/15 at 2:07 p.m., the facility administrator was notified that an immediate jeopardy situation existed for 2 of 17 sampled residents in the areas of pressure ulcers (resident #9) and weight loss (resident #15). PLAN TO REMOVE THE IMMEDIACY OF THE SITUATION The facility submitted an acceptable plan to remove the immediate jeopardy on 12/18/15 at 4:40 p.m. A summary of the facility's abatement plan to remove the immediate jeopardy included: 1) Full air mattress was put in place. 2) A turn and position protocol was put in place. 3) The care plan was updated to address and provide a list of alternatives if she refuses an outlined course of treatment. 4) The physician has assessed the resident's pain and has increased the frequency of the resident's pain medications. 5) The physician has consulted with the resident's rheumatologist and made medication changes. 6) The resident has been placed on a 1:1 for assistance with eating and to ensure supplements are being offered and to ensure the resident is getting the assistance she needs. Once the immediacy was removed, the severity and scope remained at a G. Findings include: 1. Resident #9 was admitted to the facility with [DIAGNOSES REDACTED]. WOUND During the initial tour on 12/14/15 at 1:15 p.m., staff member F stated resident #9 had a pressure ulcer, but was unsure of the location. Staff member F stated the pressure ulcer was contaminated with a [MEDICAL CONDITION] (MRSA) infection. A review Resident #9's Client Confidence Sheet, completed on 11/6/15, showed the resident's skin was intact, but that her buttocks were red. Review of Resident #9's Braden Scale for Predicting Pressure Sore Risk, dated 11/6/15, showed staff scored the resident at 18, a low risk for pressure sores. The document read, Pt already has red skin to buttocks. Pt encouraged to lay on their side in bed instead of buttocks. Pt encouraged to ask for assistance as needed. Review of Resident #9's Admission MDS Record, section M with an ARD 11/12/15, showed no pressure ulcers were present. Review of Resident #9's COMS Interactive Program notes, dated 11/16/15, showed the resident's skin was intact. Review of Resident #9's Weekly Wound Documentation, dated 11/18/15, showed staff identified the resident had two pressure sores on the right and left heels. The pressure ulcer on the right heel was 2 cm in length, 1.6 cm wide, and 0 cm deep. The pressure ulcer on the left heel was 1.8 cm in length, 1.9 cm wide, and 0 cm deep. Review of Resident #9's 14 Day MDS, section M with an ARD of 11/19/15, showed two unstageable (deep tissue) pressures ulcers. During an interview on 12/15/15 at 11:00 a.m., staff member C stated resident #9 was admitted , with her skin intact. She stated the physician assistant ordered wound care on 12/2/15 for the wound on resident #9's coccyx area. Staff member C also stated the physician ordered a culture for the pressure ulcer on the coccyx area on 12/10/15. During the interview, staff member C was reviewing the physician's orders and stated per the nurses notes, the wound care did not start until 12/11/15, nine days after the order was received. During an interview on 12/16/15 at 8:58 a.m., staff member F stated that during the care plan meeting for the resident, her skin issues were not discussed. Staff member P stated the care plan meeting focused on discharge planning and the skin issues were not a topic discussed. Review of Resident #9's Care Plan, dated 11/20/15, reflected the resident was at risk for pressure/venous/stasis ulcers due to being a diabetic (DM) type II. The care plan reflected the facility would monitor for skin changes-redness, circulatory problems, breakdown, and report to MD. The date to be initiated was 11/19/15. The care plan identified the resident's skin was intact as of 11/19/15. Interventions were identified as: 1. I want staff to monitor for any potential skin breakdown. 2. I require to be turned and repositioned every 2-3 hour PRN. 3. I require extensive assist of 1-2 staff with bed mobility. 4. I have a pressure relieving pad on my chair. 5. I have a pressure relieving mattress on my bed. 6. My skin will be observed at least weekly during my bathing process and notify nurse of any concerns. The facility did not update the care plan to reflect the resident's wounds and wound treatments. Review of Resident #9's Weekly Wound Documentation Form dated 11/23/15, showed two wound locations on the resident's body, located on her right and left heels. Review of Resident #9's electronic health records dated 11/27/15, showed that the resident was having skin issues on both heels and that they were unstageable. The note showed a pressure reducing device was in place for the resident's chair. Review of Resident #9's electronic health records dated 11/29/15, showed the resident's skin had open [MEDICAL CONDITION], the skin issue location was the coccyx area and was identified as a stage III: Full thickness skin loss. The pressure ulcer was described as nickel sized pressure ulcer located on coccyx, wound nurse notified. Review of Resident #9's weekly wound documentation form dated 11/30/15, showed the resident's two pressure ulcers on the right and left heels were present. The report showed a sacrum pressure ulcer was a stage III and measured 1.3 cm long, .8 cm wide, and 2 cm deep. During interviews on 12/15/15 at 1:35 p.m. and 3:40 p.m., staff member K stated resident #9 had two pressure ulcers on her heels. Staff member K stated the pressure ulcers developed two weeks prior to the pressure ulcer on her coccyx area. Staff member K stated the ulcer on the left heel started out as a blister and then burst opened, and both heel ulcers were a stage II because one was a blood blister. The staff member stated that the ulcers appeared post admission. Review of Resident #9's Physician/Prescriber Orders dated 12/2/15, reflected verbal orders were obtained from the physician for wound orders, instructing that the sacrum area dressings were to be changed daily, and in PM if the dressing falls off. The heels were to be offloaded with foam. Review of Resident #9's TAR (treatment administration record) dated 12/1/15-12/15/15, showed the resident was to keep heels offloaded with foam, change weekly every Monday, starting 12/14/15. The TAR showed wound care orders for the sacrum: [MEDICATION NAME], border dressing, change daily and PRN if soiled. The order was started on 12/3/15 and d/c'd on 12/7/15. The TAR showed orders for silver alginate to fill wound, cover with alginate and then border dressing to be changed daily x 1/day starting on 12/11/15. Review of Resident #9's Weekly Medicare meeting Notes from the facility dated 12/03/15, showed a wound having yellow drainage with an odor. The notes showed there was a large piece of yellow slough extruding from the wound. Staff member K made a note that the resident needs to be seen at a community health care facility. The note revealed the resident has two stage II on heels and sacrum is a stage III. Review of Resident #9's EMR nursing progress notes dated 12/4/15, showed, PT has had a large amount of serosanguinous drainage from sacral wound. It was remeasured today because it looked deeper than earlier this week. It is 1.5 cm deep now, has undermining from 12-12 with the deepest depth at 1200 of 3 cm. Review of Resident #9's Physician/Prescriber Orders dated 12/4/15, reflected verbal orders were obtained from the physician for wound care to the sacral wound: [MEDICATION NAME], silver alginate and boarder dressing to be changed daily and PRN. Review of Resident #9's weekly wound observation dated 12/07/15, showed a wound to the sacrum area measuring 1.5 cm in length, 1 cm in width, 1.5 cm in depth, and a stage III. Review of Resident #9's Physician/Prescriber Orders dated 12/7/15, reflected verbal orders were obtained by staff member K from the physician's assistant for cashe soak with dressing change; [MEDICATION NAME] 8 oz PO BID with meals (dietary); liquacel, 1 oz. PO BID with meals (nursing); referral to community health clinic for sacral wound. Review of Resident #9's weekly wound observation dated 12/14/15, showed a wound to the sacrum area measuring 2 cm in length, 1.8 cm in width, 1.5 cm in depth, and a stage III. Review of Resident #9's progress note dated 12/14/15, showed the physician's assistant stated the culture on the resident's pressure ulcer was positive [MEDICAL CONDITION], and the resident was ordered [MEDICATION NAME] for treatment. The progress note showed, resident is doing very poorly about keeping herself off of it. The resident had a stage III pressure ulcer of the sacrum that the wound nurse was following. Patient continues to be noncompliant about staying off her bottom. She needs to be reminded consistently. A review of the facility's electronic health records dated 12/14/15, nursing staff stated the resident was lying sideways in bed on back, was wet from urine, stated she did not call for help because she was on her light too much. She was reminded again about importance of staying on side. During an observation on 12/15/15 at 7:45 a.m., resident #9 was observed lying in bed, flat on her back. On the bed was a pressure relieving pad. A meal tray was on her bedside table. The food on the tray included oatmeal, bacon, and toast. The resident had not eaten. During an interview on 12/15/15 at 7:45 a.m., resident #9 stated staff had not been in her room to sit her up to eat her food. During an interview on 12/15/15 at 8:47 p.m., resident #9 stated she did not consume any of her breakfast and staff had not assisted her to sit up. During an interview on 12/15/15 at 8:50 a.m., staff member N stated resident #9 refused to eat her meal so staff removed the tray from her room. Review of a dietary note, dated 12/7/15, showed that wound was discussed with staff member K, who is initiating additional nutrition interventions beyond the Boost Breeze TID, and Bit C 500 mg already in place. Specifically Liquicel 1 oz BID and [MEDICATION NAME] BID. During an observation on 12/15/15 at 11:10 a.m., resident #9 was observed sitting up in her wheel chair with staff present. The resident was being asked questions about the meal she would prefer for lunch. The resident was struggling to identify what she would like to eat for her lunch. Review of Resident #9's TAR dated 11/1/15-11/30/15, showed the resident was to receive house protein supplements (beginning 11/9/15) TID with meals for health maintenance. The amount the resident was to receive was not specified. The TAR showed that resident received the protein supplement at 1700 on 11/9/15, 0800 on 11/10/15 and 1200 on 11/10/15. The TAR showed these were the only times the supplement was given to the resident. The TAR showed the resident was to get Boost Breeze (beginning 11/9/15) PRN as a meal replacement. The resident received Boost zero times for dates 11/1/15-11/30/15. No documentation was located showing the dietician had looked further into additional nutritional interventions such as assisting with meals, food likes and dislikes. During interviews on 12/15/15 at 1:35 p.m. and 3:40 p.m., staff member K identified herself as the person responsible for providing care for the wound on resident #9's coccyx. Staff member K stated the resident had a stage III pressure ulcer. Staff member K stated the wound was not down to the bone, but it was very close. Staff member K stated the first time she saw the wound it was a stage II, but she did not think it was finished developing. Staff member K stated the first she heard of the ulcer, she recalled the information being verbally passed along to her through the night staff. Staff member K stated the report she got from the night staff was the resident had a hole. Staff member K stated when she initially went to assess the wound, it wasn't much of anything but the next time I looked at it, I have never seen such a perfect round hole. It was about 5 cm and there was undermining in reference to the wound located on resident #9's sacrum area. During an interview on 12/16/15 at 9:21 a.m., with contractor B and staff member B reported that staff member K assessed and made the decisions on all wounds in the facility, but staff member K was not a certified wound nurse. Contractor B stated that staff member K would discuss the wounds and treatments with both with her and contractor A. The discussion of wounds in the facility were verbally discussed, but typically were not recorded because contactor A and contractor B encouraged staff member K to do whatever she thought was best. Contactor B also reported that staff member K initiated treatment and requested the orders afterwards from contractor A or contractor B at a later time. During an interview on 12/17/15 at 9:50 a.m., the medical director/physician stated meetings were held every Thursday to brief him on wound treatments that had been initiated and any wound updates. The physician stated if staff member K had questions, the community wound doctors were consulted. The physician stated written standing orders for wounds was not typical, staff member K had a specialized knowledge base in wounds and would begin treatment to the wounds when she though it was necessary. When asked if staff member K had completed a certified wound program with a completion certificate, the physician said that the staff member had not completed a program. During an interview on 12/16/15 at 2:37 p.m., staff member K stated that while she attended the wound clinic appointment with resdient #9, the wound doctor called a plastic surgeon to consult about the wound on resident #9's coccyx area. Staff member K stated the wound doctor thought it was pertinent to get the resident into surgery and place a wound vac on the wound immediately. Review of Resident #9's Comprehensive Note from a local wound clinic dated 12/16/15, showed the resident had a Stage IV sacral decubitus pressure ulcer with very significant undermining approximately 5-6 cm radically from a quarter-sized opening. The report showed there was significant necrosis deep to the skin flap and the resident required wide debridement. The note showed the plan for the resident to be taken to the operating room and saucerize the wound under general anesthesia and place a wound VAC for proper wound management and hopefully long term healing. Review of resident #9's Operative Report from a local wound care facility, dated 12/16/15, showed the preoperative and postoperative [DIAGNOSES REDACTED]. The report showed the procedure included debridement of a sacral decubitus pressure ulcer to the level of bone. The report included the operative indications included patient present with new extensive sacral pressure ulcer with very extensive undermining radially from approximately 7 o'clock to 4 o'clock extending 6 or 7 cm from the actual opening. The description of the procedure included, general endotracheal anesthesia was administered, and then resident was flipped prone. A circumferential incision was created around the quarter-sized opening. The incision diameter was approximately 8 cm in order to encompass the majority of the undermining and then necrotic fat, fascia, and sacrum were debrided using forceps, scissors, and pulse lavage irrigation to remove the extensive nonviable tissue necrosis and slough back to healthy bleeding tissue. PAIN During an observation on 12/16/15 at 8:29 a.m., resident #9 was laying in her bed on her back. Staff member K entered the room to dress the resident's wound. The resident was placed on her side by staff member K and was stating, ow ow ow. Resident was compliant with the dressing change, but was making scowling facial gestures. Resident #9 began breathing deep and asked staff member K to stop pushing her on her shoulder because of the amount of pain she was experiencing. When staff member K attempted to finish dressing the wound, the resident exclaimed, stop doing that! Staff member K asked, does that hurt? The resident replied, yes! During the same observation, resident #9 took off the oxygen tubing and stated that the tubing hurt her ears because there was no protection pad on the tubing and it was rubbing on her ears. In reference to the non-compliance of staying off back side, staff member K stated she thought the resident was not staying off her backside because the pressure on resident's shoulders caused pain and made it very difficult to find comfort lying on her side. Staff member K stated, resident is not being ignorant, just wants to be comfortable. Review of Resident #9's Admission Assessment in the electronic health records, dated 11/6/15, reflected that the resident had a Pain Score of 8 out of ten and was listed to have severe pain of the lower back, knees, wrists, shoulders, neck and fingers. Non-Medical Pain Intervention included: distraction, change in position, relaxation techniques. Medical Interventions included PRN pain medications. Review of Resident #9's Nursing Progress Notes, dated 11/12/15, showed Resident #9's was constantly in pain, at a level 9 (increase), and was also on [MEDICATION NAME] and [MEDICATION NAME] TID for pain. The pain affected ADL's. The floor staff and therapy staff were utilizing non-medication interventions to help relieve the pain. The record identified the resident was spending the majority of time in bed and in the wheel chair, which increased the risk for skin breakdown. The record showed the resident was admitted with low risk for skin breakdown and the skin was intact at this time. Review of resident #9's EMR, a note dated 11/19/15, showed the resident was seen by the physician assistant for concerns about poorly controlled pain. Review of the care plan dated 11/20/15 showed a focus area of pain. The plan showed the resident had a history of [REDACTED]. The interventions implemented on the care plan were identified as followed: 1. Please observe for signs and symptoms of pain or discomfort and report to the nurse. 2. Please try these non-pharmacological treatments: apply heat, apply ice, rub the affected area, reposition, apply pillows, distraction, relaxation, IFC. 3. Please provide me with pain medications as ordered. 2. Resident #5 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. During an observation and interview on 12/15/15 at 9:00 a.m., staff member K provided wound care to resident #5's left heel. Staff member K stated the resident had had the pressure sore for almost a year. She said the wound clinic gave up on healing and discontinued service. She said the wound had come close to healing, and then resident #5 got sick, so the wound got sick, too. Review of the resident's nursing progress note dated 1/20/15 showed an unstageable pressure ulcer with eschar,was discovered on resident #5's left heel. During an interview on 12/16/15 at 1:00 p.m. , staff member B stated she did not have documentation to show skin checks were completed for the resident in January, or preventive measures to prevent skin breakdown. She stated the long term care area did not have a process for a head to toe skin check. She also stated two staff members were disciplined because of the pressure area being discovered at a stage four. Resident #5 continued to require treatment for [REDACTED]. I sure wish this thing would heal up.

Based on observation, record review and interview, the facility failed to prevent a severe weight loss of 15.4%, in less than one month, for 1 (#15) of 17 sampled residents and failed to show alternate interventions were attempted for the resident who would not eat the provided meals. IMMEDIATE JEOPARDY The facility failed to provide adequate services to prevent a severe weight loss of 15.4% in less than one month for 1 identified resident. The facility failed to develop a plan of care based on the resident's physical limitations, cultural food preferences, and documentation of weight loss. The facility failed to notify and document the notification to the physician or physician's assistant in a timely manner. On 12/17/15 at 2:07 p.m., the facility administrator was notified that an immediate jeopardy situation existed for 2 of 17 sampled residents. PLAN TO REMOVE THE IMMEDIACY OF THE SITUATION The facility submitted an acceptable plan to abate the immediate jeopardy on 12/18/15 at 4:40 p.m. A summary of the facility's abatement plan to remove the immediate jeopardy was as follows: 1) Weighing protocol to be consistent (without brace). 2) Physician to closely monitor weekly weights. 3) Registered Dietician recommended Boost supplement with every meal. 4) Physician consulted regarding appetite stimulant, protein supplements, or other interventions. 5) Cultural food alternatives will be offered. 6) Care plan updated to address weight loss, alternatives, and interventions. 7) Care plan will be updated accordingly based on the success or failure of the alternatives. Once the immediacy was removed, the severity and scope remained at a G. Findings include: 1. Resident #15 was admitted to the facility with [DIAGNOSES REDACTED]. During an observation on 12/15/15 at 8:15 a.m., resident #15 was seated in her wheelchair in the Yellowstone dining room. She was attempting to eat scrambled eggs and toast. Her wheelchair was positioned with her left side next to the dining table. She was having to reach across her body, with her right hand, to get food on her fork. She was not being assisted by staff to eat. During an observation on 12/16/15 at 12:35 p.m., resident # 15 was in the Yellowstone dining room. Her wheelchair was positioned with her left side closest to the dining table. She had ground food on her plate. She was not being assisted by staff to eat. During an observation on 12/17/15 at 8:30 a.m., resident #15 was in the Yellowstone dining room. Her wheelchair was not positioned with her feet under the table. She was attempting to eat right handed. Staff were not seated at the table and resident #15 did not have any staff assistance while eating. Review of resident #15's weight record showed her admission weight, on 11/18/15, to be 126.5 pounds. Her weight on 12/1/15 was 119 pounds which showed a loss of 7.5 pounds, or a 5.9% weight loss. Her weight on 12/11/15 was 108 pounds which indicated a loss of 18.5 pounds, or a 14.6% weight loss. Her weight was taken again on 12/15/15 and was recorded at 107 pounds which showed a loss of 19.5 pounds, or a 15.4% weight loss since her admission to the facility. A 10% or greater weight loss in six months is classified as a severe weight loss. During an interview, 12/17/15 at 1:15 p.m., contractor C said she did not put much stock on the weights taken by the facility since she, contractor C, did not know if the weights were done with the resident's braces off or on, or if the resident was in a wheelchair or a Hoyer lift. The contractor C said she was not concerned by resident #15's weight loss because of the injuries, braces, fluid retention and pain. Contractor C said she thought resident #15's weight was 130 pounds when she was admitted to the hospital on [DATE]. Contractor C said resident #15 did not like to eat the white man's food. Review of the form titled RD Nutritional Assessment Updated and dated 11/27/15, showed the current diet for resident #15 to be, regular diet, mechanical texture, regular consistency. The assessment goes on to state resident #15's food intake, at meals, was between 25% and 50% and her fluid intake was 120 ml to 240 ml at meals. Documented under the section of the assessment titled Analysis, Diet and Care Plan Review, section e. Nutrition Diagnostic Statements: (Problem, Etiology, Signs/Symptoms), showed the resident had increased nutrient needs, R/T needs for healing, and AEB risk of loss of skin integrity. Section f. Nutrition Intervention: (Recommendation/Plan) showed the resident was to have diet as ordered, and follow appetite, weight and skin per facility routines. Also, the family was allowed to bring in extra foods to her preference. The dietician's analysis showed the resident had started to go to the dining room to eat and her appetite appeared to be picking up. The dietician completed his assessment on 11/27/15. The registered dietician's assessment failed to address resident #15's food preferences. Review of a contractor C's progress note dated 11/19/15, showed resident #15 needs to be helped to be fed. Review of a physician progress notes [REDACTED].#15 to have malnutrition of moderate degree. The physician noted resident #15 was to continue with a regular soft diet. Further review of physician progress notes [REDACTED].#15's severe weight loss. Review of physician orders [REDACTED].#15. Review of nursing progress notes, from 11/18/15 to 12/17/15, did not show the physician, physician's assistant, the medical director, or the registered dietician had been notified of a severe weight loss for resident #15. The review showed the registered dietician did not participate in any team meetings that could have addressed resident #15's weight loss. Review of resident #15's care plan focus area for Diet/Eating showed the goal for resident #15 was I want to be able to feed myself again. The interventions for resident #15 were; My current diet is mechanical soft and I require limited to extensive assistance with eating. The care plan for resident #15 did not include any goals or interventions for her severe weight loss. The care plan did not address resident #15's dietary preferences.

Based on record review and interview, the facility failed to notify the physician or physician's assistant of a severe weight loss for 1 (#15) and worsening of pressure ulcers for 1 (#9) of 17 sampled residents. Findings include: 1. Resident #15 was admitted to the facility with [DIAGNOSES REDACTED]. Review of resident #15's weight record showed the following weights: -on 11/18/15 she was 126.5 pounds -on 12/1/15 she was 119 pounds -on 12/11/15 she was 108 pounds -on 12/15/15 she was 107 pounds. Resident #15 experienced a severe weight loss of 15.4% in less than one month. Review of nursing progress notes, from 11/18/15 to 12/17/15, did not include any documentation of notification to the physician or physician's assistant of resident #15's weight loss. Review of the physician, and the physician's assistant progress notes dated 11/19/15, 11/23/15, 11/25/15, and 12/9/15 showed lack of notification by the facility's nursing staff, of the weight loss being experienced by resident #15. During an interview on 12/17/15 at 1:15 p.m., contractor C said the facility had not notified her of the resident's severe weight loss. 2. Review of Resident #9's weekly wound document dated 11/18/15, showed the resident had a breakdown of the right and left heels. Staff member K initiated treatment to include a dogbone and foam. During an interview on 12/16/15, staff member B stated that staff member K assesses and makes decisions on wounds. Staff member B stated that staff member K talks with the physician assistant and the physician weekly to update them on the current wound treatments in the facility. During an interview on 12/16/15 at 9:21 a.m., contractor B stated staff member K started treatment when the wounds were first noticed and notified the physician and physician's assistant the next time communication took place. Review of resident #9's nursing progress notes, dated 11/6/15-12/17/15, showed staff member K did not notify the physician's assistant or the physician immediately of the worsening conditions of the pressure ulcers on the heels and coccyx area.

Based on observation, record review, and interview, the facility neglected 2 (#s 9 and 15) of 17 sampled residents. The facility failed to intervene in resident #15's severe weight loss by not assisting the resident with eating as care planned and identified by the 14 day MDS assessment, since the resident had a limited upper extremity range of motion, and by not addressing the resident's dietary preferences. The facility failed to prevent a stage three pressure ulcer and prevent the worsening of a stage three to a stage four pressure ulcer; failed to address the resident's pain prior to and while receiving wound dressing changes; and failed to address why a resident would not stay repositioned on her side to assist with the prevention of pressure ulcers for resident #9. Findings include: 1. Resident #15 was admitted to the facility with [DIAGNOSES REDACTED]. Review of resident #15's weight records showed the following: -on 11/18/15 she was 126.5 pounds; -on 12/1/15 she was 119 pounds; -on 12/11/15 she was 108 pounds; -on 12/15/15 she was 107 pounds. Resident #15's weight record showed a 15.4% weight loss in one month. A weight loss of 10% or more in a six month period is classified as a severe weight loss. During an interview on 12/17/15 at 1:15 p.m., contractor C said resident #15 did not like to eat the white man's food. Contractor C said she did not put much stock on the weights taken by the facility since she, contractor C, did not know if the weights were done with the resident's braces off or on, or if the resident was in a wheelchair or a Hoyer lift. Review of nursing progress notes from 11/18/15 to 12/17/15, showed the facility failed to notify the physician, physician's assistant, or registered dietician of resident #15's weight loss. The review also showed the registered dietician did not participate in any team meetings that would have addressed resident #15's weight loss. Review of a physician's assistant's progress note dated 11/19/15, showed resident #15 needs to be helped to be fed. Review of resident #15's 14 day MDS assessment, with an ARD of 12/2/15, section G, G0110 H., reflected the resident needed extensive physical assistance of one staff when eating. Review of resident #15's care plan focus area for Diet/Eating showed the goal for resident #15 was, I want to be able to feed myself again. The interventions for resident #15 were, My current diet is mechanical soft and I require limited to extensive assisstance (sic) with eating. The care plan for resident #15 did not include any goals or interventions for her severe weight loss. The care plan did not identify any dietary preferences for resident #15. Review of the form titled RD Nutritional Assessment Updated, dated 11/27/15, failed to show the registered dietician had addressed resident #15's dietary preferences. During observations on: -12/15/15 at 8:15 a.m., resident #15 was seated in her wheelchair in the Yellowstone dining room. She was attempting to eat scrambled eggs and toast. Her wheelchair was positioned with her left side next to the dining table so she was having to reach across her body to get food on her fork. She was not being assisted by staff to eat. -12/16/15 at 12:35 p.m., resident # 15 was in the Yellowstone dining room. Her wheelchair was positioned with her left side next to the dining table. She had ground up food on her plate. She was not being assisted by staff to eat. -12/17/15 at 8:30 a.m., resident #15 was in the Yellowstone dining room. Her wheelchair was not positioned with her feet under the table. She was attempting to eat right handed, reaching across her body. She was positioned with her left hand side next to the table. Staff were not seated at the table, and resident #15 did not have any staff assistance while eating. -12/17/15 at 4:30 p.m., resident #15 was lying flat on her bed. The bedside table, placed next to the bed, had an opened package of crackers and an opened soda sitting on it. Due to the resident's limited mobility and range of motion, the bedside table, crackers, and drink were not in resident #15's reach. No staff were observed in the resident's room to offer assistance to the resident if she wanted to eat. 2. Resident #9 was admitted to the facility with [DIAGNOSES REDACTED]. a) Review of resident #9's admission MDS, with an ARD of 11/12/15, Section M, M0150 showed the resident was at risk for pressure ulcers, M0210 showed resident #9 had no unhealed pressure ulcers at the time of the assessment. Review of Resident #9's 14 Day MDS, with an ARD of 11/19/15, Section M, M0210 showed the resident had developed two pressure ulcers. M0300G section 1, showed both pressure ulcers to be deep tissue injury and unstageable at that time. Review of Resident #9's Braden Scale for Predicting Pressure Sore Risk (revised), dated 11/6/15, showed that the Resident scored an 18 and was at low risk for pressure sores. The document read, Pt already has red skin to buttocks. Pt encouraged to lay on their side in bed instead of buttocks. Pt encouraged to ask for assistance as needed. Review of resident #9's Client Confidence Sheet (temporary care plan) completed on 11/6/16, showed the resident's skin was intact, but that her buttock was red. Review of resident #9's Care Plan, dated 11/20/15, showed the resident was at risk for pressure/venous/stasis ulcers due to being a diabetic (DM), type II. The care plan showed the facility would monitor for skin changes-redness, circulatory problems, breakdown, and report to MD. The date to be initiated was 11/19/15. The care plan identified the resident's skin was intact as of 11/19/15. Interventions were identified as: 1. I want staff to monitor for any potential skin breakdown. 2. I require to be turned and repositioned every 2-3 hour PRN. 3. I require extensive assist of 1-2 staff with bed mobility. 4. I have a pressure relieving pad on my chair. 5. I have a pressure relieving mattress on my bed. 6. My skin will be observed at least weekly during my bathing process and notify nurse of any concerns. Review of Resident #9's electronic health record, dated 11/16/15, showed the resident's skin was intact. Review of Resident #9's Weekly Wound Documentation, dated 11/18/15, showed the resident had two identified pressure sores to the left and right heels. Review of Resident #9's nursing progress note, dated 11/29/15, showed the resident's skin had an open lesion on her coccyx area, and was identified as a stage III: Full thickness skin loss. The pressure ulcer was described as nickel sized pressure ulcer located on coccyx, wound nurse notified. Review of Resident #9's Weekly Wound Documentation form, dated 11/30/15, showed the resident's two pressure ulcers on the right and left heel were present. The report showed a sacral pressure ulcer (stage III) was present, and was being treated by the wound nurse with alginate and covered with a border dressing. Review of physician order's, dated 12/2/15, showed the wound nurse failed to get an order to begin treatmeant to the sacral wound until 12/2/15. Review of resident #9's progress note, dated 12/14/15, showed the physician's assistant stated the culture on the resident's pressure ulcer was positive [MEDICAL CONDITION] and the resident was being treated with [MEDICATION NAME]. Review of the resident's History and Physical, and the Discharge Summary from the hospital, did not show the resident had an history of [MEDICAL CONDITION] positive. During an observation on 12/15/15 at 7:45 a.m., resident #9 was observed lying in bed, flat on her back. A pressure relieving pad was on the bed. During an interview on 12/16/15 at 2:35 p.m., staff member R stated resident #9 had a pressure relieving mattress and pad but did not have an air mattress. During an interview on 12/16/15 at 9:21 a.m., contractor B and staff member B said, Staff member K assesses and makes the decisions on all wounds in the facility, but that staff member K was not a certified wound nurse. The discussion of wounds in the facility were verbally discussed, but typically would not get recorded because contractor B and contractor A encouraged staff member K to do whatever she thought was best. Contractor B reported that staff member K had initiated treatment and also requested the orders from contractor B at a later time for all residents that staff member K had treated for [REDACTED]. Review of resident #9's Comprehensive Note from a local wound clinic dated 12/16/15, showed the resident had a Stage IV sacral decubitus pressure ulcer with very significant undermining. The size of the wound was approximately 5-6 cm radically from a quarter-sized opening. The report showed there was significant necrosis deep to the skin flap and the resident required wide debridement. The note showed the plan for the resident was to be taken to the operating room and saucerize the wound under general anesthesia and place a wound VAC for proper wound management and hopefully long term healing. Review of Resident #9's Operative Report from a local wound care facility dated 12/16/15, showed the preoperative and postoperative [DIAGNOSES REDACTED]. During an interview on 12/17/15 at 9:50 a.m., contractor A said staff member K had not completed a certified wound program with completion certificate. b) Review of resident #9's Admission MDS, with an ARD of 11/12/15, Section J, J100 showed resident #9 was identified as having scheduled pain medications, PRN pain medications, and non-medical interventions. J400 showed that resident #9's pain was almost constant. J500 showed the pain the resident was experiencing affected her daily activities, and J600A showed the pain was rated with a score of 9 out of 10. Review of Resident #9's Admission Assessment in the electronic health records program, dated 11/6/15, showed resident #9 had a pain score of 8 out of 10, and was noted to have severe pain of the lower back, knees, wrists, shoulders, neck and fingers. Pain Intervention Non-Medical included: distraction, change in position, and relaxation techniques. Medical Interventions included PRN pain medications. Review of resident #9's admission orders [REDACTED] - [MEDICATION NAME] 100 mg, take 2 caps (200 mg) by mouth 3 times a day. - [MEDICATION NAME]-ocycodone 325 mg - 5 mg, take 1 tab by mouth every 6 hours as needed for pain. - Aleve, take 1 tab (220 mg) by mouth every 8 hours as needed for pain. - [MEDICATION NAME] 650 mg by mouth every 4 hours as needed for mild pain, headache or fever. - [MEDICATION NAME] ([MEDICATION NAME]) 5 mg by mouth 3 times a day as needed for mild to moderate pain. Review of resident #9's November 2015 MAR showed the [MEDICATION NAME] ([MEDICATION NAME]) 5 mg and the [MEDICATION NAME] 650 mg where not documented on the MAR. Review of the physician's orders [REDACTED]. Review of a physician's assistant progress notes from 11/9/15 did not document that the [MEDICATION NAME] ([MEDICATION NAME]) or the [MEDICATION NAME] 650 mg had been discontinued. Resident #9'[MEDICATION NAME] discontinued on 11/12/15 and was not replaced with another pain medication until 11/20/15. [MEDICATION NAME] 7.5 mg twice a day was added on 11/20/15 per review of the November 2015 MAR. Review of a physician's assistant progress note from 12/7/15 showed the physician had seen resident #9 on 11/19/15 to discuss the resident's concerns about poorly controlled pain. The physician prescribed [MEDICATION NAME] 7.5 mg twice a day at that time. During an interview on 12/16/15 at 2:37 p.m., staff member K stated she thought the resident was not staying off her backside because the pressure on the resident's shoulders caused her pain and made it very difficult to find comfort lying on her side. Staff member K stated, the resident is not being ignorant, she just wants to be comfortable. During an observation on 12/16/15 at 8:29 a.m., resident #9 was laying in her bed on her back. Staff member K entered the room to dress the resident's wound. The resident was placed on her side by staff member K. The resident was repeating the words, ow ow ow. The resident was compliant with the dressing change, but was making scowling facial gestures. Resident #9 began breathing deep and asked staff member K to stop pushing her on her shoulder because of the amount of pain she was in. When staff member K attempted to finish dressing the wound, the resident exclaimed, stop doing that! Staff member K asked, does that hurt? The resident replied, Yes! Review of the November and December 2015 MAR did not show a pain medication had been ordered to be administered to resident #9 prior to treatment of [REDACTED].

Based on observation, record review and interview, the facility failed to maintain the highest practicable well being for 2 (#s 9 and 15) of 17 sampled residents resulting in weight loss and worsening conditions of a pressure ulcer. Findings include: 1. Resident #15 was admitted to the facility with [DIAGNOSES REDACTED]. Review of resident #15's weight record showed the following weights: -on 11/18/15 she was 126.5 pounds -on 12/1/15 she was 119 pounds -on 12/11/15 she was 108 pounds -on 12/15/15 she was 107 pounds. The resident had a 15.4% weight loss in less than one month. A 10% or more weight loss in six months is categorized as a severe weight loss. The facility did not update the resident's care plan to reflect goals and interventions to decrease or prevent the weight loss experienced by the resident. Review of the care plan for resident #15 did not show her food preferences were addressed. The care plan showed the resident was to receive limited to extensive assistance while eating. During dining observations of resident #15 on 11/15/15 at 8:15 a.m., 11/16/15 at 12:35 p.m., 11/17/15 at 8:30 a.m., staff did not assist resident #15 while she was attempting to eat. The facility did not notify the physician, physician's assistant, or the registered dietician of the severe weight loss experienced by the resident. Review of the form titled RD Nutritional Assessment Updated dated 11/27/15, showed the registered dietician failed to address the resident's dietary preferences. During an interview on 12/17/15 at 1:15 p.m., contractor C said resident #15 did not like to eat food so culturally different than what resident #15 was accustomed to. 2. Resident #9 was admitted to the facility with [DIAGNOSES REDACTED]. Review of Resident #9's Admission MDS, with a ARD of 11/12/15, section C, C500, showed a BIMS of 14 which indicated the resident was cognitively intact, and Section C, C1300, showed the resident was not experiencing [MEDICAL CONDITION]. Section E, E800, reflected that resident #9 had not rejected care. Section G, G0110A, showed the resident needed extensive, two person physical assist for bed mobility. Section J, J100 showed resident #9 was identified as having scheduled pain medications, PRN pain medications and non-medical interventions. Section J400 showed that resident #9's pain was almost constant. Section J500 showed the pain the resident was experiencing affected her daily activities, and J600A showed the pain was rated with a score of 9 out of 10. Review of Resident #9's Admission Assessment in the electronic health records program, dated 11/6/15, reflected the resident had a pain score of 8 and was noted to have severe pain of the lower back, knees, wrists, shoulders, neck and fingers. Non-Medical Pain Intervention included: distraction, change in position, and relaxation techniques. Medical Interventions included PRN pain medications. Review of resident #9's admission orders [REDACTED] - [MEDICATION NAME] 100 mg, take 2 caps (200 mg) by mouth 3 times a day; - [MEDICATION NAME]-[MEDICATION NAME] 325 mg - 5 mg, take 1 tab by mouth every 6 hours as needed for pain; - Aleve, take 1 tab (220 mg) by mouth every 8 hours as needed for pain; - [MEDICATION NAME] 650 mg by mouth every 4 hours as needed for mild pain, headache or fever; and - [MEDICATION NAME] ([MEDICATION NAME]) 5 mg by mouth 3 times a day as needed for mild to moderate pain. Review of resident #9's November 2015 MAR indicated [REDACTED]. Review of the physician's orders [REDACTED]. Review of a physician's assistant progress notes from 11/9/15 reflected that the [MEDICATION NAME] ([MEDICATION NAME]) or the [MEDICATION NAME] 650 mg had been discontinued. Resident #9'[MEDICATION NAME] discontinued on 11/12/15 and was not replaced with another pain medication until 11/20/15. [MEDICATION NAME] 7.5 mg twice a day was added on 11/20/15 per review of the November 2015 MAR. Review of a physician's assistant progress note from 12/7/15 showed the physician had seen resident #9 on 11/19/15 to discuss the resident's concerns about poorly controlled pain. The physician prescribed [MEDICATION NAME] 7.5 mg twice a day at that time. Review of a physician's assistant progress note from 12/14/15 showed the PA had discussed with resident #9 the need to stay off of her back. The PA also documented, She acts like she has never been told to stay off of it when I talked to her about it (though I know that this is not the case.) During an interview on 12/15/15 at 11:00 a.m., staff member C stated that resident #9 was not compliant with staff requests for her to stay off her coccyx wound area. Review of Resident #9's Weekly Medicare Meeting Note dated 12/3/15, reflected staff member B noted that the resident was reminded to stay off of her back side. Review of Resident #9's Weekly Wound Documentation, dated 12/7/15, showed a note by staff member K reminding the resident to stay off of her back. Review of Resident #9's Weekly Wound Documentation dated 12/14/15 showed a note by staff member K stating that resident was reminded, again, about how important it was to stay on her side. The note showed that the physician's assistant also reminded the resident to lay on her side. During an observation on 12/16/15 at 8:29 a.m., the resident #9 was laying in her bed on her back. Staff member K entered the room to dress the resident's wound. Resident was positioned on her side by staff member K. The resident was repeating the words, ow ow ow. Resident #9 was compliant with the dressing change, but was making scowling, facial gestures. Resident #9 began breathing deep and asked staff member K to stop pushing her on her shoulder because of the amount of pain she was having. When staff member K attempted to finish dressing the wound, the resident exclaimed, stop doing that! Staff member K asked, does that hurt? The resident replied, Yes! Review of the November and December 2015 MAR indicated [REDACTED]. Review of resident #9's December 2015 MAR indicated [REDACTED] - [MEDICATION NAME] 7.5 mg by mouth twice a day. - [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg at 6 a.m., noon and twice a day prn for breakthrough pain. - [MEDICATION NAME] 200 mg three times a day. Review of resident #9's [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg PRN usage, showed she received 8 doses out of 30 possible. During an interview on 12/16/15 at 2:37 p.m., staff member K stated that resident #9 was not staying off her back side. Staff member K stated she thought the pressure on the resident's shoulders caused her pain and made it very difficult to find comfort lying on her side. Staff member K stated, the resident is not being ignorant, she just wants to be comfortable.