Every finding on record at River Valley Care Center

Based on observation, interview and record review, the facility failed to use a resident-specific pain assessment for one resident (Resident 1) when it inaccurately assessed Resident 1's pain levels.This failure had the potential to cause Resident 1 increased pain due to improperly assessed pain levels and psychosocial harm.During a record review of facility policy titled Pain Assessment and Management dated October 2022, indicated staff were to monitor for the effectiveness of interventions. Policy also indicated cognitive, cultural, familial, or gender-specific influences on the resident's ability or willingness to verbalize pain are considered when assessing or treating pain. Policy further indicated staff were to assess pain using a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level.During a record review of Resident 1's admission record, she was admitted to the facility on [DATE] with diagnoses that included bipolar disorder (mental illness characterized by extreme mood swings, including emotional highs and lows), dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking), and abnormalities of gait and mobility (any deviation from a typical walking pattern, characterized by symptoms like limping, shuffling, or an unsteady gait, often caused by neurological, musculoskeletal, or other medical conditions).During a record review of Resident 1's physician orders dated 10/30/25, indicated give Tramadol 50 milligrams (mg) (a pain medication used to treat moderate to severe pain in adults) every six hours as needed for moderate to severe pain.During a record review of Resident 1's care plan dated 12/15/22, indicated staff were to monitor and report any signs or symptoms of non-verbal pain such as changes in breathing, yelling out or silence, changes in mood such as restlessness, irritability, aggressive, eyes wide open, narrow, glazed, tearing, or no focus, face sad, worried, clenched teeth, body tense, rigid, curled up, or tense.During a record review of Resident 1's Medication Administration Record (MAR - a legal document used by healthcare professionals to record and track all medications administered to a patient) dated October 2025 and November 2025, indicated the facility assessed Resident 1's pain levels and used only the 0-10 numerical pain scale (a scale, typically from 0 to 10, where 0 is no pain and 10 is the worst imaginable pain).During an interview on 11/6/25 at 10:50 am with Licensed Vocational Nurse (LN) B, LN B stated Resident 1's pain was assessed by looking at her face. LN B stated if Resident 1 grimaced or said ow when staff touched her, she was administered Tramadol 50 mg every six hours. LN B could not confirm if she reassessed Resident 1 for pain medication effectiveness. LN B confirmed it was facility policy and best practice to reassess a resident for pain medication effectiveness after a pain medication was administered. LN B confirmed she documented Resident 1's pain levels using the numerical pain scale of 0-10 even if Resident 1 was unable to verbalize a number. LN B stated she assigned a number to the facial expression Resident 1 made. LN B confirmed this was not best practice. LN B confirmed Resident 1's pain assessments were difficult because sometimes she talks, sometimes she doesn't.During an interview on 11/6/25 at 10:53 am with Director of Staff Development (DSD), DSD confirmed Resident 1 was unable to consistently verbalize her pain level on a 0-10 numerical scale. DSD stated she expected staff to write descriptive words on Resident 1's MAR as well as utilize different pain assessment methods if Resident 1 was unable to verbalize her pain level on a 0-10 numerical scale. DSD stated facility expectation and policy was for staff to reassess a resident's pain after a pain medication was administered.During a concurrent observation and interview on 11/6/25 at 10:56 am with DSD and Director of Nursing (DON), DON stated Resident 1 stated ow whenever staff touched her body. DON stated, this is just a behavior. DON stated Resident 1 was assessed for pain by looking at her face. DON stated facility expectation for staff was to write descriptive words on the MAR if a pain medication was administered. DON stated the 0-10 numerical pain assessment scale would be inappropriate to use if a resident could not verbalize their pain with a number. During an interview on 11/6/25 at 11:44 am with Medical Director (MD), MD stated she assessed Resident 1's pain by facial expressions because Resident 1 was unable to consistently verbalize her pain level on a 0-10 numerical scale. MD stated she expected staff to assess any resident's pain with one of three pain assessment methods (0-10 numerical scale, FACES (uses pictures of faces to represent different levels of pain) or Wong-Baker (a self-assessment tool that uses a series of six cartoon-like faces to help individuals communicate their pain level.)) MD confirmed that Resident 1 was sometimes able to verbalize her pain on a 0-10 numerical scale, and sometimes unable. MD confirmed facility staff inappropriately assessed Resident 1's pain levels.During an interview on 11/6/25 at 12:30 pm with Minimum Data Set (MDS - assesses and documents patient health information in long-term care facilities, creating standardized reports for state and federal requirements like Medicare and Medicaid reimbursement) nurse, MDS stated Resident 1 was able to verbalize her wants and needs depending on the day. MDS confirmed Resident 1's pain levels are hard to determine. MDS stated Some days, she's more lucid than others.During an interview on 11/6/25 at 12:34 pm with DON, DON confirmed that staff inappropriately used the numerical 0-10 pain scale every time Resident 1 was assessed for pain. DON stated staff should have used different pain assessment methods, such as FACES or Wong-Baker, to assess Resident 1's pain if she was not able to verbalize her pain level. DON confirmed staff needed immediate pain assessment education. DON confirmed facility pain assessment policy was not followed by staff.

Based on observation, interview, and record review, the facility failed to ensure the kitchen was sanitary and food was stored, prepared, and distributed in accordance with food safety when: 1. The low temp dishwasher sanitizing solution did not meet manufacturer guidelines. 2. Primary handwashing skink for dietary staff was low flow and not warm. 3. Tortillas were not dated once received and were expired. 4. Dirty dishes were found placed under kitchen preparation area. 5. The lid for the dry powder thickener was kept open when not in use. 6. Thickened milk in the fridge was not dated when created. These failures had the potential to result in cross contamination and place residents at risk for developing a foodborne illness. Findings: 1. During a concurrent observation and interview, on 6/17/25 at 9:11 am, Dietary Aide (DA) J was using the dishwasher to wash and sanitize the post breakfast dishes. DA J was asked to test the level of chemicals used for sanitization in the dishwasher with test strips. The test strip indicated that the sanitizing solution was at a level of 10 parts per million (ppm) and it should have been at 200 ppm per the manufacture instructions on the test strip. DA J repeated the test a second time and they got the same result. DA J checked the test strips expiration date, and they were expired as of 3/2025. DA J and DA K continued to wash dishes and did not inform the Dietary Service Supervisor (DSS) or start three-compartment manual dish washing. During a concurrent observation and interview, on 6/17/25 at 11:10 am, three-compartment manual dish washing was taking place in the kitchen. DA I stated that dishes needed to be left in the sanitizing solution for three to five minutes. DA I confirmed that there was no policy regarding dwell time for the three-compartment sink close by for them to reference to ensure the correct dwell time. DA I stated they would need to go and ask the DSS to confirm the dwell time. During an interview with the Director of Maintenance (DOM) on 6/17/25 at 12:33 pm, the DOM stated they were unaware of any issues with the dishwasher. 2. During a concurrent observation an interview, on 6/17/25 at 9:10 am, the hand washing station (also used as an eye washing station) in the kitchen had low flow and it took several minutes to have hot water. [NAME] stated that management had been informed that the sink has had a low flow and slow to get hot water. During an interview with the DSS on 6/17/25 at 9:38 am, the DSS stated, I am sure maintenance is aware of the issues with the handwashing sink it has been like that for a while. The DSS stated that the sink should have higher flow and warmer water. During an interview with the DOM on 6/17/25 at 12:33 pm, the DOM stated they are aware of the issues with the handwashing sink in the kitchen and have known about it since June or July of 2024. DOM stated that the Administrator has been informed of the issue as well. DOM stated that there is an issue with the plumbing in the whole building and DOM is wanting to do a large project for the whole facility which would fix the issue with the kitchen handwashing sink. 3. During a concurrent observation and interview on 6/17/25, at 9:25 am, in the dry storage room six packages of flour tortillas were expired on 6/15/25, and two packages of corn tortillas did not have a received date and were expired as of 2/14/25. During an interview with the DSS, at 9:38 am, the DSS confirmed that the tortillas were expired. A review of the facility policy and procedure titled Labeling and Dating of Foods, dated 2023, indicates food delivered to facility needs to be marked with a received date. A review of the facility Dry Goods Storage Guidelines, dated 2023, indicates that corn and flour tortillas are good for one month unopened on the shelf. This guideline is to be followed if there is no manufacturer recommendation indicating otherwise. 4. During a concurrent interview and observation on 6/17/25, at 9:20 am, two dirty dishes were sitting under the kitchen preparation table next to other clean dishes. During an interview with the DSS, at 9:38 am, the DSS confirmed that there should not be any dirty dishes under the kitchen preparation table. 5. During a concurrent observation and interview on 6/17/25, at 9:19 am and 11:06 am, the lid to the large container of dry powder thickener was left open when not in use by dietary staff. During an interview with the DSS, at 9:38 am, the DSS confirmed that the lid to the thickener should be closed when not in use. 6. During a concurrent observation and interview on 6/17/25, at 9:19 am, there was a container of nectar thick milk that had been mixed and placed into the fridge with no date. At 9:38 am, the DSS confirmed that the milk should have a date on it once it has been made. The DSS then asked a staff member to put a date on the nectar thick milk that was already in the fridge. A review of the facility policy and procedure titled Labeling and Dating of Foods dated 2023, indicates all prepared foods need to be covered, labeled, and dated.

Based on observation, interview, and record review, the facility failed to ensure an infection control program was implemented by staff to reduce the spread of infection in the facility when: 1. A COVID outbreak was not reported timely to the Department of Public Health. 2. Certified Nursing Assistant (CNA) F did not perform hand hygiene when doing patient cares. These failures had the potential to result in the development and transmission of infectious diseases to residents, staff, and visitors. Findings: 1. A review of a facility policy titled, Unusual Occurrence Reporting, with a revised date of October 2024, indicated, Our facility will report the following events to appropriate agencies: An outbreak of any communicable disease . This policy further indicated, Unusual occurrences shall be reported . to appropriate agencies as required . Within twenty-four (24) hours of such incident . A review of a facility policy titled, Infection Prevention and Control Program, with a revised date of October 2024, indicated, The medical staff will help the facility comply with pertinent state and local regulations concerning the reporting and management of those with reportable communicable diseases. During an interview on 6/19/25 at 10:00 am with Infection Preventionist (IP), stated the COVID outbreak was reported to the local public health office on 6/11/25, but it was not reported to The California Department of Public Health (CDPH). IP stated, I wasn't sure if I needed to report it to CDPH, so I didn't report it. 2. A review of the facility's policy titled Handwashing/Hand Hygiene (undated), indicated this facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections [infections that happen in the nursing home]. Indications for Hand Hygiene F. Before moving from a work on a soiled body site to a clean body site on the same resident: and after glove removal. A review of Resident 26's admission record indicated, Resident 26 was readmitted to the facility on [DATE] after a hospital stay, with diagnoses that included respiratory failure with hypoxia (lack of oxygen to the brain), pneumonitis (lung infection) due to inhalation of food and vomit, dysphagia (difficulty with swallowing), aphasia (unable to talk), Alzheimer's (progressive brain disease which causes a decline in thinking, reasoning, and memory), and diabetes (high sugar in the blood). Resident 26 was unable to make her own health care decisions. A review of Resident 26's Significant Change in Status Minimum Data Set (a comprehensive assessment to determine a resident's care plan) dated 5/30/25, indicated that Resident 26's ability to think, reason, and remember was severely impaired. Resident 26 was dependent (requiring the assistant of two or more helpers to complete the activity) on staff for toileting hygiene (changing her brief and cleaning up afterword), bathing, upper and lower body dressing, and rolling from left to right or right to left. Resident 26 was incontinent of bowel and bladder. During an observation on 6/18/25 at 10:22 am, CNA F was observed changing a soiled brief for Resident 26. CNA F applied alcohol hand rub onto her hands, entered Resident 26's room and donned (put on) gloves. Resident 26 was lying in bed and CNA F rolled Resident 26 over and removed the soiled brief. CNA F used wipes to wipe Resident 26's bottom that had feces and urine on it. Resident 26 continued to expel feces and CNA F continued to wipe her bottom until it was clean of feces. CNA F threw the soiled brief and wipes in the garbage then with the same soiled gloved hands, CNA F picked up a clean brief and put it on Resident 26, adjusted Resident 26 in bed with her soiled gloves, and touching the bed controllers. CNA F then removed the soiled gloves and without doing hand hygiene she put on new gloves and applied a draw sheet under the resident and a new gown on the resident. During an interview on 6/18/25 at 10:40 am, CNA F confirmed that she did not remove her soiled gloves or do hand hygiene after contact with Resident 26's soiled body site and before touching a clean brief and a clean body site and she should have. CNA F confirmed that she did not perform hand hygiene after she removed her soiled gloves and before putting on new clean gloves and she should have. During an interview on 6/18/25 11:06 am, the IP indicated that it was their policy to do hand hygiene and change gloves when going from a soiled site to clean site and hand hygiene should be done when gloves are removed.

Based on observation, interview, and record review, the facility failed to ensure the communication call light system ( a communication system which relays the call directly to a staff member or to a centralized staff work area) was working for five of seven residents (Residents 21, 55, 69, 81 and 440) sampled for working call lights, when these residents had been given hand bells when their call light cord broke and the Director of Maintenance (DOM) indicated she did not have time to fix their call light cords. This failure had the potential for Resident 21, 55, 69, 81, and 440, to be at risk for accidents and their care needs not being met. Findings: A review of the facility's policy titled Maintenance Service revised 12/2023, indicated The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner in a practicable timeframe. A review of the DOM job description dated 2/2024, indicated Make periodic rounds to check equipment and to assure the necessary equipment is available and working properly. A review of Resident 81's admission record indicated that Resident 81 was admitted to the facility on [DATE] with diagnoses that included heart disease, muscle weakness, and unsteadiness of feet. Resident 81 was placed in room [ROOM NUMBER]-B on 5/21/25. A review of Resident 81's At Risk for Falls care plan dated 3/14/25, included an intervention to Be sure the resident's call light is within reach The resident needs prompt response to all requests for assistance. A review of Resident 21's admission record indicated that Resident 21 was admitted to the facility on [DATE] into room [ROOM NUMBER]-A with diagnoses that included heart disease, difficulty walking, and pain in right lower leg. A review of Resident 21's At Risk for Falls care plan dated 4/30/25, included an intervention to Be sure the resident's call light is within reach The resident needs prompt response to all requests for assistance. During a concurrent observation on station two in room [ROOM NUMBER] bed A and bed B, and an interview on 6/17/25 from 2:30 pm thru 2:56 pm, Resident 81 and Resident 21 were observed lying in their respected beds. They both had hand bells sitting on their overbed tables. At 2:30 pm, Resident 81 demonstrated the use of the hand bell by picking up the bell and ringing it a couple of times then setting it back down. From 2:30 pm thru 2:56 pm, staff never responded to the bell. Resident 81 indicated that he had to keep ringing the hand bell to get assistance from staff. Resident 21 indicated that he did not want to wake his roommate during the night, so he did not like to ring the bell at night. Both residents indicated that the call light cord that was in their room had not worked for a couple of weeks, so they were supposed to use hand bells. During a concurrent observation in the hallway, on station two outside of room [ROOM NUMBER], and interview on 6/17/25 at 2:57 pm, Registered Nurse (RN) E was observed walking down the hallway and confirmed that she did not hear a hand bell ring and was unaware that the residents in room [ROOM NUMBER] had hand bells instead of a working call light. During a concurrent observation in the hallway, on station two outside of room [ROOM NUMBER], and interview on 6/17/25 at 2:59 pm, Certified Nursing Assistant (CNA) G, indicated the residents in room [ROOM NUMBER] had hand bells as their call light system but that she was unable to hear the bell when she was in another resident's room or when she was at the nurse's station. During an interview on 6/20/25 at 8:38 am, Social Service Assistant (SSA) stated sometimes residents get ruff with the call lights, so we give them hand bells. SSA continued to say, staff will tie the cords to the side rales and then when the residents pull on them the wires will separate. A review of Resident 55's admission record indicated Resident 55 was admitted on [DATE] with diagnoses that included dementia, depression, and vertigo (dizziness). Resident 55 was placed in room [ROOM NUMBER]-A on 5/9/25. A review of Resident 55's admission Minimum Data Set (MDS, a comprehensive assessment) dated 4/9/25, indicated that Resident 55 required maximum assistance from staff with personal hygiene, toileting, and dressing. A review of Resident 69's admission record indicated Resident 69 was admitted on [DATE] with the diagnoses that included stroke (brain damage), muscle weakness, muscle spasms, and dysphagia (difficulty swallowing). Resident 69 was placed in room [ROOM NUMBER]-B on1/22/25. A review of Resident 69's Quarterly MDS dated [DATE], indicated Resident 69 was dependent on staff for transfers in and out of bed, toileting, and bed mobility. A review of Resident 440's admission record indicated Resident 440 was admitted to the facility on [DATE] with diagnoses that included lung disease, difficulty in walking, muscle weakness, and dementia. Resident 440 was placed in room [ROOM NUMBER]-B on 6/7/25. A review of Resident 440's At Risk for Falls care plan dated 6/7/25 indicated an intervention to keep call light within reach. A review of the maintenance logbook for station two identified documentation that included: *6/1/25 room [ROOM NUMBER] A&B (Residents 55 & 69) call light not working; can't find replacement both beds given bells. *6/10/25 room [ROOM NUMBER]B (Resident 440) Need [call] light replaced requested also on 5/28/25 Parts ordered. *6/15/25 room [ROOM NUMBER] A&B (Resident 21 & 81) Call light broken on both Call lights ordered. A review of the facility's invoice from a call light company indicated 12-10ft (foot) double call cords were ordered on 5/1/25 and were shipped out to the facility on 6/11/25. Durning an interview on 6/20/25 at 9:54 am, DOM showed me a large pile of broken call light cords. DOM indicated that residents drop them or pull the wiring apart and then we have to re-wire them. DOM indicated that she had ordered new call lights on 5/1/25 but was told that they were back ordered and would take a while for them to come in. DOM indicated they ran out of working call light cords around 6/1/25 and because she had not had time to fix the broken call lights the residents had to use the hand bells until the new shipment came in. DOM confirmed that room [ROOM NUMBER]-A&B had hand bells since 6/1/25, room [ROOM NUMBER]-B had a hand bell since 5/28/25, and room [ROOM NUMBER]-A&B had hand bells since 6/15/25. DOM stated We did not rewire them right then [when they broke] because we did not have time to do it. Giving them a hand bell was our way to resolve the issue. If a resident breaks their call light it is going to be a minute (a while) before they will get a new one. DOM indicated that on the evening of 6/17/25 (after the first day of the recertification survey), she and her assistant re-wired 12 broken call lights and then placed them in the rooms that had hand bells. On 6/20/25 at 10:00 am, DOM indicated that the shipment of 12-10ft call lights were delivered to the facility on 6/18/25.

Based on observation, interview, and record review, the facility failed to ensure that food was in the appropriate form for one of three residents (Resident 7) to meet her dietary needs. This failure had the potential for Resident 7 to aspirate (ingestion of food or fluid into the airway or lungs), choke, and have weight loss. Findings: During review of Resident 7's medical record revealed Resident 7 was admitted on [DATE] with diagnoses of Alzheimer's, underweight, blindness, contracture (deformity and rigidity of joints) of the left hand, and dysphagia (difficulty swallowing). A review of Dietary Note dated 12/18/24, at 1:00 pm, indicated that Resident 7 had a food intake range of 51-75% with meals being mechanical soft (foods that are easy to chew and swallow), pureed (a creamy paste or thick liquid made from cooked food) meat, and fortified (extra calories). A review of a Dietary Note dated 4/2/25, at 10:33 am, indicated that Resident 7's food intake was 0-26% with meals being mechanical soft, pureed meat, and fortified. A review of a Dietary Note dated 5/16/25 at 3:57 pm, indicated that the Infection Preventionist (IP) was assisting Resident 7 with lunch and noted that Resident 7 was spitting out the vegetables and carbohydrates. Resident 7 would use her tongue to flatten the food in their mouth. Resident 7 does not have any teeth. The IP indicated that Resident 7 did good eating the pureed fish and ice cream and downgraded (to pureed for swallowing safety) Resident 7's diet order. At 4:23 pm, IP informed the Physician and Resident 7's Responsible Party of the diet change. IP stated speech therapy was not needed. IP noted this was a food texture issue not a chocking issue for Resident 7. Charge nurse notified and dietary staff given diet change. A review of Clinical Physician Orders dated 5/16/25 at 4:01 pm, indicated a change in the diet order to a fortified diet, pureed textures. During an observation, on 6/17/24 at 12:22 pm, Resident 7 was sitting in the dinning room eating her meal with no help. She was eating pureed food with her hands and feeling around for the food. At times, Resident 7 was just sitting there and not eating. After 10 minutes, the Director of Staff Development (DSD) came over to help Resident 7 by directing the resident to where the utensils were. Resident 7's tray card indicated a dislike for green salad. On the plate was pureed meat, chopped tomatoes with lettuce, tater tots, and a tomato basil salad. During an interview, on 6/18/24 at 11:50 am, the Registered Dietitian (RD) stated that on 5/16/25 there was an order to change the diet for Resident 7's meals to be all pureed, but that information was not communicated to the RD. Resident 7 had been receiving the discontinued diet of pureed meats only for 33 days. RD updated the diet order for the dietary staff. RD confirmed that having the wrong diet put Resident 7 at risk for choking and weight loss. During a review of Rehab Dysphagia Screening Form, dated 8/29/24 for Resident 7, this was the last time Resident 7 had speech therapy evaluate her swallowing ability.

Based on observation, interview, and record review, the facility failed to properly store supplies in a medication room. This was evident in one out of two sampled medication storage rooms where unorganized products were found. Additionally, resident care supplies were found under the sink, which further indicated improper storage practices. The facility also failed to properly label resident medications in two out of four sampled medication carts. Disorganized storage of supplies and products in a nursing home can lead to medication errors, delays in treatment, and potential adverse health effects. Failing to properly label resident medications has the potential to put residents at risk for harm from receiving incorrect, expired, and potentially contaminated or ineffective medications. Findings: 1. During a record review of facility policy titled Medication Labeling dated [DATE], indicated the medication label included the expiration date as determined by the manufacturer, and resident's name. During a concurrent observation and interview of the medication cart 2B on Station 2 on [DATE] at 8:17 am, nicotine patches were found unlabeled in a drawer without the resident's name and expiration date. Registered Nurse (RN) E confirmed nicotine patches were not labeled with the resident's name and expiration date and should have been. During a concurrent observation and interview of the medication cart 1 on Station 1 on [DATE] at 8:47 am, D-Mannose (a simple sugar that can help prevent bacteria from sticking to the urinary tract walls) 500 milligrams (mg) was not labeled with the resident's name and expiration date and 30 Restasis single use artificial tears vials 0.4 milliliters (mL) were not labeled with the resident's name and expiration date. Licensed Nurse (LN) A confirmed both resident medications were not properly labeled with resident name and expiration date and should have been. 2. During a record review of facility policy titled Storage of Medications dated [DATE], indicated that nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. During an observation on [DATE] at 10:43 am, medication room number two on station two was inspected. Medication room number two's upper cabinets had a variety of syringes and intravenous (IV) supplies scattered in unlabeled boxes, unorganized, and improperly placed on the shelves. A resident's heart monitor was observed under the sink amongst cleaning supplies. The wound supply cabinet had supplies scattered in unlabeled boxes, and unorganized. During an interview with Licensed Nurse (LN) B on [DATE] at 10:50 am, LN B confirmed he was the unit manager. LN B confirmed the unit manager was responsible for the organization and accessibility of the medication room. LN B confirmed medication room number two was unorganized and inaccessible to staff. LN B confirmed there was a resident's heart monitor under the sink and confirmed that it needed to be picked up by the manufacturer and should not be under the sink with cleaning supplies.

Based on observation, interview, and record review, the facility failed to maintain a medication error rate below 5%, as 10 medication errors were observed out of 28 opportunities. The error rate was calculated by dividing 10 by 28 and multiplying by 100, resulting in an error rate of 35.7%. This failure led to inaccurate dosing and multiple medication errors. Findings: 1. During a record review of facility policy titled Administering Medications dated 2001, indicated medications are administered in accordance with prescriber orders. Facility policy further indicated staff would check the label three times to verify the right resident, right medication, right dosage, right time and right method of administration before giving the medication. Facility policy also indicated the expiration/beyond use date on the medication label is checked prior to administering. During a record review of Resident 46's Medication Administration Record (MAR) dated 6/4/25, indicated Resident 46 was prescribed Hydrocodone-Acetaminophen (Norco - a pain medication) 5-325 milligrams (mg) by mouth two times a day for chronic pain. During a record review of Resident 46's MAR dated 6/19/25, indicated Licensed Nurse (LN) A documented Resident 46's pain level as a seven out of ten (indicated severe pain on a zero to ten pain scale). During an observation on 6/18/25 at 8:12 am, LN A failed to accurately document medication administration for Resident 46. Resident 46 refused to take a crushed Norco 5-325 mg in applesauce. LN A asked Resident 46 if it was the applesauce that she did not like. Resident 46 nodded her head yes. LN A did not offer Norco 5-325 mg to Resident 46 in another food item. LN A documented the pain medication as refused on Resident 46's MAR. During a record review of Resident 288's physician orders dated 5/22/25, indicated Resident 288's medications crushed unless contraindicated. During an observation on 6/18/25 at 8:25 am, LN A failed to crush Resident 288's cranberry 450 mg and Lexapro 20 mg per physician orders. During an observation on 6/18/25 at 8:25 am, LN A failed to check medication expiration dates per facility policy prior to administration for Resident 288. During an interview with LN A on 6/18/25 at 8:39 am, LN A confirmed she incorrectly documented Resident 46's refusal of the applesauce as a refusal of the Norco 5-325 mg. LN A stated she knew Resident 46 did not like applesauce, but her medication cart was out of pudding. LN A stated she should have put a pudding on her medication cart when she noted there was none prior to medication administration. LN A also confirmed Resident 288's cranberry 450 mg and Lexapro 20 mg were not completely crushed per physician orders. LN A further confirmed she did not check the expiration dates of Resident 288's medications prior to administration. 2. During a record review of Resident 59's physician orders dated 3/30/25, indicated Resident 59 was prescribed Ascorbic acid (vitamin C) tablet 500 mg, give 1000 mg by mouth once daily. During an observation on 6/18/25 at 8:41 am, LN B failed to follow physician medication orders for Resident 59 when he gave Resident 59 four Vitamin C 250 mg tablets instead of two Vitamin C 500 mg tablets per physician orders. During an observation on 6/18/25 at 8:41 am, LN B failed to check Resident 59's medications against the MAR three times per facility policy. During an interview with LN B on 6/18/25 at 8:51 am, LN B confirmed he did not check Resident 59's medications against the MAR three times. LN B confirmed facility policy stated staff were to check medications against the resident's MAR three times prior to administration. LN B stated he should not have given Resident 59 four Vitamin C 250 mg tablets because that was not what the provider ordered. LN B stated he should have contacted the provider prior to administration for a new medication order. 3.During a record review of a manufacturer's insert for Breo Ellipta (a corticosteroid inhaler commonly prescribed for Chronic Obstructive Pulmonary Disease (COPD - a condition caused by damage to the airways or other parts of the lungs) dated May 2023, indicated the following steps as part of a six-step instructive guide for patient use: 1. While holding the inhaler away from your mouth, breath out fully. 2. Take one long, steady, deep breath in through your mouth. Do not breathe in through your nose. 3. Remove the inhaler from your mouth and hold your breath for about three to four seconds. 4. Breathe out slowly and gently. 5. Do not swallow water after you rinse your mouth. Spit it out. During an observation on 6/18/25 at 8:55 am, Registered Nurse (RN) E did not instruct Resident 45 to empty her lungs completely. RN E did not instruct Resident 45 to take one long and steady breath through her mouth, and Resident 45 breathed in through her nose. RN E did not instruct Resident 45 to hold her breath for three to four seconds after the medication was administered. Resident 45 swallowed the water after she rinsed her mouth and did not spit it out. During an interview with RN E on 6/18/25 at 9:02 am, RN E confirmed she did not follow manufacturer guidelines to administer the Breo Ellipta inhaler to Resident 45. RN E could not confirm the difference between a steroid and non-steroid inhaler. RN E could not confirm why spitting the water out after an administered steroid inhaler was necessary. RN E confirmed there were five Breo Ellipta inhalers in her medication cart, and only two contained manufacturer's inserts. RN E stated she did not know where the other three manufacturer's inserts were. RN E stated facility expectation was for staff to know how to administer inhalers to facility residents per manufacturer's guidelines found on the box or box inserts. During an interview with Director of Nursing (DON) on 6/19/25 at 9:21 am, DON stated facility expectation was for staff to follow facility's medication administration policy and for staff to understand how to administer different inhalers. DON stated facility expectation was for staff to read the outside of the inhaler box or the manufacturer's insert prior to administration.

Based on observation, interview, record review, the facility failed to maintain a safe, clean, comfortable and homelike environment when 10 out of 21 resident rooms in the locked unit, and one courtyard in the locked unit had the following: 1. Resident rooms 131, 133, 134, 137, 138, and 140 were observed as undecorated and not personalized to individuals. 2. room [ROOM NUMBER] was found on multiple dates as having a foul, unpleasant urine-like smell. 3. room [ROOM NUMBER] and 141 were observed to have mismatched toilet parts covered in tape, as well as other broken parts. 4. rooms [ROOM NUMBER] were observed to have patchy, or scratched off paint visible to, and near resident beds. 5. Uncovered outlets with patchy paint were found near room [ROOM NUMBER]. 6. The outdoor courtyard for locked unit had uneven pavement, dead plants, no shade, and an unpleasant appearance. 7. Several resident rooms were found to have unpleasant, sewage-like smells in bathrooms. This failure placed Residents at risk for psychosocial harm when they had to live in an environment that was not homelike and in disrepair. Findings: During an observation on 6/17/25 at 10:00 am, rooms 131, 133, 134, 137, 138, and 140 were found to be plain and undecorated. Other rooms were found to be undecorated and lacking any individual belongings, wall decorations, and did not appear homelike. During an interview 6/19/25 at 8:20 am with Activities Director (AD) regarding the locked dementia unit, she stated I'd like to improve and decorate more rooms over there, it's a work in progress. During multiple observations on 6/17/25, 6/18/25, and 6/19/25, room [ROOM NUMBER] was found to have a severe, foul, urine-like smell inside, with sticky, unknown liquid stains on the floor. During a concurrent interview and observation with LN A on 6/20/25 9:04 am, she stated Yes, it smells like urine. She explained that Resident in 137B had urinary issues, and that housekeeping was aware of the problem. During multiple observations on 6/17/25 through 6/20/25, rooms [ROOM NUMBERS]'s shared bathroom was found to have broken, ill-fitting parts taped down, and a broken toilet paper dispenser. During an interview on 6/17/25 2:53 pm with CNA L, she verbally confirmed toilets in resident's rooms smell like sewage, and she wished maintenance would come around more to fix things. During multiple observations on 6/17/25 through 6/20/25 by multiple surveyors, rooms [ROOM NUMBER] were found to have peeling, scratched off, or patchy paint. Mismatched paint patches or drywall spackle were found in multiple areas. room [ROOM NUMBER] was found to have large patches of green paint scratched off, showing beige paint, directly next to the resident's bed. During multiple observations on 6/17/25 through 6/20/25, facility hallways were found to have patchy, mismatched paint or possibly drywall spackling in multiple spots. The facility hallways also had an uncovered electrical outlet near room [ROOM NUMBER] with paint patches surrounding it. During multiple observations on 6/17/25 through 6/20/25, the only outdoor recreation space for the locked unit was found to have uneven pavement, dead plants, tall, uncut weeds, dead grass, no shade, and the general appearance was not homelike. The courtyard appeared to have full sun exposure for most of the day. The courtyard was adjacent and visible to the smoking area of the facility, as well as the storage sheds along a driveway. During an interview with CNA H on 6/20/25 at 9:13 am, when asked about the resident courtyard, CNA H stated, It could be improved. The facility policy and procedure titled Homelike Environment dated 2001, shows the facility staff shall provide, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. It also shows Residents are provided with a safe, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible or as practicable.

Based on observation, interview and record review, the facility failed to ensure three dietary aides (responsible for dishwashing) was competent on the use of the three-compartment sink (used in food services to properly wash, rinse, and sanitize dishes and utensils) procedure for manual dish washing in the kitchen. This failure placed all residents at risk for cross contamination and acquiring food-borne illnesses. Findings: A review of the facility policy titled Manual Warewashing [dishes and utensils], revised 10/2022, indicated all cookware, dishware, and serviceware that is not processed through the dish machine will be manually washed and sanitized (using chemicals to kill bacteria). The dining service staff will be knowledgeable in proper technique including: - Soap dispensing. - Wash temperature at no less then 110 degrees Fahrenheit. - Chemical sanitizing dispensing. - Chemical sanitizer testing and concentration. Appropriate test strips will be utilized to measure the concentration of the sanitizer solution. Results will be recorded on the Three-Compartment Sink Log. All serviceware and cookware will be air dried prior to storage. During a concurrent observation and interview, on 6/17/25 at 9:11 am, Dietary Aide (DA) J was using the dishwasher to wash and sanitize the post breakfast dishes. DA J was asked to test the level of chemicals in the dishwasher used for sanitization with test strips. The test strip indicated that the sanitizing solution was at a level of 10 parts per million (ppm) and it should have been at 200ppm per the manufacture instructions on the test strip. DA J repeated the test a second time and got the same result. DA J checked the test strips expiration date, and they were expired as of 3/2025. DA J and DA K continued to wash dishes and did not inform the Dietary Service Supervisor (DSS) or start three-compartment manual dish washing. A review of a dish machine report, dated 6/17/25, indicated an emergency service for machine sanitizer for the dishwasher occurred. Service technician found a hole in the tube that delivered sanitizer to the dishwasher and replaced the tube. During a concurrent observation and interview, on 6/17/25 at 11:10 am, three-compartment manual dish washing was taking place in the kitchen. DA I stated that dishes needed to be left in the sanitizing solution for three to five minutes. DA I confirmed that there was no policy regarding dwell time for the three-compartment sink close by for them to reference to ensure the correct dwell time. DA I stated they would need to go and ask the DSS to confirm the dwell time. During review of manufacture guidelines for [NAME] Chemicals Sani Tech, indicated when used surfaces need to remain visibly wet for at least 60 seconds. During an interview with the Registered Dietitian (RD) on 6/17/25 at 11:10 am, the RD confirmed that dietary staff should not be using test trips that are expired, and they should have immediately started the three-compartment sink procedure, and dietary staff should know the dwell time for sanitization for manual dishwashing. During an interview with the Director of Maintenance (DOM) on 6/17/25 at 12:33 pm, the DOM stated they were unaware of any issues with the dishwasher.

Based on observation, interview and record review, the facility failed to ensure the safety of one of nine sampled residents (Resident 79) reviewed for accidents and hazards when Resident 79 was found to have nine razors and one pair of tweezers in her room. This failure had the potential for Resident 79 to cause physical and psychosocial harm to herself and to other residents in the secured unit. Findings: During a record review of facility policy titled Safety and Supervision of Residents dated October 2024, indicated employees shall be trained in potential accident hazards, how to identify and report accident hazards, and try to prevent avoidable accidents. Facility policy further indicated that resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. During a record review of Resident 79's admission record, Resident 79 was admitted to the facility on [DATE] with diagnoses that included dementia (a decline in mental ability severe enough to interfere with daily life) with psychotic disturbance (the presence of hallucinations and/or delusions), visual hallucinations (perceptions of visual stimuli that are not present), and anxiety disorder (excessive fear, worry, or unease). During a concurrent observation and interview on 6/17/25 at 9:16 am, Resident 79 stood in the doorway of her room and held a brush in her hands. Resident 79 stated she liked to tweeze the hairs of her upper lip. Resident 79 was observed with upper lip redness, inflammation and three red scabs. Resident 79 called a passing resident a thief and stated she had to stand in her doorway to keep people out and protect her belongings. Resident 79 stated she had to use her brush to defend herself against intruders. During a concurrent observation and interview on 6/18/25 at 3:01 pm, Resident 79 sat on her bed. Resident 79 opened her bedside table and produced nine double-bladed disposable razors and one pair of tweezers. Resident 79 stated the razors were to shave her face and legs. Resident 79 stated staff were aware she had them in her room. During an interview on 6/18/25 at 3:17 pm, with Registered Nurse (RN) D, RN D stated she knew Resident 79 had tweezers in her room and used them on her face. RN D stated she did not know there were nine disposable razors in Resident 79's room. RN D stated it was possible a family member brought them to Resident 79. RN D stated staff would call a family member to come remove the razors from Resident 79. RN D stated staff was not comfortable going into Resident 79's room because she had a tendency to be combative. RN D confirmed that Resident 79 should not have disposable razors in her room due to safety concerns for herself and other residents. During a concurrent observation and interview on 6/18/25 at 3:40 pm, there were no razors or tweezers observed in Resident 79's room. RN D confirmed items had been removed by staff. During an interview on 6/19/25 at 9:21 am, with Director of Nursing (DON), DON stated she was surprised staff knew about the tweezers in Resident 79's room. DON confirmed disposable razors and tweezers were a safety concern and Resident 79 should not have them.

Based on observation, interview, and record review, the facility failed to ensure an evaluation and documentation, of a red area, was completed for one of two residents (Resident 26) sampled for skin conditions, when Resident 26 was identified to have a red area on her bottom on admission but there was no further documentation about the red area for the next three weeks. This failure had the potential for Resident 26's skin condition to become worse and cause significant pain and negative clinical outcomes. Findings: A review of the facility's policy titled Prevention of Pressure Ulcers/Injuries revised September 2024, indicated Monitoring 1. Evaluate, report and document potential changes in the skin. A review of Resident 26's admission record indicated, Resident 26 was readmitted to the facility on [DATE] after a hospital stay, with diagnoses that included respiratory failure with hypoxia (lack of oxygen to the brain), pneumonitis (lung infection) due to inhalation of food and vomit, Dysphagia (difficulty with swallowing), aphasia (unable to talk), Alzheimer's (progressive brain disease which causes a decline in thinking, reasoning, and memory), and diabetes (high sugar in the blood). Resident 26 was unable to make her own health care decisions. A review of Resident 26's Significant Change in Status Minimum Data Set (MDS, a comprehensive assessment to determine a resident's care plan) dated 5/30/25, indicated that Resident 26's ability to think, reason, and remember was severely impaired. Resident 26 was dependent (requiring the assistant of two or more helpers to complete the activity) on staff for toileting hygiene (changing her brief and cleaning up afterwards), bathing, upper and lower body dressing, and rolling from left to right or right to left. Resident 26 was always incontinent of urine and bowel (feces) movements. During an observation on 6/18/25 at 10:22 am, Certified Nursing Assistant (CNA) F was observed turning Resident 26 on her left side, removing a soiled brief (disposable underwear to catch urine and feces), and wiping urine and feces off of her bottom. Resident 26 was observed to have a wound dressing on her bottom. CNA F stated the dressing was to cover a red area on Resident 26's bottom. A review of Resident 26's weekly skin assessments dated 6/8/25 and 6/15/25 indicated Resident 26's skin had no new skin issues and skin was clear and intact. A review of the admission Comprehensive Skin Evaluation/Assessment dated 5/28/25, indicated Resident 26 had redness to the sacrum (an area on Resident 26's bottom at the end her spine). There was no documented measurements or cause for the redness. During a concurrent interview with Licensed Nurse (LN) B and record review on 6/19/25 at 12:59 pm, Resident 26's admission Comprehensive Skin Evaluation/Assessment dated 5/28/25, was reviewed. LN B indicated the redness that was identified on Resident 26's bottom during admission was due to moisture associated skin damage (MASD, when the skin gets inflamed/irritated due to urine or feces on the skin). LN B confirmed that the reason for the redness was not identified or measured on the assessment evaluation, and it should have been. LN B indicated that Resident 26 continued to have redness on her bottom, and that there was a daily treatment for this area. Resident 26's 6/8/25 and 6/15/25 weekly skin assessments was also reviewed and LN B confirmed that there was no follow-up or evaluations of the redness for Resident 26 and there should have been. During an interview on 6/19/25 at 1:25 pm, the Treatment Nurse (TN) indicated that she was doing daily treatments for Resident 26's redness on her bottom but said the redness had never been measured or evaluated to determine how it was progressing (if it was getting better or worse) and there should have been documentation on this. During an observation on 6/20/25 at 9:30 am, TN and LN B were observed changing the dressing on Resident 26's bottom. Resident 26's bottom presented with a large egg-shaped, fist size, purple/red area, with pealing skin, that spread to both sides of Resident 26's bottom. TN confirmed the wound's size, shape, color, and that the skin was peeling off of Resident 26's bottom.

Based on observation, interview, and record review, the facility did not provide Resident 7 with extensive assistance while eating her lunch, as deemed necessary by her care plan (a document that outlines a resident's specific goals and needs). This failure had the potential to foster a decrease in the resident's participation in her activities of daily living (ADLs) to maintain good nutrition. Findings: A review of a facility policy titled, Activities of Daily Living (ADL), Supporting, with a revised date of August 2024, indicated, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs) as practicable as possible. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition A review of a facility policy titled, Care Plans, Comprehensive, with a reviewed date of September 2024, indicated, A comprehensive care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The comprehensive care plan will: aid in preventing or reducing decline in the resident's functional status and/or functional levels A review of the facility's records indicated Resident 7 was admitted to the facility on [DATE], with diagnoses that included Alzheimer's Disease with late onset (a gradual decline in cognitive function, including memory loss, confusion, and difficulties with thinking, language, and judgment), Underweight, Vascular Dementia (problems with reasoning, planning, judgement, and memory), Unspecified Glaucoma (eye condition that can lead to vision loss or blindness), Blindness right eye, contracture left hand (hardening of muscles leading to deformity of joints), and Dysphagia (difficulty or discomfort during swallowing). A review of Resident 7's care plan with an initiated date on 10/25/2022, indicated, Resident 7 had an ADL Self Care Performance Deficit, due to diagnoses of Alzheimer's, Dementia, contractures. Resident requires EXT (extensive) assist for . meals. She is unable to verbalize needs. All needs must be anticipated and met. A review of a facility progress note dated 5/16/25 at 3:57 pm by Infection Preventionist (IP), indicated Resident 7, Was spitting out her vegetables and carbs. She uses her tongue to flatten her food. During an observation on 6/17/25 at 12:22 pm, Resident 7 was observed sitting and eating her meal at the dining table with no help. Resident 7 was seen eating her puree food with her hands as she could not see her food. At times, Resident 7 was sitting there not eating her food. After approximately 10 minutes, a staff member came over and helped direct Resident 7 as to where her utensils and food were. During an interview on 6/19/25 at 8:45 am with IP, confirmed that an individual can not eat pureed foods with their hands. IP stated she remembered watching Resident 7 try to chew her carrots and she was smashing them and would spit them out. During an interview on 6/19/25 at 9:48 am with the Director of Nursing (DON), stated that Resident 7, sometimes needs a lot of queuing (verbal direction), while eating. DON confirmed that Resident 7's care plan indicated extensive assistance and is still current. DON confirmed that due to this care plan, Resident 7 would be a one on one for feeding.

Based on observation, interview, and record review, the facility failed to develop and implement a person-center care plan for one of four residents (Resident 26) sampled for care plans, to reflect Resident 26's required need of the assistance of two helpers with Activity of Daily Living (ADL's, which included turning resident in bed, bathing, and changing her brief [incontinent underwear that absorb urine and feces]). This failure had the potential to lead to inaccurate provision of care and adverse health outcomes for Resident 26. Findings: A review of the facility's policy titled Care Plans, Comprehensive reviewed 9/2024, indicated A comprehensive care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. 1. The care plan interventions are derived from analysis of the information gathered as part of the comprehensive assessment. The comprehensive care plan will: .b. Describe the services that are to be furnished. d. Describe any specialized services to be provided. A review of Resident 26's admission record indicated, Resident 26 was readmitted to the facility on [DATE] after a hospital stay, with diagnoses that included respiratory failure with hypoxia (lack of oxygen to the brain), pneumonitis (lung infection) due to inhalation of food and vomit, Dysphagia (difficulty with swallowing), aphasia (unable to talk), Alzheimer's (progressive brain disease which causes a decline in thinking, reasoning, and memory), and diabetes (high sugar in the blood). Resident 26 was unable to make her own health care decisions. A review of Resident 26's Significant Change in Status Minimum Data Set (MDS, a comprehensive assessment to determine a resident's care plan) dated 5/30/25, indicated that Resident 26's ability to think, reason, and remember, was severely impaired. Resident 26 was dependent (requiring the assistance of two or more helpers to complete the activity) on staff for toileting hygiene (changing her brief and cleaning up afterwards), bathing, upper and lower body dressing, and rolling from left to right or right to left. During an observation on 6/18/25 at 10:22 am, Certified Nursing Assistant (CNA) F was observed turning Resident 26 on her left side and removing a soiled brief and replacing it with a clean one. CNA F rolled Resident 26 on her left side by pushing on Resident 26's right shoulder and right hip. CNA F then removed her right hand from Resident 26's hip and kept pushing on Resident 26's right shoulder to keep Resident 26 from rolling on her back while she cleaned Resident 26's bottom and place a new brief. Resident 26 was grabbing at CNA F, pushing against CNA F and moaning during the event. During an interview on 6/18/25 at 11:06 am, CNA F indicated she usually changed Resident 26's brief by herself. CNA F stated, I do not know if she (Resident 26) needs two people. A review of Resident 26's comprehensive care plan revised 11/20/23, showed a focus area titled ADL Self Care Performance Deficit. Resident is unable to make needs known. All needs must be anticipated. She requires extensive to total assist with ADLS . There were no interventions to indicate number of helpers needed for the ADL tasks. During a concurrent interview and record review with the Director of Nursing (DON) on 6/18/25 at 11:10 am, Resident 26's MDS and Care Plans were reviewed. The DON indicated that Resident 26 was dependent with her ADL's and required two helpers with turning in bed and brief change. The DON indicated that Resident 26 was unable to help with these activities and there should be two helpers to prevent injury and provide comfort for Resident 26. The DON confirmed that Resident 26's care plan did not specify the need for two helpers, but it should have.

Based on observation, interview, and record review, the facility did not accurately assess Resident 7 when the Minimum Data Set (MDS, a standardized, comprehensive assessment to evaluate resident's health status, functional abilities, and care needs) indicated Resident 7 required partial to moderate assistance with eating; however, the care plan (a document that outlines a resident's specific goals and needs) indicated Resident 7 required extensive assistance with eating. This failure had the potential to not accurately reflect Resident 7's status, which could cause a decline in the resident's status and ability to receive proper nutrition. Findings: A review of a facility policy titled, Resident Assessments, with a revised date of October 2024, indicated, The results of the assessments are used to develop, review, and revise the resident's comprehensive care plan. A review of a facility document titled, Job Description: MDS Nurse . with a date of August 2019, indicated the essential duties of an MDS nurse included, Responsible for the data entry function to assure accurate data entry and electronic submission of MDS assessments. Performs corrections when necessary and maintains appropriate records. Assists disciplines in formulating and revising care plans. Ensures that resident's present//potential problems are identified and prioritize; realistic goals are established, and nursing intervention is appropriate. Evaluates resident care plans for comprehensiveness and individuality. Ensures that the resident's care plan is reassessed and revised appropriately . A review of the facility's records indicated Resident 7 was admitted to the facility on [DATE], with diagnoses that included Alzheimer's Disease with late onset (a gradual decline in cognitive function, including memory loss, confusion, and difficulties with thinking, language, and judgment), Underweight, Vascular Dementia (problems with reasoning, planning, judgement, and memory), Unspecified Glaucoma (eye condition that can lead to vision loss or blindness), Blindness right eye, contracture left hand (hardening of muscles leading to deformity of joints), and Dysphagia (difficulty or discomfort during swallowing). A review of a facility document titled, MDS 3.0 Section GG - Functional Abilities, with a date of 4/3/25, indicated, Resident 7 required partial to moderate assistance with eating. A review of Resident 7's care plan with a revised date on 3/30/25, indicated, Resident 7 had an ADL Self Care Performance Deficit, due to diagnoses of Alzheimer's, dementia, contractures. Resident requires EXT (extensive) assist for . meals. She is unable to verbalize needs. All needs must be anticipated and met. During an observation on 6/17/25 at 12:22 pm, Resident 7 was observed sitting and eating her meal at the dining table with no help. Resident 7 was seen eating her pureed food with her hands as she could not see her food. At times, Resident 7 was sitting there not eating her food. After approximately 10 minutes, a staff member came over to help and helped direct Resident 7 as to where her utensils and food were. During an interview on 6/19/25 at 9:48 am with the Director of Nursing (DON), stated that Resident 7, sometimes needs a lot of queuing (verbal direction), while eating. DON confirmed that Resident 7's care plan indicated extensive assistance and is still current. DON confirmed that due to this care plan, Resident 7 would be a one on one for feeding. During an interview on 6/19/25 at 1:35 pm with MDS, confirmed that the care plan indicated Resident 7 required extensive assistance with meals, even though the MDS indicated Resident 7 required partial to moderate assistance with eating. MDS confirmed that both of the assessments (MDS and care plan) did not state the same level of help required, leading to an inaccurate assessment of Resident 7.

Based on observation, interview and record review, the facility failed to develop a baseline care plan for one resident out of three (Resident 238) within 48 hours after admission for respiratory care issues and oxygen needs. This failure had the potential for Resident 238 to not receive effective and person-centered care when no respiratory goals or interventions were included in the baseline care plan. Findings: During a review of the facility's policy and procedure titled, Care Plans - Baseline, revised October 2024, indicated, a baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight hours of admission. During an observation on 6/17/25 at 11:17 am, in Resident 238's room, there was an oxygen concentrator administering oxygen to Resident 238 via nasal cannula (a thin, flexible tube that wraps around your head, typically hooking around your ears. On one end, it has two prongs that sit in your nose and deliver oxygen. The other end of the tube connects to an oxygen supply). Resident 238 was observed to be laying flat and having a difficult time breathing. During a review of Resident 238's physician orders dated on 6/15/25, indicated Resident 238 was to receive continuous oxygen support via nasal cannula at 2 liters per minute. During a review of Resident 238's medical records on 6/18/25, indicated Resident 238 was admitted to facility on 6/15/25 from an acute care hospital with acute respiratory failure, heart failure, pneumonia, and chronic obstructive pulmonary disease (a progressive lung disease that makes it difficult to breathe). Resident 238 was able to make own healthcare decisions. During a review of Resident 238's baseline care plan on 6/18/25, the care plan did not indicate the patient was on oxygen or had any respiratory problems. During a concurrent interview and record review on 6/19/25 at 3 pm, with the Director of Nursing (DON), the DON confirmed Resident 238's baseline care plan should have included respiratory goals and interventions including oxygen therapy.

Based on interview and record review, the facility failed to have an effective Quality Assurance Performance Improvement (QAPI - a quality management program which takes a systematic, interdisciplinary, comprehensive, and data-driven approach to maintaining and improving safety and quality) when the committee did not develop, implement, and identify performance improvement activities related to a scabies outbreak. Refer to F 880 and F 658. This resulted in 31 residents and all staff, vendors, and visitors being at risk for exposure to scabies. Findings: A review of a facility policy titled Quality Assurance and Performance Improvement (QAPI) Program revised February 2020, indicated this facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI Program that is focused on indicators of the outcomes of care and quality of life for our residents. Policy Interpretation and Implementation The objectives of the QAPI Program are to provide a means to measure current and potential indicators for outcomes of care and quality of life. Provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators Reinforce and build upon effective systems and processes related to the delivery of quality care and services. Establish systems through which to monitor and evaluate corrective actions. The owner and/or governing board (body) of our facility is ultimately responsible for the QAPI Program. The governing board/owner evaluates the effectiveness of its QAPI Program at least annually and presents findings to the QAPI Committee. The Administrator is responsible for assuring that this facility's QAPI Program complies with federal, state, and local regulatory agency requirements. The QAPI Committee reports directly to the Administrator. During review of resident outbreak line listings (tracking tool of infectious outbreaks) were documented as follows: -Line listing dated 04/15/2024, indicated an outbreak of scabies was documented on Nursing Station 1 (secure dementia unit) a total of 18 residents identified. The area for the date of specimen collected and laboratory (lab) results returned indicated not applicable (no entries) for all 18 residents. The area for prescribed medication for treatment was blank for all 18 residents. The area for date of recovery and present status and condition was blank for all 18 residents. The area for date Medical Director (MD) notified indicated Yes, no specific date. -Line listing dated 08/02/2024, indicated a second outbreak of scabies for a total of 13 residents on Nursing Station 2 (right outside doors to secure dementia unit) were identified. The area for the date of specimen collected and lab results returned indicated not applicable (no entries) for all 12 residents, Resident 2 had a specimen collected for lab testing on 07/29/2024, with no date documented for lab results. The area for prescribed medication for treatment was blank for all 13 residents. The area for date of recovery and present status and condition was blank for all 13 residents. The area for MD notified indicated 08/02/2024, when Resident 2 had a date of onset of 07/01/2024 on the line listing. A review of the Monthly Infection Control meeting minutes indicated: -On 04/30/2024, it was documented under discussion skin infections. Under the departmental reports from Nursing and Housekeeping indicated Skin issues. The actions taken for both Nursing and Housekeeping departments indicated in-services for staff with a date of completion 04/30/2024. -On 05/31/2024, it was documented under departmental reports for housekeeping deep cleans (cleaning and disinfecting hard-to-reach areas and surfaces that are not typically cleaned as part of routine daily or weekly cleaning) not being performed. There were no actions taken documented for this issue. -On 07/01/2024, it was documented under discussion ongoing skin issues, action taken was treatment/investigation and date of completion ongoing. Under departmental reports, nursing indicated hand hygiene and infection prevention education, no date of completion. Housekeeping indicated issues with glove changes and deep cleaning during infection, no action taken and ongoing no completion date. -July 2024, there was no documentation about any outbreak of scabies or skin issues. -August 2024, it was documented under discussion follow up on skin issues. A review of QAPI minutes dated 08/28/2024 for the previous quarter, indicated attendees included Administrator (Admin), Director of Nursing (DON), Infection Preventionist (IP), and MD. Under section Identify , Clarify, and Prioritize indicates skin issues on station 2, under Understand, Cause and Analysis stated residents noted to have dryness and redness to skin (no mention of scabies), under Solution, Plan, and Mobilize indicated to keep on in-servicing housekeeping on proper infection control and continue the use of A &D, for residents experiencing these issues monitor effects and results .residents treated with ivermectin effectively - treatment effective, under Implement, Monitor, and Evaluate stated monitor skin issues and make changes in treatment accordingly. A review of an infection note dated 07/31/2024 at 6:46 am, a dermatology report indicated Resident 2 was positive for scabies and to continue treatment/isolation. During a concurrent interview and record review, on 02/28/2025 at 1:55 pm, the DON confirmed that the infection control meeting minutes related to the scabies outbreak was lacking tracking and trending information. During a concurrent interview and record review, on 02/28/2025 at 3 pm, IP 2 confirmed that there should be more information on the scabies outbreak on the infection control meeting minutes. During a concurrent interview and record review on 03/13/2025 at 10:25 am, the Admin confirmed the July meeting minutes do not include documentation demonstrating the development, implementation and evaluation, of corrective actions or performance improvement actions related to the possible scabies outbreak. During an interview on 04/09/2025 at 2:04 pm, the Admin confirmed that there are no QAPI minutes for the time period of April - June of 2024.

Based on interview and record review, the facility failed to ensure that the Medical Director (MD) supervised the development and implementation of mitigating a scabies outbreak that effected 31 residents. This failure resulted in a six-month scabies outbreak in the facility. Findings: A review of Medical Directorship Agreement, dated 01/01/2019 indicates the MD is involved at all levels of individualized patient care and supervision, and for all persons served by the facility. The MD services as the clinician who oversees and guides the care that is provided'. The MD is responsible for coordinating of medical care in the facility to ensure that adequate and appropriate medical services are provided to the patients in the facility, reviewing incidents and accidents in the facility to identify hazards to human health and safety, serving as a member of the infection control committee at the facility. A review of alert charting, dated 04/05/2024 at 11:05 pm indicated a new order for permethrin 5% topical cream (a cream to treat scabies) for possible scabies treatment needs to be done tomorrow, continue isolation per doctor order. The order for permethrin 5% to start on 04/05/2024 end on 04/07/2024. During an interview on 03/19/2025 at 12:40 pm, MD stated best practice is two treatments of permethrin is always beneficial in treating scabies, especially if you are seeing signs that the issue is not resolved. MD explained after two treatments it is considered resolved unless skin issues continue. A review of WD progress note, dated 04/15/2024 and 04/29/2024 indicated excoriation on knee, forearm, thigh, lesion on back, wrist, hand, fingers dry skin. Clobetasol 0.05% (ointment to be applied to the skin for eczema and psoriasis) to excoriated areas twice a day for 14 days. WD documented plan for biopsy if not improved. A review of infection note documentation, dated 05/09/2024 at 2:05 pm, indicated Resident 2 had a rash across chest, abdominal wall, bilateral hip, and thigh. Mild bumpy redness some scabs noted. Scraping (remove skin for testing) performed in house negative for scabies confirmed by unidentified second nurse. Continue ivermectin (an anti-parasitic medication used to treat scabies) as ordered. Previous treatment of permethrin ineffective, tac cream (a topical corticosteroid used to reduce inflammation, itching, and redness) ineffective, hydrocortisone (a steroid medication can treat skin conditions) ineffective, environmental sciences instructed to deep clean room. A review of skin and wound note, dated 07/25/2024 at 1:11 pm, indicated a call was made for a dermatology consult for Resident 2's ongoing rash. Dermatology appointment was scheduled for 07/26/2024 at 2 pm, over three months since RP gave permission and WD requested to arrange if rash unresolved. A review of the Monthly Infection Control meeting minutes indicated: -MD was in attendance. -On 04/30/2024, it was documented under discussion skin infections. Under the departmental reports from Nursing and Housekeeping indicated Skin issues. The actions taken for both Nursing and Housekeeping departments indicated in-services for staff with a date of completion 04/30/2024. -On 5/31/24, it was documented under departmental reports for housekeeping deep cleans (cleaning and disinfecting hard-to-reach areas and surfaces that are not typically cleaned as part of routine daily or weekly cleaning) not being performed. There were no actions taken documented for this issue. -On 07/01/2024, it was documented under discussion ongoing skin issues, action taken was treatment/investigation and date of completion ongoing. Under departmental reports, nursing indicated hand hygiene and infection prevention education, no date of completion. Housekeeping indicated issues with glove changes and deep cleaning during infection, no action taken and ongoing no completion date. -July 2024, there was no documentation about any outbreak of scabies or skin issues. -August 2024, it was documented under discussion follow up on skin issues. During an interview on 03/19/2025 at 12:40 pm, MD stated that they did remember a few patients that were identified with scabies and was unaware of that the line listings included 31 residents. MD indicated that they did not know what to expect when it comes to tracking and trending for scabies. MD stated that on infection control meeting minutes it would be expected that the issue would be discussed in detail and state that it is resolved in a timely manner. MD stated they do not know who does the scrapings for scabies at the facility and that an experienced nurse who has been trained in scrapping for scabies should be the one performing a scraping. MD stated that they would not even do the scrapping themselves and would have another medical professional do the scrapping who was trained, as well as send it out to a laboratory to be tested .

Based on interview and record review the facility failed to identify a scabies (a highly contagious skin infestation caused by human itch mites that causes intense itching of the skin) outbreak, implement appropriate precautions, monitor the effectiveness of the corrective actions and prevent further transmission when: 1. The facility's surveillance system (line listing that tracks infectious outbreaks) was incomplete. 2. Infection control committee did not monitor the scabies outbreak and evaluate the effectiveness of the corrective actions taken. 3. The nursing and housekeeping department did not implement appropriate precautions to prevent spread of scabies outbreak. 4. The staff were not trained in infection prevention and control practices to prevent further spread of scabies outbreak. 5. The facility did not take appropriate steps to diagnose and manage the resident scabies cases for two of the 31 residents. This resulted in a scabies outbreak from April to August 2024 which affected 31 residents and one direct care staff member and put all residents in the facility at risk for disease. Findings: 1. A review of a facility policy titled, Infection Prevention and Control, dated June 2022, indicated an infection prevention and control program is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The infection prevention and control program consist of coordination/oversight, surveillance, data analysis, and prevention of infection. -Surveillance (adherence to infection prevention and control practices) and outcome surveillance (incidence and prevalence of healthcare acquired infections) are used as measures of the Infection Prevention Control Program effectiveness. Surveillance tools are used for recognizing the occurrence of infections, recording the number and frequency, detecting outbreaks and epidemics, monitoring employee infection, monitoring adherence to infection prevention and control practices, and detecting unusual pathogens with infection control implications. -Data Analysis is gathered during surveillance and is used to oversee infections and identify trends. Monthly rates can be plotted graphically or otherwise compared side-by-side to allow for trend comparison. -Outbreak Management is a process that consists of: (1) determining the presence of an outbreak. (2) managing the affected residents. (3) preventing the spread to other residents. (4) documenting information about the outbreak. (6) educating the staff and the public. (7) monitoring for recurrences. (8) reviewing the care after the outbreak has subsided; and (9) recommending new or revised policies to handle similar events in the future. -Prevention of Infection include: (1) following established general and disease-specific guidelines such as those of the Centers for Disease Control (CDC). During review of resident outbreak line listings (tracking tool of infectious outbreaks) were documented as follows: -Line listing dated 04/15/2024, indicated an outbreak of scabies was documented on Nursing Station 1 (secure dementia unit) a total of 18 residents identified. The area for the date of specimen collected and laboratory (lab) results returned indicated not applicable (no entries) for all 18 residents. The area for prescribed medication for treatment was blank for all 18 residents. The area for date of recovery and present status and condition was blank for all 18 residents. The area for date Medical Director (MD) notified indicated Yes, no specific date. -Line listing dated 08/02/2024, indicated a second outbreak of scabies for a total 13 residents on Nursing Station 2 (right outside doors to secure dementia unit) were identified. The area for the date of specimen collected and laboratory results returned indicated not applicable (no entries) for all 12 residents, Resident 2 had a specimen collected for lab testing on 07/29/2024, with no date documented for lab results. The area for prescribed medication for treatment was blank for all 13 residents. The area for date of recovery and present status and condition was blank for all 13 residents. The area for MD notified indicated 08/02/2024, when Resident 2 had a date of onset of 07/01/2024 on the line listing. During a concurrent interview and record review on 02/11/2024, at 11:31 am, with the Infection Preventionist (IP), she confirmed for both outbreak line listings dated 04/15/2024 and 07/01/2024 there is missing information which included: -The date the specimen was collected -The date the lab results were returned -What medication was prescribed by physician -Date of recovery -Present status and condition IP stated all missing data on the line listing forms were essential for tracking and trending the scabies outbreak and should have been documented on the forms. 2. A review of a facility policy titled, Infection Prevention and Control, dated June 2022, indicated the coordination and oversight of the infection prevention and control program is overseen by an infection prevention specialist (infection preventionist). The infection prevention and control committee is responsible for reviewing and providing feedback on the overall program. Surveillance data and reporting information is used to inform the committee of potential issues and trends. Some examples of committee reviews may include: (1) documented incidents and corrective actions taken; (2) whether physician management of infections is optimal; (3) whether there is appropriate follow-up of acute infections. (4). The committee meets regularly and consists of team members from across disciplines. During record review from Monthly Infection Control Meeting minutes from April - September 2024, indicated the facility staff attendance included the MD, Director of Staff Development, Director of Nursing (DON), IP, Administrator (Admin), Activities Director, Housekeeping/Laundry Director, Maintenance Director and Dietary department. A review of the Monthly Infection Control meeting minutes indicated: -On 04/30/2024, it was documented under discussion skin infections. Under the departmental reports from Nursing and Housekeeping indicated Skin issues. The actions taken for both Nursing and Housekeeping departments indicated in-services for staff with a date of completion of 04/30/2024. -On 05/31/2024, it was documented under departmental reports for housekeeping deep cleans (cleaning and disinfecting hard-to-reach areas and surfaces that are not typically cleaned as part of routine daily or weekly cleaning) not being performed. There were no actions taken documented for this issue. -On 07/01/2024, it was documented under discussion ongoing skin issues, action taken was treatment/investigation and date of completion ongoing. Under departmental reports, nursing indicated hand hygiene and infection prevention education, no date of completion. Housekeeping indicated issues with glove changes and deep cleaning during infection, no action taken and ongoing no completion date. -July 2024, there was no documentation about any outbreak of scabies or skin issues. -August 2024, it was documented under discussion follow up on skin issues. During a concurrent interview and record review of the infection control meeting minutes on 02/28/2024, at 1:55 pm, the DON confirmed the meeting minutes were incomplete when there was no tracking and trending information documented or discussed amongst the team members. DON confirmed there were no consistent plans to mitigate the scabies outbreak. During a concurrent interview and record review, on 2/28/2025 at 3 pm, the IP confirmed that there should be more information on the infection control meeting minutes related to the scabies outbreak. 3. A review of alert charting for Resident 2, dated 04/05/2024 at 11:05 pm indicated a new order for permethrin 5% topical cream (a cream to treat scabies) for possible scabies treatment needs to be done tomorrow, continue isolation per doctor order. A review of the housekeeping records for Resident 2's room [ROOM NUMBER]A (scabies outbreak from 4/1/24-8/1/24) had weekly deep cleaning completed on 04/27/2024, (22 days after start of isolation for scabies). A review of alert charting dated 07/30/2024 at 5:21 am, 07/30/2024 at 2:35 pm, and 07/30/2024 11:46 pm, indicated tolerating isolation due to scabies. During an interview on 3/12/25 at 11:15 am, the Director of Housekeeping (HKD) stated that she did remember the scabies outbreak last year and she thinks that it happened in the middle on the facility around rooms 201 or 203. HKD explained the DON was the one who informs her of rooms that needed to be deep cleaned for an infection reason and when she can stop. HKD explained with rooms identified with scabies would do an initial deep clean and then you would clean it every day. HSK stated when there was a deep cleaning done on a room a form was filled out and signed. HSK was asked to provide documentation of any type of cleaning Rm 201 received from April-September 2024 and documentation of DON notification which room had scabies and when it started and stopped. HKD was unable to provided documented evidence that deep cleaning occurred for Rm 201 during the outbreak, and when to start and stop deep cleaning for rooms effected by scabies. 4. A review of an Inservice Sign In sheet for scabies outbreak dated 08/04/2024, indicated facility staff were educated about scabies. The scabies in-service was four months after Resident 2 was identified as possible scabies on 04/01/2024 and Resident 4 was identified on 04/05/2024, and an additional18 residents in the secure unit on 04/15/2024. 5. A review of Resident 2's medical record indicated she was admitted to the facility on [DATE], with diagnoses that included dementia, adult failure to thrive, prediabetes, and major depressive disorder. A review of the Minimum Data Set (MDS, a resident assessment) dated 04/12/2024, indicated Resident 2 has severe cognitive impairment. Resident 2 has a responsible party (RP) who makes health care decision for them. A review of skin/wound charting, dated 04/01/2024 at 1:03 pm, indicated Wound Doctor (WD) was in the facility to assess skin excoriation (a wound or scratch caused by picking at the skin) to back, chest and legs for Resident 2. WD ordered clobetasol 0.05% (ointment to be applied to the skin for eczema and psoriasis) twice daily for 14 days. WD documented a plan for a biopsy (a medical procedure that involves removing tissue or cells from the body for examination) if the skin wounds did not improve, consent was given from RP for biopsy. A review of skin/wound note, dated 05/08/2024 at 1:55 pm, indicated Resident 2 has a rash on bilateral chest, abdominal wall, bilateral hip and bilateral thigh red raised bumps, no fluid, resident was itching. MD was in house and assessed Resident 2. DON and IP were notified. A review of infection note documentation, dated 05/09/2024 at 2:05 pm, indicated Resident 2 had a rash across chest, abdominal wall, bilateral hip, and thigh. Mild bumpy redness some scabs noted. Scraping (remove skin for testing) performed in house negative for scabies confirmed by unidentified second nurse. Continue ivermectin (an anti-parasitic medication used to treat scabies) as ordered. Previous treatment of permethrin ineffective, tac cream (a topical corticosteroid used to reduce inflammation, itching, and redness) ineffective, hydrocortisone (a steroid medication can treat skin conditions) ineffective, environmental sciences instructed to deep clean room. A review of skin and wound note, dated 06/07/2024 at 2:54 pm, indicated Certified Nursing Assistant (CNA) reported Resident 2 had a rash on entire body. Pink/red raised skin rash on back, arms, shoulders, chest abdomen, and buttocks. Resident 2 complained of itching. A verbal order for [NAME] lotion (anti-itch lotion) twice a day until resolved. A review of skin and wound note, dated 07/25/2024 at 1:11 pm, indicated a call was made for a dermatology consult for Resident 2's ongoing rash. Dermatology appointment was scheduled for 07/26/2024 at 2 pm, over three months since RP gave permission and WD requested to arrange if rash unresolved. A review of an infection note dated 07/31/2024 at 6:46 am, a dermatology report indicated Resident 2 was positive for scabies and to continue treatment/isolation. Residents 2 and 4 were roommates in Rm 201 during the scabies outbreak. Review of Resident 4 medical record revealed the resident was admitted [DATE] with diagnoses that included Alzheimer's, dementia, and muscle weakness. Resident 4 has a RP who makes health care decisions for them. A review of the MDS dated [DATE] reveled that Resident 4 has sever cognitive impairment. A review of alert charting dated 04/05/2024 11:03 pm, 04/06/2024 10:53 pm, 04/0720/24 12:17 am, 04/08/2024 11:29 pm, 04/09/2024 11:02 pm, indicated permethrin 5% topical cream for possible scabies applied all over body and soul of feet not applied to face. A review of weekly skin observation dated 04/08/2024, 04/15/2024, 05/06/2024, 05/20/2024, 05/27/2024, 07/08/2024 indicated redness on the buttocks. A review of infection note dated 07/29/2024 at 1:37 pm, indicated that the resident was put on isolation for skin rash with unknown cause. A review of alert charting dated 07/31/2024 3:29 pm, 08/01/2024 3:10 pm, indicated resident is on isolation precautions for exposure to scabies, no itching noted. A review of infection note dated 08/05/2024 at 6:51 pm, indicated Resident 4 was on treatment for possible exposure to scabies. Buttocks and back of thighs have mild red bumps with evidence of scratching present. A review of IDT (interdisciplinary team) Skin Management note, dated 08/09/2024 3:58 pm, indicated rash to buttock, roommate positive for scabies treatment of ivermectin in place. During an interview on 02/28/2025, at 3 pm, IP stated that if they had a resident with possible scabies, they would put the resident on isolation precautions and notify the MD. IP confirmed the licensed nurses at the facility should not have performed the scraping for Resident 2. IP confirmed the only in-services they could find for direct care staff for scabies was dated 08/04/2024. During an interview on 03/19/2025 at 12:40 pm, MD stated that they did remember a few patients that were identified with scabies and was unaware that the line listings included 31 residents.

Based on interview and record review the facility failed to ensure the services provided for one of 31 residents (Resident 2) met professional standards of quality during an outbreak of scabies. This resulted in a widespread scabies outbreak over a six-month period and caused pain and suffering for all residents affected by the skin sores. Findings: A review of Resident 2's medical record indicated they was admitted to the facility on [DATE], with diagnoses that included dementia, adult failure to thrive, prediabetes, and major depressive disorder. A review of the Minimum Data Set (MDS, a resident assessment) dated 04/12/2024, indicated Resident 2 has severe cognitive impairment. Resident 2 has a responsible party (RP) who makes health care decision for them. A review of skin/wound charting, dated 04/01/2024 at 1:03 pm, indicated Wound Doctor (WD) was in the facility to assess skin excoriation (a wound or scratch caused by picking at the skin) to back, chest and legs for Resident 2. WD ordered clobetasol 0.05% (ointment to be applied to the skin for eczema and psoriasis) twice daily for 14 days. WD documented a plan for a biopsy (a medical procedure that involves removing tissue or cells from the body for examination) if the skin wounds did not improve, consent was given from RP for biopsy. A review of alert charting, dated 04/05/2024 at 11:05 pm indicated a new order for permethrin 5% topical cream (a cream to treat scabies) for possible scabies treatment needs to be done tomorrow, continue isolation per doctor order. The order for permethrin 5% to start on 04/05/2024 end on 04/07/2024. A review of a website resource of the Centers for Disease Control and Prevention (CDC) permethrin 5% cream can be applied to all areas of all the body from the neck down and is effective with a single application, however two or more applications each about a week apart may be necessary to eliminate all mites. During an interview on 03/19/2025 at 12:40 pm, Medical Director (MD) stated best practice is two treatments of permethrin is always beneficial in treating scabies, especially if you are seeing signs that the issue is not resolved. MD explained after two treatments it is considered resolved unless skin issues continue. A review of an outbreak line listing (tracking tool of infectious outbreaks) indicated on 04/15/2024 a possible resident outbreak of scabies on Station 1, a total of 18 residents. A review of WD progress note, dated 04/15/2024 and 04/29/2024 indicated excoriation on knee, forearm, thigh, lesion on back, wrist, hand, fingers dry skin. Clobetasol 0.05% to excoriated areas twice a day for 14 days. MD documented plan for biopsy if not improved. A review of skin/wound note, dated 05/08/2024 at 1:55 pm, indicated Resident 2 has a rash on bilateral chest, abdominal wall, bilateral hip and bilateral thigh red raised bumps, no fluid, resident was itching. MD was in house and assessed Resident 2. Director of Nursing (DON) and Infection Preventionist (IP) were notified. A review of infection note documentation, dated 05/09/2024 at 2:05 pm, indicated Resident 2 had a rash across chest, abdominal wall, bilateral hip, and thigh. Mild bumpy redness some scabs noted. Scraping (remove skin for testing) performed in house negative for scabies confirmed by unidentified second nurse. Continue ivermectin as ordered. Previous treatment of permethrin ineffective, tac cream (a topical corticosteroid used to reduce inflammation, itching, and redness) ineffective, hydrocortisone (a steroid medication can treat skin conditions) ineffective, environmental sciences instructed to deep clean room. A review of a website resource of the CDC an institution should maintain a high index of suspicion that undiagnosed skin rashes and conditions may be scabies even if characteristic signs or symptoms of scabies are absent. Skin scrapings should be obtained and examined carefully by a person who is trained and experienced in identifying scabies mites. A review of Resident 2's physician order dated 05/10/2024, indicated ivermectin (an anti-parasitic medication used to treat scabies) 12 milligrams (mg) given for one time only. A review of alert charting dated 05/12/2024 at 11:49 pm, 05/13/2024 at 11:38 pm, 05/14/2024 at 11:25 pm, and 05/15/2024 at 1:18 pm Resident 2 was still itching all over body. A review of WD note, dated 05/20/2024 indicated excoriation chest, arms, and leg, general examination skin: resolved back lesion, lower leg excoriation, wrist, hand fingers dry skin treatment resolved. A review of weekly skin assessments for Resident 2, dated 04/08/2024, 05/13/2024, 05/20/2024, 05/27/2024, 06/10/2024, 06/17/2024, 06/24/2024, 07/01/2024, 07/08/2024, 07/15/2024, 07/22/2024, 08/05/2024, and 08/12/2024 indicated there were no new skin issues noted. Only the weekly skin assessment from 07/29/2024 indicated any kind of rash on the body. A review of skin and wound note, dated 06/07/2024 at 2:54 pm, indicated CNA (Certified Nursing Assistant) reported Resident 2 had a rash on entire body. Pink/red raised skin rash on back, arms, shoulders, chest abdomen, and buttocks. Resident 2 complained of itching. A verbal order for [NAME] lotion (anti-itch lotion) twice a day until resolved. A review of nurse note, dated 06/07/2024 at 11:34 pm, stated prednisone (corticosteroid used to decrease inflammation) 40 mg to be given at bedtime for rash for 7 days, urgent dermatology consults for ongoing rash. A review of alert charting dated 06/08/2024 at 4:05 pm, 06/09/2024 at 2:55 pm, 06/10/2024 at 2:51 pm, and 06/11/2024 at 3:35 pm, indicated Resident 2 had rash on upper body, no signs and symptoms of infection. A review of nurse note, dated 07/24/2024 at 12:33 pm, indicated new order for A&D ointment (moisturizer to treat dry, rough, scaly, itchy skin and minor skin irritations) topically for skin rash. A review of skin and wound note, dated 07/25/2024 at 1:11 pm, indicated a call was made for a dermatology consult for Resident 2's ongoing rash. Dermatology appointment was scheduled for 7/26/24 at 2 pm, over three months since RP gave permission and WD requested to arrange if rash unresolved. A review of nurse note, dated 07/26/2024 at 4:54 pm, indicated Resident 2 went to dermatology appointment and saw physician who gave orders for permethrin external cream 5 % to be applied from neck to toe one time only for scabies, apply cream again in seven days on 08/03/2024. Give ivermectin 9 mg by mouth one time only for scabies until 07/27/2024. Repeat tabs again in one month on 08/27/2024. A review of an infection note dated 07/31/2024 at 6:46 am, a dermatology report indicated Resident 2 was positive for scabies and to continue treatment/isolation. A review of electronic Medication Administration Record note, dated 07/31/24 at 11:18 pm, indicated resident on contact precaution for unknown rash for possible scabies for 10 days. A review of Facility job description titled Job Description: Infection Control Nurse dated 02/2024 indicated the IP should assist in the scheduling of care plans to be presented and discussed at each committee meeting in relation to prevention and control of infection diseases. The IP should plan, develop, organize, implement, evaluate, coordinate, and direct our Infection Control Program. The IP should ensure that residents with known communicable or infection disease are placed in isolation or on infection control precautions. During an interview on 02/28/2025, at 3 pm, IP 2 stated there has been no training for licensed nurses on how to scrape the skin when testing for scabies. IP stated that if they had a resident with possible scabies, they would put the resident on isolation precautions, and call physician to do the scabies scraping. IP confirmed the licensed nurses at the facility should not have performed the scraping for Resident 2. During an interview on 03/06/2025 at 12:15 pm, DON confirmed that there was no physician order for the skin scraping to test for scabies for Resident 2 that was performed on 05/09/2024. DON confirmed licensed nurses were not trained on this procedure and it was not within their scope of practice to determine whether residents had scabies. During an interview on 03/19/2025 at 12:40 pm, MD stated they do not know who does the scrapings for scabies at the facility and that an experienced nurse who has been trained in scrapping for scabies should be the one performing a scraping. MD stated that they would not even do the scrapping themselves and would have another medical professional do the scrapping who was trained, as well as send it out to a laboratory to be tested .

Based on observation, interview, and record review, the facility failed to ensure the safety measures were provided to prevent accident hazards for three of five residents sampled for accidents (Resident 1, 4, 8) when the wheels attached to the headboard of the bed were not locked. This failure had the potential to negatively affect the residents' well-being and increased the risk of accidents or injuries to the residents. Findings: During a review of U.S. Food & Drug (FDA) document titled, A Guide to Bed Safety Bed Rails in Hospitals, Nursing Homes and Home Health Care: The Facts , revised 4/2010 , indicated that to meet the patients' needs for safety, keep the bed in the lowest positions with wheels locked was one of the recommended practices. During a review of the American Parkinson Disease Association (APDA) website document titled, Impaired Balance and Falls in people with Parkinson's Disease , dated 6/8/21, indicated, One of the most challenging symptoms of Parkinson's disease (PD) that fundamentally affects quality of life is balance impairment that can lead to falls. During a review of Resident 1's clinical record, indicated that Resident 1 was admitted to the facility on [DATE] with diagnoses which included right hip fracture, fall, and Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements) without dyskinesia (uncontrolled, involuntary muscle movement). Resident 1 was her own healthcare decision maker. During a review of Resident 1's Minimum Data Set (MDS - an assessment and care screening tool), dated 12/25/24, the MDS indicated that Resident 1 had a brief interview for mental status (BIMS) score of 15, at section C Cognitive Patterns indicating that her cognition was intact. During a review of Resident 1's MDS, dated [DATE], at the section GG (refers to a section on the MDS assessment form used in nursing homes, which stands for Functional Abilities and Goals; it specifically assesses a patient's ability to perform self-care tasks and mobility activities, including their admission performance, discharge goals, and how much assistance they require for these functions) - Functional Abilities - Admission, Self-Care and Mobility (Assessment period is the first 3 days of the stay), indicated that Resident 1 needed maximal assistance (helper does more than half the effort) for: 1. Toileting hygiene: the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. 2. Lower body dressing: the ability to dress and undress below the waist. 3. Sit to lying: the ability to move from sitting on side of bed to lying flat on the bed. 4. Lying to sitting on side of bed: the ability to move from lying on the back to sitting on the side of the bed and with no back support. 5. Sit to stand: the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed. 6. Chair/bed-to-chair transfer: the ability to transfer to and from a bed to a chair (or wheelchair). 7. Toilet transfer: the ability to get on and off a toilet or commode. During a review of Resident 1's Fall care plan, dated 12/19/24, indicated, Resident is at risk for falls with or without injury related to history of falls resulting in fracture/major injury, current mobility limitations related to recent hip fracture repair. During a review of Resident 4's clinical record, indicated that Resident 4 was admitted to the facility on [DATE] with diagnoses which included diabetes (high blood sugar), unspecified sequelae of cerebral infarction (known as the long-term effects of a stroke, can include: difficulty speaking, weakness or paralysis on one side of the body .), and muscle weakness. Resident 4 was her own healthcare decision maker. During a review of Resident 4's MDS, dated [DATE], the MDS indicated that Resident 4 had a BIMS score of 15, at section C Cognitive Patterns indicating that her cognition was intact. During a review of Resident 4's MDS, dated [DATE], at the section GG - Functional Abilities - Admission, Self-Care and Mobility (Assessment period is the first 3 days of the stay), indicated that Resident 4 needed moderate assistance (helper does more than half the effort) for: Toileting hygiene, Shower/bath, Lower body dressing, Sit to stand, Chair/bed-to-chair transfer, and Toilet transfer. During a review of Resident 8's clinical record, indicated that Resident 8 was admitted to the facility on [DATE] with diagnoses which included unspecified sequelae of cerebral infarction, abnormalities of gait and mobility, and dementia (a progressive state of decline in mental abilities). Resident 8 was his own healthcare decision maker. During a review of Resident 8's MDS, dated [DATE], the MDS indicated that Resident 8 had a BIMS score of 14, at section C Cognitive Patterns indicating that her cognition was intact. During a review of Resident 8's MDS, dated [DATE], at the section GG - Functional Abilities - Admission, Self-Care and Mobility (Assessment period is the first 3 days of the stay), indicated that Resident 8 needed moderate assistance (helper does more than half the effort) for: Toileting hygiene, Shower/bath, Lower body dressing, Sit to stand, Chair/bed-to-chair transfer, and Toilet transfer. During a concurrent observation and interview on 1/23/25, at 11:09 am, in Resident 1's room, Resident 1 stated she needed to go to the bathroom. She then pressed the call light, and the Assistant of Director of Nursing (ADON) entered the room within a minute and asked Resident 1 what Resident 1 needed. While Resident 1 told the ADON that she needed to go to the bathroom, the ADON told Resident 1 that she needed to find another staff to help her to transfer Resident 1 to the wheelchair. Resident 1 stated, No, I need to go now!! and insisted the ADON to stay with her. Resident 1 then attempted to sit up in the bed and tried to get out of the bed. While the ADON attempted to explain to Resident 1 the importance of the safe transfer, License Nurse (LN) A walked by Resident 1's room, LN A was asked to come into the room to assist the ADON. The ADON and LN A were observed positioning themselves on either side of Resident 1, while they were holding Resident 1's upper arms, and assisting Resident 1 to stand up from the side of the bed, the bed moved away from Resident 1. The ADON and LN A were then observed attempting to sit Resident 1 back down to the bed, Resident 1 was screaming and saying, No! No! I need to go now !! . Resident 1 was then assisted to sit down on the wheelchair and brought to the bathroom. The ADON later confirmed that Resident 1 had an accident (Resident 1 soiled herself) and she had to help Resident 1 to clean up. Inspection of Resident 1's bed with the Director of the Maintenance (DOM), the DOM confirmed that the bed wheels at the headboard were not locked. The DOM stated, It's not my job to check each bed and to make sure the wheels were locked. The ADON stated, CNAs should have checked the wheels were locked It usually happened while the CNAs were providing shower to the resident, they had to move the bed to use the lifter, and perhaps forgot to lock the wheels The ADON agreed that Resident 1 could have fallen if the staff were not with her. During a concurrent observation and interview on 1/23/25 at 11:19 am, with the DOM, in ROOM D, observed the DOM pushed the bed that near the entrance door (bed A), and the bed was moved. The DOM confirmed that the wheels at the headboard of the bed were not locked. During a concurrent observation and interview on 1/23/25 at 11:30 am, in ROOM E, with the ADON, observed the ADON pushed the bed that near the entrance door (bed A), and the bed was locked, the bed did not move. The ADON stated, I expected the bed wheels to be locked at all times. CNAs should ensure all the wheels were locked while providing care to the residents. During a concurrent observation and interview on 1/23/25 at 11:40 am, in Resident 8's room, observed Resident 8 was lying in bed, and the ADON confirmed the wheels at the headboard of the bed were not locked. Observed the ADON pushed the bed, and the bed was moved. Resident 8 stated, Wow, I did not know it wasn't locked. During a concurrent observation and interview on 1/23/25 at 11:43 am, in Resident 4's room, observed the Occupational Therapy (OT) transferring the roommate from standing to sitting position from the bed. Observed Resident 4 was lying in the bed, while inspected Resident 4's bed, the wheels at the headboard of the bed were not locked and the bed was moved. Resident 4 stated, Oh, I did not know it was not locked. The OT stated, It happened to me couple times. The bed was moved while I was trying to get the residents out of the bed. I was by myself, so I had to sit the residents back down, lock the wheels, and get the residents up again The residents could have a fall if the bed was not locked! During an interview on 1/23/25, at 2:07 pm with DON, in DON's office. The DON stated, I could not find a policy for bed safety; however, the staff need to ensure the wheel brakes were locked. It should be CNAs' job to make sure it's locked. If it's malfunction, it would be the maintenance's job.

Based on interview and record review, the facility failed to provide the necessary care and services to one of three sampled residents (Resident 1) to attain or maintain Resident 1's highest practicable physical, mental, and psychosocial wellbeing in accordance with Resident 1's comprehensive assessment and plan of care when: 1. Resident 1's urinalysis (UA, a urine specimen that determines if there is a bacterial infection in the urine) was not obtained when the physician placed the order on 11/9/2023. 2. The facility failed to notify the physician that the above order was not completed. 3. The facility failed to notify the physician in a timely manner when the second UA was sent on 11/17/2023 (7 days after the initial UA was ordered), and the Urine Culture (a lab test to check for bacteria or other germs in a urine sample) was reported on 11/19/2023. The physician was notified on 11/22/2023, 6 days after it was collected, and 3 days after it was reported. 4. The facility failed to ensure the Infection Control department verified Resident 1's urinary infection result, and the physician was notified with the choice of antibiotics. These failures resulted in delayed treatment (a total of 14 days delayed), increased pain and discomfort. Resident 1 was later transferred to Hospital 1 on 12/3/2023, with diagnoses which included hemorrhagic cystitis (a condition in which the bladder lining becomes inflamed, leading to hematuria (blood in the urine) and pain.) Findings: During a review of Resident 1's clinical record, indicated that she was admitted to the facility on [DATE] with diagnoses which included end stage renal disease (a person's kidneys cease functioning on a permanent), dependence on renal dialysis (the process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally), diabetes (high blood glucose), and muscle weakness. Resident 1 was her own health care decision maker. During a review of Resident 1's Minimum Data Set (MDS - an assessment and care screening tool), dated 10/27/2023, the MDS indicated that Resident 1 had a brief interview for mental status (BIMS) score of 12, at section C Cognitive Patterns indicating that her cognition was moderately impaired. During a review of Resident 1's progress note titled, Nursing Practitioner Note, dated 11/9/2023 at 10:39 am by the Nurse Practitioner (NP), indicated, Resident 1 reported burning urination, will collect UA with culture if indicated . During a review of Resident 1's physician order, indicated an order of UA with culture If indicated .blood in stool was placed on 11/9/2023. During a review of Resident 1's progress note, dated 11/9/2023 at 6:57 pm by License Nurse (LN) 5, the note indicated, Received order to collect UA with culture if indicated . During a review of Resident 1's Medication Administration Records (MARs) in 11/2023, indicated a UA with culture, one time only for discomfort/blood in stool was ordered on 11/10/2023. The order was marked by the LN 6's initial at 10:58 pm, which indicated that the order was completed, and the urine sampled was collected by LN 6. However, an UA report for 11/10/2023 was not found in Resident 1's medical record. During a concurrent interview and record review on 12/5/2023 at 3 pm with the DON, Resident 1's 11/2023 MARs and progress notes were reviewed. The DON acknowledged that Resident 1 had an UA with culture order on 11/10/2023, and the DON agreed that the record indicated that the sample was collected by LN 6, however, the DON confirmed that she could not locate the UA laboratory report. LN 6 was not available for interview. During a concurrent interview and record review on 12/5/2023 at 4:26 pm with LN 5, Resident 1's Progress note, Received order to collect UA with culture if indicated ., dated 11/9/2023 at 6:57 pm by LN 5, was reviewed. LN 5 said that she printed out the order and put it in the communication binder for the next shift to review and complete. She said the process was to let the nurse know, and when the night shift came, they would collect it. They generally would collect it in the morning . LN 5 said her shift finished at 8:30 pm and she did not know whether the order was completed or not. During a review of Resident 1's laboratory report record, indicated an UA with culture was done on 11/17/2023, the culture results were received on 11/19/2023. The record indicated: 1. There were two organisms found in Resident 1's Urine Culture. One was Escherichia Coli (E. Coli, a bacterium that is commonly found in the gut of humans, can cause infections in the gut, urinary tract (the body's drainage system for removing urine). The other organism was Morganella Morganii (a bacterium that is commonly found in the feces of humans). 2. A physician's initial and a circle around the bacterium of E. Coli (made by MD) were noted on the first page of the report (a total of 5 pages), dated 11/22/2023, along with a written order, Macrobid (an antibiotic that killed the bacteria)100 mg, by mouth, twice a day x 7 days. 3. There was no circle made around the bacterium of Morganella Morganii. 4. Morganella Morganii had high resistance to the antibiotic chosen by MD, which meant that the antibiotic- Macrobid would not kill this bacterium and the bacteria would continue to grow in Resident 1's urinary tract. During a review of Resident 1's progress notes, dated 11/28/2023 at 7:55 am by Infection Preventionist (IP)1, indicated that the IP 1 noticed Resident 1's UA had over 100,000 colonies of E. Coli. Sample may have been contaminated (been soiled). Will see MD (Medical Doctor) wants to redo the UA . During a review of Resident 1's record titled, Emergency Department (ED) Physician Notes from Hospital 1's Emergency Department Reports, dated 12/3/2023, at the section of Medical Decision Making, the record indicated: 1. UA was obtained by the Registered Nurse, and appeared thick and grossly bloody, suspect cause of worsening anemia, likely hemorrhagic (bleeding) Urinary Tract Infection . 2. Resident 1 was diagnosed with Hemorrhagic Cystitis (inflammation of the bladder). During an interview on 12/5/2023 at 11:57 am, with Family 1, Family 1 stated that Resident 1 had become very disoriented on 12/3/2023 and was transferred to Hospital 1. Family 1 stated: 1. The doctor in ER was trying to get urine sample. They had to put a catheter in her. They showed me the catheter after it was removed. The catheter had sludge on it - a coffee ground color with some red color. The doctor told me It didn't look good. 2. The doctor told me There's no way this would happen overnight. Either they did not send her urine culture, or they did not give her antibiotic . During a concurrent interview and record review on 12/5/2023 at 12:41 pm with the Director of Nursing (DON), Resident 1's urine culture report, dated 11/19/2023, was reviewed. The DON stated that a Urine Culture report usually took 72 hours to get back. The DON was unable to answer why the MD did not receive the report and start the antibiotics on 11/19/2023. The DON stated that the facility received the lab report from the fax machine, I heard the medical record was saying that something happened to the fax machine . During a concurrent interview and record review on 12/5/2023 at 4:42 pm with Infection Preventionist (IP) 1, Resident 1's IP progress note, Resident 1 UA had over 100,000 colonies of E. Coli. Will see MD wants to redo the UA ., dated 11/28/2023 at 7:55 am by IP 1, was reviewed. The IP 1 stated she had become the Director of Staff Development (DSD) in December, and she did not know whether MD was notified or not. IP 1 stated I would have to follow up with the new IP - IP 2 and the MD, I would get back to you . (IP 1 had never gotten back to this surveyor) During a concurrent interview and record review on 1/2/2024 at 10:28 am with the MD, the MD stated: 1. She would expect to receive the Urine Culture report within 72 hours after the urine was collected. 2. She only received the first page of the 5-page Urine Culture report, and she admitted that she did not see the second organism (Morganella Morganii) even though it was indicated on the first page of the report. 3. Neither IP 1 nor IP 2 had notified her about the results of Resident 1's UA and Urine Culture report. She said that the nursing staff did not discuss with her whether they needed to repeat Resident 1's UA or not. 4. She agreed that not having been treated with correct antibiotic might have caused Resident 1's hemorrhagic cystitis. MD stated, Something went wrong here; we are trying our best to fix it. I felt really bad about this. This shouldn't happen to anybody. I had discussed with the DON, and told her that we needed to update our communication binder . During a concurrent interview and record review on 1/2/2024 at 12:04 pm with IP 2, the IP 2 stated: 1. She was still a floor nurse on 11/9/2023, Resident 1 was her patient. She noticed the blood coming out of Resident 1's rectum. IP 2 notified NP and NP ordered UA with culture. She said that she had a busy day and wasn't able to collect the urine sample, so she notified the PM shift and was hoping the PM shift would complete the order. IP 2 said from 11/9/2023 to 11/12/2023, I did not know what happened. It was not collected. I didn't know where the order went. On 11/17/2023, Family 1 called me and asked about the UA result, I could not find it, so I called MD to get the order . 2. She became IP on 11/20/2023, and she was trained with an IP consultant. 3. She admitted that herself and the IP consultant reviewed Resident 1's Urine Culture report and they also missed the second organism. She said, we only saw E. Coli. 4. IP 1 left Resident 1's UA report on her desk with a note stating, take a look, E. Coli over 100,000 . She said that she was new, she did not know what to do, so she showed it to the IP consultant, and she was told that E. Coli was a common bacterium, Resident 1 already had Macrobid, so they did not alert MD.

Based on observation, interview and record review, the facility failed to maintain acceptable parameters of nutritional status when staff did not identify insidious weight loss (gradual, unintended, progressive weight loss over time), implement or modify a plan of care that was individualized and consistent with the resident's needs or preferences for one of four sampled residents. (Resident 19) These failures resulted in severe weight loss and put Resident 19 at risk for further health decline. Findings: Review of the policy and procedure titled, Weight Assessment and Intervention, dated 2001 and revised April 2012, indicated the Dietician will review the resident's weights, following trends over time. Negative weight trends will be evaluated by the treatment team. Severe weight loss is defined as greater than 5% loss in one month, greater than 7.5% loss in three months and greater than 10% loss in six months. Information is to be analyzed by the multidisciplinary team, conclusions made, identify causes, including Inadequate availability of food or fluids. Care plans will be updated, and interventions should consider resident preferences and functional factors. A review of records indicated Resident 19 was admitted to a secured unit for residents with Dementia (general term for memory loss, also known as Alzheimer's Disease) on 5/20/2021. Resident 19 was admitted with a diagnoses of Alzheimer's Disease, Major Depressive Disorder (continuous feelings of sadness and loss of interest) and Cervicocranial Syndrome (bones in the neck do not line up, can cause pain in the head, face, ears, and vision problems). A review of the Vital Records, upon admission Resident 19 weighed 126.3 pounds and had a body mass index (BMI, a calculation that uses a person's height and weight to measure body fat) of 22.37. BMI calculator (used to determine if a person is overweight, at an ideal weight or underweight) from National Heart, Lung, and Blood Institute (NIH, nhlbi.nih.gov) stated that a person with a BMI of 18.5-24.9 had a normal weight and less than 18.5 was underweight. A review of the record titled, Nutritional Care Plan, dated 5/20/2021, initiated by Licensed Vocational Nurse (LVN) 1 indicated Resident 19 was at risk for altered nutritional status, malnutrition and dehydration related to chewing/swallowing issues, fluid restrictions, [CONDITION(S)] (procedure to remove waste and fluid from the blood when the kidneys stop working) and planned weight loss. The Nutritional Care Plan indicated prior to admission Resident 19 had a BMI less than 19, complained about the taste of many foods, Hospice (end of life care for people with six months or less to live), anorexic medications (medication that increases the desire to eat), enteral feeding (tube feeding), and [CONDITION(S)] (extra fluid under the skin that causes swelling). The nutritional care plan contained long-term goals for Resident 19; eating and drinking 50-100% of meals/drinks, no signs and symptoms of dehydration, no complaints of hunger or thirst, will tolerate tube feedings, will have no further weight loss, and will have no further weight gain. A review of Resident 19's record indicated no diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Records did not support the problems listed in the Nutritional Care Plan for chewing/swallowing issues, fluid restrictions, [CONDITION(S)], planned weight loss, BMI less than 19, complains about the taste of many foods, Hospice, anorexic medications, enteral feeding or [CONDITION(S)]. A review of the record indicated on 5/24/2021, Food and Nutritional Services (FNS) updated the care plan's problem section, removing all the problems mentioned above and replaced it with at risk for Altered Nutritional Status, Malnutrition and Dehydration Related To diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The interventions had not been changed. A review of Food and Nutrition note dated 5/24/2021, indicated Resident 19's usual body weight was unknown, had no swallowing issues, feeds self, eats 76-100% of meals, had a weight of 126.3 pounds on admission, is 63 inches tall (five feet, three inches) tall, and had a BMI of 22.37. Resident 19 had a normal BMI upon admission. The document indicated to perform weekly weights for 4 weeks. A review of the Physician's Orders did not indicate an order was placed for weekly weights. A review of the record titled, Vitals Report dated 5/25/2021 indicated Resident 19 weighed 124.3 pounds and the BMI was 22.02. That indicated a 1.58% weight loss. Resident 19 lost 2 pounds in 5 days. A review of the record titled, The Minimum Data Set, (MDS, a resident assessment) dated 5/27/2021, titled Cognition Patterns, showed Resident 19 had a score of 03, severely impaired cognition (memory, judgement, reasoning). Section G under eating, indicated she required supervision oversight and set up help only with meal. A review of the record Nutrition Observation note dated 5/27/2021, written by Registered Dietician (RD) 2, indicated that Resident 19's weight was stable, on a regular diet that provided 2400 kilocalorie (a different word to describe calories), 105 grams of protein, resident's meal intake had been excellent since admission, overall meeting est (estimated) nutritional needs and that Resident 19 does pace back and forth in the halls. Resident 19 record contained no documentation of enteral feeding, a nutrition diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The RD 2 indicated to Continue with diet as ordered. A review of the Nutritional Care Plan indicated that it had not been updated to reflect changes. A review of the Vitals Record dated 6/1/2021, indicated that Resident 19 weighed 117.5 pounds and had a BMI of 20.8, triggering a warning stating that Resident 19 had a 5% change in weight in 30 days. That indicated a 6.97% weight loss. Resident 19 lost 8.8 pounds in 12 days which was the first decrease in weight that was considered severe. A review of record titled, Progress Note dated 6/3/2021, the RD 3, indicated Resident 19 was meeting nutrition needs despite 6.8-pound weight loss, continuing to pace up and down the hallway, had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . RD 3 recommended to continue with current nutritional needs, change the diet to a fortified diet (adding nutrients to food) and adding a health shake three times a day (TID). There was no change to the nutritional goals for the amount of meals consumed and the weight goal remained the same. The plan included fortifying current diet order and to initiate health shakes three times a day. A review of the Nutritional Care Plan indicated the goal section was modified adding weekly weights for 4 weeks and a weight goal of 125 pounds, add or minus 3 pounds. There had been no changes added to the interventions. A review of the records did not indicate a weekly weight order was entered. Progress Note dated 6/4/2021 entered by Infection Preventionist (IP) indicated the RD weight meeting indicated a 6.8-pound weight loss in one week. This was the only note in the record indicating a weight meeting took place from 5/20/2021 through 12/2/2021. There was no Interdiciplinary Team Meeting (IDT- group of healthcare disciplines that discuss resident care needs) notes found in Resident 19' record. A review of Nursing/Dietary Communication dated 6/8/2021, indicated that Resident 19 did not sit long enough to eat, requesting finger foods Resident 19 can carry around to eat. A review of the record indicated that no new diet order including finger foods had been entered. A review of Vital Record indicated on 7/6/2021, Resident 19 weighed 110.9 pounds and had a BMI of 19.64. That indicated a 12.19% weight loss. Resident 19 lost 13.4 pounds in 47 days which remained severe. A review of the Progress Note dated 7/15/2021, entered by RD 1 indicated Resident 19 had a 12.2% weight loss since admission, variable meal consumption, not meeting needs, increase energy expenditure due to pacing, limited ability to sit long enough to eat. Meal consumption fluctuates 25-85% with average intakes of 51%. RD 1 recommended finger foods as a regain of lost weight and indicated the goal weight was 125 pounds. The plan indicated an increase in meals greater than or equal to 60-65%. A review of the Care Plan indicted that on 7/15/2021, RD1 made changes to Resident 19's Care Plan. RD1 changed the problem statement to inadequate intake related to not meeting needs. That was evidenced by a less than or equal to 50% meal intake with signs of weight loss since admission, regain of lost weight- plus 2-4 pounds a month, with the same goal weight of 125 pounds and did not recommend weekly weights. There had been no changes to the interventions. A review of the record did not reflect a diet change order for finger foods had been entered. A review of Vitals Report dated 8/3/2021 indicated Resident 19 weighed 108.8 pounds and had a BMI of 19.27, nearing the lower end of a normal BMI. That indicated a 13.86% weight loss. Resident 19 lost 15.5 pounds in 76 days, which remained severe. There was 19 days where no weights were documented. (7/6/2021 through 8/3/2021) A review of MDS for Nutritional Status dated 8/27/2021, indicated the Resident 19 did not have a weight loss of 10% or more in the last 6 months and weighed 109 pounds, although her record reflected a severe weight loss. Section G eating, indicated she required supervison oversight and set up help of meal. A review of Progress Note dated 8/30/2021, FNS entered a quarterly dietary Progress note indicating Resident 19 had an intake range of mostly 76-100% meals and snacks, down 2 pounds in 28 days, continue plan of care, weekly weights. A review of the record indicated no weekly weight monitoring for severe weight loss was performed for Resident 19 from 6/15/2021 through 9/7/2021. A review of Vitals Report dated 9/7/2021, Resident 19 weighed 106.8 pounds and had a BMI 18.92. Resident 19 lost 17.5 pounds in 111 days, indicating a 15.44% weight loss, and remained severe. A review of Progress Note dated 9/9/2021 entered by RD 1, indicated Resident 19 had a 15.4% weight decrease since admission, significant, not desirable. RD 1 recommended a medication to enhance appetite, finger foods and to monitor weight and meal consumption, 14 weeks after weight loss was identified. A review of the Nutritional Care Plan dated 9/9/2021 indicated RD1 updated the problem list to include unavoidable risk factors of weight decline. The goal section was modified to remove the weight goal. No changes to the interventions were noted. A review of Progress Notes dated 9/10/2021, indicated the Director of Staff Development (DSD) entered an event related to weight changes. The note indicated a 10% weight loss, to start weekly weights, change diet to finger foods, and follow up with the doctor about the appetite stimulant. A review of the record indicated no physician orders were entered for the appetite stimulant, weight monitoring or weekly weights. A review of the Physician Order report indicated a diet of fortified finger foods had been entered on 9/10/2021, 94 days after the first recommendation for finger foods was documented. A review of the Physician Order Report, indicated on 9/21/2021 [MEDICATION(S)] (medication to enhance appetite, also known as [MEDICATION(S)]) was ordered, 12 days after RD 1 entered the recommendation. A review of the Vitals Record dated 9/21/2021, indicated a weight of 104.9 pounds and a BMI of 18.58, this is the low end of normal which indicated Resident 19's weight was declining to an unhealthy level. Resident 19 lost 19.4 pounds in 124 days, indicating a 16.94% weight loss which remained severe. A review of Vitals Record dated 10/19/2021 indicated Resident 19 weighed 103.2 pounds and had a BMI of 18.28, classified as underweight. This reflected a 21.1-pound, 18.29% weight loss over 152 days which remained severe. A review of the record did not indicate any changes to the Plan of Care had been made. The only weight meeting note found in the record was dated 6/4/2021. A review of Vitals Record dated 11/2/2021 indicated Resident 19 weighed 102.5 pounds and had a BMI of 18.16. Resident 19 remained underweight and continued to lose weight. This indicated a loss of 23.8 pounds, an 18.84% weight loss in 166 days. Resident 19 remained underweight with a severe weight loss with no weekly weights taken from 10/19/2021 through 11/2/2021 despite recommendations made. No weights were entered after 11/2/2021 through last record review of 12/2/2021. A review of the record titled, MDS dated [DATE], Section G under eating, indicated she required supervision oversight and set up help only with meals. A review of the Progress Note entered on 11/21/2021 by FNS indicated Resident 19 consumed 51-75% of meals, weighed 102.5 pounds, was underweight, continue current plan of care and monthly weights. A review of the Nutritional Care Plan indicated that on 11/29/2021 Registered Nurse (RN) 1 updated the goal section changing the long-term goal date from 7/20/2021 to 1/29/2022. The intervention section remained unchanged from 5/20/2021 to 11/29/2021. During a concurrent observation and interview on 11/29/2021 at 3:35 pm, Resident 19 was observed pacing the hallway continuously and wearing baggy clothes. While pacing the hallway with Resident 19, an interview was attempted. Resident did not answer questions; however, did state Yes when asked if hungry. During a concurrent observation and interview on 12/01/21 at 12:27 pm, lunch trays were served in the dining room. Resident 19 was not able to sit long enough to eat the meal due to the need to pace the hallway. Staff had to redirect Resident 19 to the lunch tray multiple times. Resident 19's lunch tray consisted of noodles, green beans, a bowl of cut up meat, an unopened bag of potato chips, a small bowl of red liquid, a glass of juice, milk and a nutritional health shake. Resident 19 ate most of the noodles and green beans. The rest of the meal, including the fluids, had been untouched. Resident 19 began pacing the hallway without any further interventions provided. Certified Nursing Assistant (CNA) B stated she would document Resident 19's lunch tray as 75% of meal eaten. A second review of the meal tray was performed, CNA B agreed that Resident 19 did not eat any protein or drink any of the fluids. CNA B stated that Resident 19 ate 75% of the meal. Another staff member overheard this conversation and called the kitchen for a finger food meal substitute. Staff encouraged Resident 19 to sit down and eat the substituted finger food meal (a grilled cheese sandwich). Resident 19 did not sit and continued to pace the hallway and dining room. A staff member handed half of the substituted, finger food (grilled cheese sandwich) to Resident 19. While pacing the hallway and dining room, Resident 19 ate 100% of the substituted grilled cheese sandwich. During a concurrent interview and record review on 12/2/2021 at 1:56 pm, RD 1 confirmed Resident 19 was at high risk for weight loss upon admission due to weight loss of 100 pounds prior to admission, pacing (walking back and forth) and having dementia. RD 1 stated that some of the recommendations made had not been implemented correctly or in a timely manner, such as weekly weights, finger foods and an appetite stimulant. RD 1 stated that weekly weights had not been completed as requested and there was a delay in placing Resident 19 on an appetite stimulant. RD1 stated that Resident 19 had a significant weight loss, with the most weight lost between the months of June and July. RD 1 was not aware that Resident 19's weight loss from admission to current totaled -18.81%. RD 1 confirmed -18.81% was a severe weight loss. RD 1 stated that the RD recommendations go to the Director Staff Development (DSD) then to the Director of Nursing (DON) to be followed up. RD 1 also stated an inability to review the data the DSD entered into the record due to not knowing where the documents are located. RD 1 stated that she was unaware that meal percentages had been entered incorrectly but knew that staff had been in-serviced and trained on calculating meal percentages. RD 1 stated some of the information used for RD assessments (percentages of meals, snacks and supplements) are obtained directly from the Vitals Records where staff recorded meal percentages and through communication with staff. RD 1 agreed that if Resident 19 had been eating 75-100% of all meals, supplements and snacks as documented, the weight loss might not be so severe. A review of food items delivered to Resident 19 was discussed with RD 1. RD 1 stated that noodles are not a carry and go finger food. RD 1 also stated that there were two other RD's (RD 2, RD 3) monitoring resident weights. RD 1 stated they have been short staffed in the kitchen and has had to perform other roles such as cooking and meal prep so that meal trays are delivered on time. This made it difficult to perform all RD duties since days worked at this facility were already limited. RD agreed that Resident 19 required more staff monitoring and assistance during meal time. During a concurrent interview and record review with Licensed Vocational Nurse (LVN) 1 on 12/6/2021 at 10:52 pm, LVN 1 stated finger foods are described as anything you can hold in your hand with your finger. LVN 1 stated that dietary staff are responsible for making sure the food on the plate was what had been ordered. LVN 1 stated that finger foods were ordered on 9/10/2021. LVN 1 also stated that the nurse was responsible for reviewing the tray card and tray to make sure the tray being served was correct. LVN 1 stated on 12/2/2021 the DSD assigned a new in-service that taught a new way to calculate meal percentages. (the amount of food eaten). LVN 1 stated Can't say for sure if they come back to make sure if new training was understood. During a concurrent interview and record review with the DSD on 12/6/2021 at 11:30 am, the DSD confirmed that Resident 19 was at high at risk for weight loss due to dementia, pacing and 100-pound weight loss prior to admission. DSD stated that he was on leave of absence (LOA) March through June of 2021 and was not present during the initial weight loss for Resident 19 and was not aware of which staff members if any had followed up on DSD duties while on LOA. The DSD requested finger foods and for a follow up on the appetite stimulant 9/10/2021. DSD stated that maybe he needed to be more specific with finger foods, Sitting versus standing to the kitchen and staff. DSD assigned a new in-service to all staff on 12/2/2021. This in-service taught staff a more accurate method of calculating meal percentages. The DSD also shared a card that all staff should wear. It had picture samples of what a meal percentage should be based off the amount of food missing off the plate. During a concurrent interview and record review on 12/6/2021 at 11:41am, DON confirmed Resident 19 was at a high risk for weight loss due to dementia, prior 100-pound weight loss and pacing. DON stated that health shakes were ordered in June, That should help. DON was not aware that Resident 19 does not always drink health shakes. DON was unsure of which staff members monitored resident weights during the DSD's LOA or who attended the weight meetings. DON stated she will go back and look at the record.

Based on observation, interview, and record review, the facility failed to provide adequate supervision to each resident and identify, evaluate, prevent and monitor avoidable falls for two of 20 sampled residents (Residents 7 and 17) when: 1. For Resident 7, the facility failed to have a comprehensive, individualized plan of care to meet Resident 7's supervision and care needs and to prevent injuries of unknown origin, resident to resident altercations, falls and falls with injuries, from July 2016 through May 2017. These failures resulted in Resident 7 sustaining lacerations (deep cuts) to her head after three separate falls, requiring staples (u-shaped metal units used for skin closure) to her head wounds on 12/4/16, 4/8/17, and 5/5/17 from avoidable falls/accidents. Due to an immediate threat to Resident 7's health and safety, an immediate jeopardy (IJ) situation was called on 5/11/17 at 12:10 pm, in the presence of the Nursing Home Administrator (Admin) and Director of Nurses (DON) for lack of adequate supervision and care to prevent falls and accident hazards and protect Resident 7, and potentially other residents, from further injuries. The IJ was removed on 5/12/17 at 4:01 pm in the presence of Admin and DON. 2. For Resident 17, the facility failed to have a comprehensive, individualized plan of care to meet Resident 17's supervision and care needs to prevent falls and to provide evidence of completed hourly checks, as determined to be necessary by the Interdisciplinary Team (IDT, staff from different disciplines that meet to review and evaluate resident care needs). These failures resulted in avoidable falls/accidents for Resident 17. These failures had the potential for other residents who are at risk for injury from falls or accident hazards to be injured. Findings: 1. Resident 7 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 7's most recent quarterly Minimum Data Set (MDS, resident assessment), dated 1/27/17, indicated Resident 1 had a brief interview for mental status (BIMS, cognitive assessment) score of one, which indicated Resident 7 was severely cognitively impaired. The MDS indicated Resident 7 required supervision with one person assistance for walking in her room and in the facility's hallway. The facility's initial fall risk assessment for Resident 7 indicated she was at risk for falling in the facility due to a history of falls at home and while in the hospital. Resident 7's MDS stated her vision was adequate (sees fine detail, such as regular print in newspapers/books). During an initial tour of the facility on, 5/9/17 at 9:10 am, Resident 7 was observed walking down the hallway, with a quick shuffled gate. Resident 7 was noted to have 10 staples to a wound that was located from the top of her forehead into her hairline. Resident 7 had swollen discolored areas around her eyes. Resident 7 was observed walking into another residents room and then quickly returned to the hallway, where she proceeded to wander up and down the hallway. Resident 7 was observed without direct supervision and was allowed to wander in and out of other residents rooms. During a concurrent interview and observation on 5/9/17 at 9:48 am with a certified nursing assistant (CNA 1), CNA 1 stated Resident 7 frequently walked around the locked unit (locked area of the facility designated for residents with dementia), without ever sitting down. Resident 7 was observed walking into room numbered 137 (this was not Resident 7's room) and lying down in another residents bed for a few seconds, prior to getting back up and pacing around again. CNA 1 stated, Resident 7 seemed to prefer room 137 and that staff attempted to encourage Resident 7 to rest. CNA 1 stated Resident 7 had fallen and that is why she had a head wound with staples and bruised, swollen eyes. During an observation, on 5/9/17 at 1 pm, Resident 7 was observed walking in and out of the locked unit dining room area with a plastic fork in her hand. Resident 7 attempted to grab another resident's food and was redirected out of the dining area by staff. Resident 7 was given a peanut butter sandwich and proceeded to walk the hallways while eating her sandwich. During an observation, on 5/10/17 at 5:15 pm, Resident 7 was walking out of room number 137 (this was not Resident 7's room). During a concurrent observation and interview with Licensed Nurse (LN) C on 5/10/17 at 5:20 pm, LN C stated Resident 7 had been placed on 1:1 supervision (staff designated to directly supervise the residet at all times) until a special helmet arrived that would be used to prevent a head injury from falls. Resident 7 was observed being followed by a facility staff member. During an interview with the Director of Nurses (DON), on 5/10/17 at 5:30 pm, she indicated interventions had been put in place to help with Resident 7's injuries from falls. DON stated the plan for Resident 7 was to prevent injuries from falls. The plan did not include prevention of falls. DON stated one new intervention was to place a helmet on Resident 7 to reduce head injury when she falls. Another intervention was to decrease Risperdal (a drug used to treat psychotic disorders and works by changing the effects of chemicals in the brain) due to Resident 7 having a lean to the left when she walked and a more unsteady gait. During a record review, Resident 7's April and May 2017 Physician order [REDACTED]. The electronic order and MARs for Risperdal both had special instructions to give Risperdal 1.5 milligrams (mg) instead of the 1 mg that was ordered by the physician on 4/10/17, the intervention to reduce the Risperdal dose, to prevent injuries from falls, was not followed correctly and was not monitored or evaluated for effectiveness from 4/10/17 through 5/11/17. Lexicomp, an online pharmaceutical resource, indicated Risperdal may increase the risk for falls due to sleepiness, low blood pressure, low blood pressure when standing, loss of balance control, shuffling walk and stiffness or weakness of the arms and legs. Risperdal is not approved for use of psychotic conditions related to dementia. Risperdal should be avoided in residents [AGE] years or older with dementia due to increased risk of death, increased risk of stroke, and a greater rate of cognitive decline with use. Resident 7's record included IDT notes, nursing progress notes, and care plans which were reviewed on 5/10/17 at 2:30 pm. Resident 7's record indicated Resident 7 had witnessed falls/accidents, unwitnessed falls/accidents, injuries of unknown origin, and was involved in resident to resident altercations as follows: June 2016 A nursing progress note, dated 6/10/16 at 9:33 am, indicated Resident 7 was re-admitted to the facility on [DATE]. An at Risk for Falls Care Plan, dated 6/9/16, indicated Resident 7 was at risk for falls related to constant pacing, wandering behaviors, poor safety awareness, antidepressant use (medication used to treat prolonged feelings of sadness), antipsychotic use (medication used to treat behavioral disturbances) history of falls and poor vision. Resident 7's risk for falls care plan indicated the long term goal was for Resident 7 to have reduced risk for injury due to falls for 3 months. The care plan interventions included call light within reach, provide verbal reminder/cues to ask for assistance as needed, position bed in the lowest position, rehab screen as needed, medication regimen review as indicated and provide proper, well maintained footwear, and orient to new environment as indicated. July 2016 An IDT note, dated 7/1/16 at 10:07 am, indicated Resident 7 had an abrasion to her right inner upper arm and she was unable to verbalize how the injury happened; and An IDT note, dated 7/28/16 at 10:37 am, indicated Resident 7 was involved in a resident to resident altercation when Resident 7 was walking down the hallway with a pillow. The other resident involved stated the pillow was hers and grabbed the pillow. Both residents started to hit and slap each other with open hands. September 2016 An IDT note, dated 9/8/17 at 10:06 am, indicated Resident 7 had a fall. Resident 7 walked into a chair and fell down face first. No injuries were documented; and An IDT note, dated 9/19/16 at 10:42 am, indicated Resident 7 fell in the dining room on 9/17/16 during lunch. Resident 7 was found on the floor next to her chair. The at risk for falls care plan was updated on 9/27/16, with interventions that included, shoes to be worn by Resident 7 if she will allow, encourage the resident to attend activities and social services to assess for any pants that are too long and notify family. December 2016 An IDT note, dated 12/5/16 at 10:45 am, indicated Resident 7 was found on the floor, on her back, in the dayroom, on 12/4/16 at 2:10 pm. Resident 7 was found to have a head wound to the back of her head. A nursing progress note, dated 12/4/16 at 6:54 pm, indicated Resident 7 required two staples to head wound; An IDT note, dated 12/14/16 at 10:14 am, indicated Resident 7 tripped on her own feet and fell in the dining room, on 12/13/16 at 4:30 pm. Resident 7 had landed on her right arm. There were no updated interventions to the fall risk care plan, despite Resident 7 falling and hitting the back of her head requiring staples to the wound, on 12/4/16. January 2017 An IDT note, dated 1/4/17 at 9:41 am, indicated Resident 7 had a skin tear to her left forearm. The noted indicated Resident 7 probably bumped her arms in the hallway. There was no care plan developed to prevent injuries of unknown origin or new interventions developed which indicated the need for increased supervision to prevent injuries. February 2017 An IDT note, dated 2/6/17 at 11:33 am, indicated Resident 7 was found on the floor in the hallway, Resident 7 had last been seen ambulating in the hallway prior to her fall; and An IDT note, dated 2/17/17 at 9:50 am, indicated Resident 7 had a witnessed fall on the floor with no head injury on 2/12/17. Resident 7 was trying to get around other residents. The IDT intervention included to reduce the risk of injuries through nursing/staff interventions. The at risk for falls care plan was updated on 2/20/17 with interventions that included, encourage/assist resident to bed when she becomes exhausted and her gait becomes unsafe. March 2017 An IDT note, dated 3/30/17 at 9:48 am, indicated Resident 7 was involved in a resident to resident altercation. Resident 7 grabbed another resident's spoon and the other resident slapped Resident 7 on her left shoulder. April 2017 An IDT note, dated 4/6/17 at 10:14 am, indicated Resident 7 was found by staff, sitting on the floor, on her bottom. Resident 7 asked a staff member to pick her up. No injuries were noted; and An IDT note, dated 4/10/17 at 10:20 am, indicated Resident 7 had a fall on 4/9/17 at 7:45 am. Resident 7 was found on the floor, lying flat on her back, with a laceration to the back of her head. Resident 7 was sent to the emergency room and returned with 5 staples to the back of her head. There were no updates to the fall risk care plan in April 2017, despite Resident 7 falling on two different occasions 4/09/17. May 2017 An IDT note, dated 5/2/17 at 9:53 am, indicated Resident 7 was found on her back in the hallway outside of a room on 5/1/17 at 2:11 pm, another resident was also found on the floor on his back. The IDT intervention included for staff to redirect resident for safety; An IDT note, dated 5/3/17 at 10:44 am, indicated Resident 7 was involved in a resident to resident altercation when she stood next to another resident and he shoved her. Resident 7 then shoved the other resident back. No injuries were noted; and An IDT note, dated 5/8/17 at 10:13, indicated Resident 7 was in the hallway on 5/5/17, and was observed tripping over the legs of a lift. Resident 7 fell and received a laceration to the front of her head requiring transfer to a hospital and 10 staples to her head wound. The at risk for falls care plan was updated on 5/8/17 with an intervention that included lift to be kept out of hall while not in use. A second at risk for falls care plan was created and updated on 5/10/17 with interventions that included: encourage rest when the resident appears tired or gait is unsteady, keep hallways clear as much as possible, non-skid socks as tolerated, resident removes at times, and redirect resident from unsafe situations. During an interview with DON, on 5/11/17 at 7:55 am, DON stated the goal was to obtain a helmet for Resident 7, that would prevent future head injuries from falls. DON stated if the helmet worked then hopefully Resident 7 would not require 1:1 supervision. DON stated the goal was to prevent injuries and injuries from falls because falls are not preventable for this particular resident. A 1:1 supervision care plan was created on 5/11/17. During an interview with the facility Administrator (ADMIN), on 5/11/17 at 12:10 pm, he stated Resident 7 is a difficult resident and the facility cannot prevent her falls. Admin stated the only thing this particular facility could do to prevent falls/injuries for Resident 7 would be to not admit her to the facility in the first place. During an interview with LN B on 5/11/17 at 4:11 pm, LN B stated Resident 7 was difficult to re-direct and will try to run away if you try to encourage her to do something. LN B stated they try to encourage Resident 7 to rest, but she rarely rests. During an interview with Resident 7's family member (FM), on 5/12/17 at 9:50 am, she stated Resident 7 does not have good vision caused from her brain mass. Resident 7's FM stated Resident 7 was an outdoor person who enjoyed horses, gardening and even when the dementia started she was never a violent person. Resident 7's FM stated if the facility would try more interventions like using pull ups instead of diapers, so resident wasn't sitting on big, bulky plastic wet diapers, potentially allowing her to feel more comfortable to rest from pacing. Resident 7's FM stated the facility might want to treat Resident 7's pain more aggressively due to her history of having a bad back or have a staff member perform more frequent checks on her to make sure she was safe. Resident 7's FM stated she had not been afforded the opportunity to discuss interventions or her thoughts about how to keep Resident 7 more safe and prevent falls/injuries and resident to resident altercations with the facility's IDT. During an interview with the facility's Medical Director (MD 1), on 5/12/17 at 10:47 am, he stated Resident 7's falls could be from poor vision and balance issues resulting from her brain mass. MD 1 stated he was unaware of Resident 7's brain mass until a recent head scan was completed which indicated the mass had increased in size, stating, the record of the mass was lost in the hospital paperwork. MD 1 stated he was aware Resident 7's family member knew about the mass, but he had not personally discussed the issue with the family member. MD 1 stated the facility did report Resident 7's falls to him or his nurse practitioner, however he was unaware that the facility was having issues with multiple residents having multiple falls. During an interview with DON on 5/12/17 at 4 pm, DON confirmed the fall risk care plans did not depict all the interventions she had stated were being completed for Resident 7. Resident 7's fall risk care plan did not depict her potential vision and balance issues caused from her brain mass and her increased need for supervision to prevent falls and accident hazards. A review of the facility's policy and procedure titled, Falls- Clinical Protocol, dated April 2013, indicated the facility staff and physician would identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling .the staff would try various relevant interventions, based on assessment of the nature of category of falling, until falling reduces or stops. 2. A review of Resident 17's record indicated Resident 17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 17's Fall Care Plan, dated 9/16/16, indicated Resident 17 was at risk for falls related to altered mental status, unsteady gait, altered balance while standing or walking, decreased muscular coordination, antidepressants, diuretic (removes excess fluid from the body), antipsychotic (used to treat psychosis), blood pressure medication, cardiovascular disease and Parkinson's disease. The plan indicated the short term goal was for the resident to have reduced risk for injury x 3 months. The interventions dated 9/16/16 indicated to keep bed in lowest position with brakes locked, keep call light within reach, keep personal and frequently used items within reach, medication regimen review as indicated, obtain Physical Therapy and Occupational Therapy consults as indicated, orient to new environment as indicated, provide verbal reminders or cues to ask for assistance as needed and to provide proper, well-maintained footwear as indicated. On 10/11/2016, the care plan was updated to include a pressure pad (detects movement and alarms to alert staff) to wheelchair or bed at all times. On 11/7/16 the care plan was updated to include encouraging activities in high visibility areas. A review of Resident 17's Minimum Data Set (MDS, an assessment tool), dated 9/23/16, indicated that Resident 17 had a Brief Interview for Mental Status (BIMS) score of 5 (a score of 0-7 would indicate severe mental impairment) and he required extensive assistance with 2 or more staff members for most Activities of Daily living (ADLs). A review of Resident 17's Quarterly/Annual Fall Risk Assessment, dated 10/4/16, indicated Resident 17 was at risk for falls and to continue to care plan. A review of Resident 17's Inter Disciplinary Team (IDT) notes, dating from 10/5/16-11/07/16, indicated Resident 17 had 12 falls in just over a month: Fall #1: IDT note dated 10/5/16 indicated Resident 17 had an assisted slide to the floor during a transfer on 10/4/16. The risk factors listed included unsteady during transfers with some confusion and weakness. The IDT reviewed medications, psychotropic drug use was Celexa for depression and Lithium for bipolar disorder. The new intervention implemented was to ensure non-skid socks or tennis shoes be worn with all transfers. Fall #2: IDT note dated 10/7/16 indicated on 10/06/16 Resident 17 was found on the floor and yelling for help in the bathroom. The Certified Nurses Aid (CNA) had just assisted the resident to bed, had emptied his Foley bag (urine collection bag) and he was wearing non-skid socks. The new interventions implemented included a Personal Alarm (PA, detects movement and alarms to alert staff), due to confusion. Fall # 3: IDT note dated 10/10/16 indicated on 10/7/16 at 9:20 am Resident 17's PA alarm was sounding and the resident was found on the floor by his bed and indicated Resident 17 was last seen at 8:45 am when he completed his breakfast and then went to sleep. The new intervention implemented was to have a care conference with Resident 17's spouse on 10/12/16 and suggested the resident get up for meals and assess for Foley Catheter (FC) removal. Fall # 4: IDT note dated 10/11/16 indicated Resident 17 yelled out for help and the CNA responded. Resident 17 was found on the mat on the floor with his head toward the sink with bed in low position. Call light was not on and he had removed the PA. The preventative measures prior to the event included a PA alarm and non skid socks. The new interventions implemented included a pressure alarm to be used while in bed and in the wheelchair. Fall # 5: IDT note dated 10/21/16, indicated on 10/20/16 Resident 17 was found on the floor in the restroom with the PA alarming. FC drainage bag was attached to the wheelchair. The CNA was previously in the room to remove his breakfast tray and assisted the resident with going to the bathroom. Resident 17 was left in his wheelchair next to his bedside table. Resident 17 was identified as impulsive and having poor safety awareness. New interventions included to continue pressure pad alarm while in bed and in wheelchair, trial again to remove FC (2 previous failed attempts). Fall # 6: IDT note dated 10/24/2016, indicated on 10/23/16 Resident 17 was found on the floor in his room, the PA did not alarm and staff replaced it. Resident 17 had a history of [REDACTED]. New interventions implemented included to continue with pressure pad alarm while in bed and wheelchair. The facility failed to identify the pattern or trending of Resident 17's falls and failed to implement any new interventions. Falls # 7, 8 and 9: IDT note dated 10/26/16, indicated on 10/25/16 at 9:00 am, Resident 17 was found sitting on the floor in his room on the floor mat with his back against the bed. The alarm did not sound. He just had an x-ray and the alarm was turned off to position him for the x-ray. At 9:15, Resident 17 was again found in the same position, sitting on the floor mat with his back against the bed. The alarm was sounding and he was asking to go to the bathroom. At 4:30 pm, the PA alarm was sounding. The CNA witnessed the resident try to get out of bed and slide to the floor before the staff member could get to him. The PA was on and working. The new interventions included to have the Nurse Practitioner (NP) assess prescriptions for urinary and bowel health, staff to do hourly checks and encourage the resident to go to activities. Falls #10 and 11: IDT note dated 11/04/16, indicated on 11/3/16 Resident 17 slid on to the floor mat from his wheelchair in the doorway. Continue to hourly checks to make sure the resident is safe due to poor safety awareness On 11/4/16, Resident 17 was found on the floor next to his wheelchair. He stated he wanted to take a nap. The CNA was in another room assisting with another resident when he fell and activities had not started yet. New interventions included, staff to continue to do hourly checks and encourage resident to go to activities, NP note regarding Megace (medication to stimulate appetite) to see if that is causing his confusion. Fall #12: IDT note dated 11/7/16, indicated that on 11/4/16 Resident 17 had an in room unwitnessed fall. New interventions included, MD reviewed medications and determined they were non-contributory to falls. MD indicated falls are likely due to Parkinson's. Encourage activities and high visible areas. During an interview with Director of Nursing (DON) on 5/15/17 at 9:36 am, DON stated the facility's goal for Resident 17 was to prevent injuries from falls, not to prevent falls, and the care planned interventions were focused on preventing injury and were not effective in preventing falls. During an interview with DON on 5/16/17 at 10:15 am, evidence of the hourly checks identified as an intervention by the IDT were requested. The DON indicated the facility was unable to provide evidence of completed hourly checks for Resident 17.

Based on observation, interview, and record review, the facility failed to provide quality of care for three of 23 sampled residents (Resident 1, 16, and 23) and one out of sample resident (Resident 21) when: 1. Resident 23's pain management needs were not being met over a five month time period, due to a language (translation) issue which lead to inconsistent pain assessments and management. Resident 23 received a pain medication used for mild pain multiple times when moderate to severe pain was reported by the resident. 2. Resident 21's pain management needs were not being met due to lack of pain assessments to determine the effectiveness of her pain management program. 3. Resident 16's [MEDICAL TREATMENT] (process to remove wastes from blood due to failure of kidneys) communication forms did not include useful information necessary (vitals signs including blood pressure, pulse, blood sugars) to coordinate care of resident between both facilities. 4. Resident 1's pain management needs were not being met due to not receiving needed dental services that resulted in significant weight loss. The inadequate pain management resulted in Residents 1, 21, and 23 suffering pain unnecessarily and had the potential for all residents with pain not to receive the necessary care and services to ensure effective pain management. The incomplete communication forms for Resident 16 had the potential to affect all residents who have [MEDICAL TREATMENT] treatments in the facility and put them at risk for complications related to their disease management. Findings: The facility policy titled Pain Clinical Protocol revised June 2013, was reviewed and indicated the physician and staff will identify individuals who have pain or who are at risk for pain. This included a review of each person's known [DIAGNOSES REDACTED]. The nursing staff will assess each individual for pain upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is a new pain or worsening of existing pain. The staff and physician will identify the nature (location, intensity, frequency and pattern etc.) and severity of pain. The nursing staff will identify any situations or interventions where an increase in a resident's pain may be anticipated. The staff and physician will also evaluate how pain is affecting mood, activities of daily living, sleep, and quality of life including complications. The physician will help identify causes of pain by examining the resident directly, reviewing resident's history, and via discussion with the staff. As part of the medical assessment the physician will help identify the underlying cause and how this can be addressed or reversed. The staff will evaluate and report how much and how often the individual asks for as needed (PRN) medications. If there are more than occasional [MEDICATION NAME] requests, the physician will consider changing to a regular administration of at least one [MEDICATION NAME] with another medication for PRN use, increase the standing dose or switch to another [MEDICATION NAME]. The staff will reassess the individual's pain and related consequences at regular intervals at least each shift for acute pain or significant changes in levels of chronic pain at least weekly in stable pain. Periodically the physician will evaluate and summarize the status of the individual with chronic or fluctuating pain including active conditions that exacerbate pain, complications of pain, and effectiveness of current interventions for pain. The staff will discuss significant changes in levels of comfort with the Attending Physician who will consider adjusting interventions. 1. A review of the facility's admission records indicated Resident 23 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 23 was able to make health care decisions for himself. His primary language was Spanish. The physician orders [REDACTED]. From 6/16/15 to 1/20/16, [MEDICATION NAME] (narcotic pain medication) 5/325 milligrams (mg) one tablet for pain once a day at 8 am. From 2/19/15 to 2/12/16, [MEDICATION NAME] 5/325 mg one tablet every four hours as needed for moderate to severe pain (used to measure pain on a number scale mild 1-3, moderate 5-6, and severe 7-10). From 2/19/15 to 1/20/16, Tylenol (pain medication to treat minor aches and pain) 650 mg every four hours for pain. There were no pain parameters indicated in the physician order. A review of the Medication Administration Records (MAR)s indicated, Resident 23 reported severe pain 18 times for the month of 9/2015, 27 times for 10/2015, 27 times for 11/2015, 29 times for 12/2015, and 30 times for 1/2016 over a five month period. The MARs had no post pain assessment after the routine [MEDICATION NAME] was given at 8 am from 9/2015 to 1/20/2016. The MARs from 9/2015 to 1/2016, indicated the as needed pain medications [MEDICATION NAME] and Tylenol used for the breakout pain (pain that returns) were given consistently three to four hours after the routine [MEDICATION NAME] scheduled at 8 am everyday. The Licensed Nurses (LN) recorded moderate to severe pain on the MARs for Resident 23 and administered Tylenol eight times in the month of 9/2015, 15 times in 10/2015, 28 times in 11/2015, nine times in 12/2015, and one time in 1/2016. A review of a physician order [REDACTED]. A physician order [REDACTED]. The MARs indicated Resident 23 was given as needed [MEDICATION NAME] and Tylenol for pain nine times for the month of 9/2015, 26 times in 10/2015, 44 times in 11/2015, 48 times in 12/2015, 47 times in 1/2016 and 25 times in half a month for 2/2016. There was no documentation found in the record that the physician was notified of the increase use of the as needed [MEDICATION NAME] and Tylenol over a five month period. A physician order [REDACTED]. The physician progress notes [REDACTED]. The physician progress notes [REDACTED]. Per the interpreter patient reports no pain and the numbness and tingling went away. No changes in medications and indicated to monitor patient for increased weakness, pain and numbness. The nursing resident progress notes indicated: On 1/14/16, a Certified Nursing Assistant (CNA) reported Resident 23 had complaints of pain really bad to left arm, starting at the shoulder down arm to fingers with numbness and tingling. On 1/15/16, resident complained of pain to the left shoulder area and medicated with routine [MEDICATION NAME], though still had 5/10 (moderate) pain. On 1/16/16 at 12:42 pm, resident complained of numbness and discomfort to the left arm. The as needed [MEDICATION NAME] was given and he reported some relief. No pain parameters were used to define some relief. On 1/16/16 at 5:50 pm, resident complained of severe pain to left arm and shoulder. The as needed [MEDICATION NAME] was given and he reported some relief. No pain parameters were used to define some relief. On 1/28/16, resident has complained of pain to shoulder somewhat resolved with routine [MEDICATION NAME]. No pain parameters were used to define somewhat resolved. On 2/12/16, new physician orders [REDACTED]. The as needed [MEDICATION NAME] dose was also increased. The weekly nursing summaries indicated: On 1/6/16, Resident 23 continues on routine [MEDICATION NAME] at 8 am and as needed every four hours. On 1/13/16, Resident 23 had as needed [MEDICATION NAME] available for breakthrough pain. On 1/20/16, resident received routine and as needed [MEDICATION NAME]. On 1/27/16, resident complained of pain somewhat resolved with routine and as needed [MEDICATION NAME]. No pain parameters were used to define somewhat resolved. On 2/3/16, there was no weekly nursing pain assessment noted in the record. On 2/10/16, there was no weekly nursing pain assessment noted in the record. On 2/17/16, resident has tolerated the increased in [MEDICATION NAME] and denies any complaints of breakthrough (return of) pain. In the physician progress notes [REDACTED]. Per the translator, Resident 23 stated the pain medications were more effective. During a interview on 2/22/16 at 10:10 am, the Director of Nursing (DON) confirmed the pain policy was not followed. The DON stated Resident 23's continued requests for as needed [MEDICATION NAME] should have prompted physician notification and a change in pain medication coverage. The DON stated communication was part of the issue related to the need for Spanish translation to adequately assess Resident 23's pain management needs. The DON confirmed the pain management assessments were not consistently documented and reported. During an interview on 2/22/16 at 10:30 am, a Spanish translator was used to communicate with Resident 23. Resident 23 stated his pain was regular and everyday since his stroke. Resident 23 described his pain in the middle to high range (5 to 7, moderate to severe) on the pain scale and admitted he had a high tolerance for pain. Resident 23 explained his pain returned quickly after his regular morning pain medication. Resident 23 stated sometimes he has waited a long time (up to an hour or more) after he had asked for more pain medication. Resident 23 stated sometimes staff do not ask him if the pain medication worked after it was given and do not bring a translator. Resident 23 stated the recent increase in pain medication on a regular schedule had improved his pain, though sometimes the pain still returns. During an interview on 2/22/16 at 11:30 am, LN D stated Resident 23 had regular pain and that it had been worse in the past month. LN D stated Resident 23 reported that it was hard to communicate his pain to most staff due to the language barrier. LN D stated Resident 23 guards his left arm and shoulder due to the pain. LN D stated Resident 23 explained the pain medications do not last very long and the pain returns. 2. A review of the facility's admission records indicated Resident 21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 21 was unable to make health care decisions for herself. The initial admission and pain assessment dated [DATE], indicated Resident 21 was alert and oriented, reasonable and decisions were consistent. A review of the acute care facility records dated 2/12/16, indicated Resident 21 presented with confusion, high potassium, and low pulse. Resident 21 was also noted to have high carbon [MEDICATION NAME] in lungs due to long term narcotic (pain medication) use and was taking [MEDICATION NAME] and [MEDICATION NAME] for pain management. The admission pain assessment dated [DATE], indicated Resident 21 had describe her pain as very severe, horrible, the worst pain that was sharp and throbbing. Resident 21 described the pain as constant and persistent. Resident 21 reported pain medication effective when given. Resident 21 indicated pain frequency as constant and severe the last five days. During initial tour of the facility on 2/16/16 at 9:30 am, Resident 21 was observed lying in bed on her back. Resident 21 stated she was in pain, 8.5 on a pain scale (severe) and had asked for a pain medication from the nurse at 8 am and had not received one yet (1.5 hours ago). Resident 21 stated this happened before and that she often waits for her pain medications. Resident 21 stated the pain was interfering with her sleep and she was not comfortable. A LN overheard the conversation and then administered the pain medication. The MAR and physician orders [REDACTED]. There were no pain assessment entries found on the MAR from 2/12-2/15/16. During an interview on 2/18/16 at 8 am, the DON confirmed Resident 21 had severe pain and that their were no regular pain assessments found in the record from 2/12-2/15/16 in the MAR or in the nursing progress notes. The DON stated the expectation for staff was to put in the the physician order [REDACTED]. The DON stated the facility had new staff and the resident was admitted over the weekend as a reason why the pain assessments were not initiated. A record audit was done on 2/15/16, which caught the error. The DON stated the facility pain policy was not followed. 3. A review of the facility's admission records indicated Resident 16 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 16 was able to make health care decisions for himself. The facility policy titled [MEDICAL CONDITION], Care of Resident with revised September 2010, indicated staff caring for residents with [MEDICAL CONDITION] including residents that receive care outside the facility, shall be trained in the care and special needs of the residents. Education and training of staff include specifically the type of assessment data that is to be gathered about the resident's condition on a daily or per shift basis; how to recognize and intervene in medical emergencies; timing and administration of medications before and after [MEDICAL TREATMENT]. Agreements between the facility and the [MEDICAL CONDITION] facility include all aspects of the resident's care will be managed including how the care plan will be developed and implemented and how information will be exchanged between the facilities. Resident 16's physician orders [REDACTED]. (The American Diabetes Association indicated very often symptoms occur when blood glucose levels are low and fall below 70. Low blood sugar symptoms include anxiety, confusion, [MEDICAL CONDITION], coma and can be life threatening if not acted upon.) A Nursing Resident Progress note dated 2/9/16 at 11:01 pm, indicated Resident 16 was not feeling well, refusing snacks, and care. Resident 16's blood sugar was in the 40s. Resident 16 was given orange juice and was refusing ordered glucose gel (raises blood sugar). Resident 16's blood sugar rechecked at 15 minutes, now 78. LN went to reassess Resident 16 and found that the resident was unresponsive and blood sugar was 48. [MEDICATION NAME] (raises blood sugar) was given and emergency medical team was initiated. Resident 16 and his son refused request for a transfer to acute care hospital. Resident 16's blood sugars were monitored every 2 hours to monitor for low blood sugars. Resident 16's blood sugars were monitored four times a day and indicated: On 2/9/16, the blood sugars were 78 at 5 pm and 81 at 10 pm. On 2/10/16, the the blood sugar were 69 at 7 am, 66 at 12 pm, 84 at 5 pm, and 80 at 10 pm. On 2/11/16, the blood sugars were 62 at 7 am. Resident 16 had a physician order [REDACTED]. Recheck FSBG in 15 minutes and notify medical doctor. The Nursing Resident Progress note dated 2/11/16 at 11:50 am, indicated Resident 16's blood sugar at 7:15 am was 62, orange juice was given and blood sugar was then 52 at 7:33 am. resident complained of blurry vision, glucose gel was given and blood sugar was 84 at 7:40 am. Resident left facility at 7:40 am with communication paper and medication list. The facility's [MEDICAL TREATMENT] Communication Report, dated 2/11/16, was reviewed and indicated Resident 16's vital signs had been recorded and noted he had low BS. There was no information provided to the [MEDICAL TREATMENT] facility about the recent low blood sugars, on 2/9/16, 2/10/16 and 2/11/16. There was no information about the nursing interventions done including the administration of medications and blood sugar monitoring as a result of the low blood sugars. The return documentation from the [MEDICAL TREATMENT] center did not include any vital signs and blood sugar information done while at the center. During an interview on 2/19/16 at 10:30 am, the DON stated more resident specific information could be coordinated between the facility and the [MEDICAL TREATMENT] center. The DON stated the facility nursing staff could call the [MEDICAL TREATMENT] center to discuss Resident 16's recent low blood sugars. The DON confirmed the [MEDICAL TREATMENT] communication reports lacked pertinent resident specific information about vital signs and blood sugars. The DON was unaware if the [MEDICAL TREATMENT] center monitors blood sugars. During an interview on 2/19/16 at 4 pm, LN D stated she did not want Resident 16 to leave for [MEDICAL TREATMENT] until his blood sugars were stable and was going to be late for [MEDICAL TREATMENT] on 2/11/16. LN D stated the physician and the [MEDICAL TREATMENT] center were not notified of the low blood sugars that morning. LN D stated the [MEDICAL TREATMENT] center called on 2/11/16 to inquire where Resident 16 was and that the [MEDICAL TREATMENT] center requested his medication list to be sent with him. LN D was unaware of the blood sugar issues on 2/9/16 as well. LN D stated 61 was a stable blood sugar. 4. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS, a comprehensive assessment of each resident's functional capabilities that helps nursing home staff identify health problems), dated 1/12/16, showed Resident 1's cognition (brain function) was moderately impaired and that his daughter was his decision maker. The MDS described him having Obvious or likely cavities or broken natural teeth. On 2/17/16 the facility's Dental Services policy, dated 12/2013, showed that Routine and emergency dental services are available to meet the residents' oral health services in accordance with the resident's assessment and plan of care. Resident 1's Teeth in Poor Condition care plan, dated 7/23/14, included one update on 3/23/15 that showed the facility would refer to dietary for needed changes (due to dentition) and social services for dental care. There were no further updates or interventions for his dental pain or dental care. Resident 1's Social Services notes, dated 3/6 and 3/24/15, noted tooth pain. Resident 1's Social Services note, dated 3/25/15, documented the plan for him to see an oral surgeon for extraction. Resident 1's Dental note, dated 3/25/15, showed he was experiencing dental pain, had multiple broken teeth and was being evaluated for extractions. Resident 1's Oral Surgeon for Tooth Extraction care plan, dated 3/27/15, showed the facility would monitor his intake for changes and refer to dietary and that nursing would monitor his pain and assess his facial stress. The care plan was discontinued on 8/18/15. Resident 1's record included orders for scheduled [MEDICATION NAME] (narcotic pain medication) that he received three times daily. He had orders for Tylenol, one tablet every six hours as needed for pain. Resident 1's Nursing Progress note, dated 8/21/15, showed he refused his lunch due to dental pain and often complains of tooth ache to the CNA (certified nurse assistant) staff. On 2/17/16 at 12 noon, CNA F was interviewed about Resident 1. CNA F stated that she had assisted Resident 1 with eating in the dining room over the past several months, and that he experienced continued pain with eating. CNA F stated that she thought Resident 1's tooth pain had contributed to his weight loss. On 2/17/16 at 12:10 pm, CNA G stated that she worked with Resident 1 a lot. CNA G stated that Resident 1 had visibly shown tooth pain while eating hot and cold foods. CNA G stated that Resident 1 would grimace and withdraw when he experienced tooth pain during meals. On 2/17/16 at 12:15 pm, Resident 1 was observed and interviewed in the dining room, concurrently with CNA G. Resident 1 was observed to have several missing and broken bottom teeth and his gums were reddened. When Resident 1 was asked if his teeth hurt he grimaced and made a cry sound, then visibly withdrew. On 2/17/16 at 2:15 pm, the facility's Dietary Services Supervisor and Registered Dietician were concurrently interviewed and confirmed that they were not aware of Resident 1's dental pain and problems and had they known, would have changed his diet. On 2/18/16 at 11:45 am, LN I confirmed that he had assessed and documented Resident 1's pain during the past several months and that he experienced dental pain. Resident 1's Weight Variance Report showed he weighed 189.90 pounds on 8/3/15, 161.9 pounds on 10/4/15 and 151.10 pounds on 12/20/15; total weight loss of 41.80 pounds. Resident 1's record included a nurse's Progress Note, dated 10/2/15, that showed the Family Nurse Practitioner (FNP) and Resident 1's family member had been contacted about his weight loss and it was agreed he would receive dental evaluation and treatment. On 2/17/16 at 4 pm, Resident 1's FNP Progress Note, dated 10/2/15, was concurrently reviewed with FNP. It showed Resident 1 had experienced a 24 pound weight loss in a month and a 13 pound weight loss in 89 days and that he would be evaluated by the dentist. FNP concurrently confirmed the connection between Resident 1's dental problems and his weight loss. She stated that she had spoken with Resident 1's daughter and understood he would be treated for [REDACTED]. On 2/17/16 at 4:30 pm, Social Services Designee (SSD) was interviewed. FNP's Progress Note on Resident 1, dated 10/2/15, was concurrently reviewed with SSD. SSD stated that she was not aware that Resident 1's family member had agreed for him to get dental treatment and that Resident 1 was to be scheduled (a service scheduled by Social Services). SSD confirmed that she should have been notified to schedule Resident 1 to see the dentist. On 2/17/16 at 5 pm, Resident 1's physician (MED) was interviewed about Resident 1's dental problems. MED stated he had not examined Resident 1's mouth since his initial exam (admitted [DATE]). MED was asked about why the facility had not treated Resident 1's dental pain. He stated he had not spoken to Resident 1's family about his dental problems and had not discussed the risks versus benefits of treating Resident 1's dental pain with pain medication. On 2/18/16 at 3 pm, Resident 1's family member stated that she did not want Resident 1 to be in pain and wanted him to get needed dental work done. On 2/24/16 at 11 am, the SSD was not able to explain why Resident 1's Teeth (dental pain) and Oral Surgery care plan, dated 3/27/15, interventions were not continued or updated. SSD stated she was not aware of Resident 1's continued tooth pain.

Based on observation, interview and record review, the facility failed to provide dental services that met one of 23 sampled residents' needs when he experienced mouth pain due to diseased teeth. This resulted in the resident experiencing pain with eating/drinking and resulted in significant (loss of 5 percent in one month or 7.5 percent in three months or 10 percent in 6 months of the usual body weight) weight loss. (Resident 1) Findings: Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The facility's minimum data set (MDS, an assessment tool), dated 1/12/16, showed his cognition (brain function) was moderately impaired and that his daughter was his decision maker. The MDS described him having Obvious or likely cavities or broken natural teeth. The facility's Dental Services policy, dated 12/2013, showed that Routine and emergency dental services are available to meet the residents's oral health services in accordance with the resident's assessment and plan of care Nursing Services is responsible for notifying Social Services of a resident's need for dental services . Social Services personnel will be responsible for assisting the resident/family in making dental appointments and transportation arrangements as necessary. Resident 1's Teeth in Poor Condition care plan, dated 7/23/14, included one update on 3/23/15 that showed the facility would refer to dietary for needed changes (due to dentition) and social services for dental care. There were no further updates or interventions for his dental pain or dental care. Resident 1's Social Services notes, dated 3/6 and 3/24/15, noted tooth pain. Resident 1's Social Services note, dated 3/25/15, documented the plan for him to see an oral surgeon for extraction. Resident 1's Dental note, dated 3/25/15, showed he was experiencing dental pain, had multiple broken teeth and was being evaluated for extractions. Resident 1's Oral Surgeon for Tooth Extraction care plan, dated 3/27/15, showed the facility would monitor his intake for changes and refer to dietary and that nursing would monitor his pain and assess his facial stress. The care plan was discontinued on 8/18/15. Resident 1's record included orders for scheduled [MEDICATION NAME] (narcotic pain medication) that he received three times daily. He had orders for Tylenol, one tablet every six hours as needed for pain. Resident 1's Nursing Progress note, dated 8/21/15, showed he refused his lunch due to dental pain and often complains of tooth ache to the CNA (certified nurse assistant) staff. Resident 1's Weight Variance Report showed he weighed 189.9 pounds on 8/3/15, 161.9 pounds on 10/4/15 and 151.1 pounds on 12/20/15; total weight loss of 41.8 pounds (during the months he was to get his painful teeth extracted). On 2/17/16 at 12 noon, Certified Nurse Assistant (CNA) F was interviewed about Resident 1. CNA F stated that she had assisted Resident 1 with eating in the dining room over the past several months, and that he experienced continued pain with eating. CNA F stated that she thought Resident 1's tooth pain had contributed to his weight loss. On 2/17/16 at 12:10 pm, CNA G was interviewed and stated that she worked with Resident 1 a lot. CNA G stated that Resident 1 had visibly shown tooth pain while eating hot and cold foods. CNA G stated that Resident 1 would grimace and withdraw when he experienced tooth pain during meals. On 2/17/16 at 12:15 pm, Resident 1 was observed and interviewed in the dining room, concurrently with CNA G. Resident 1 was observed to have several missing and broken bottom teeth and his gums were reddened. When Resident 1 was asked if his teeth hurt he grimaced and made a cry sound, then visibly withdrew. On 2/18/16 at 11:45 am, Licensed Nurse I was interviewed and confirmed that he had assessed and documented Resident 1's pain during the past several months and that Resident 1 experienced dental pain. Resident 1's record was reviewed and included a nurse's Progress Note, dated 10/2/15, that showed the Family Nurse Practitioner (FNP) and his daughter had been contacted about his weight loss and it was agreed he would receive dental evaluation and treatment. On 2/17/16 at 4 pm, during a concurrent interview and record review with FNP. A FNP Progress Note, dated 10/2/15, showed Resident 1 had experienced a 24 pound weight loss in a month and a 13 pound weight loss in 89 days and that he would be evaluated by the dentist. FNP concurrently confirmed the connection between Resident 1's dental problems and his weight loss. She stated that she had spoken with Resident 1's family member and understood he would be treated for [REDACTED]. On 2/17/16 at 4:30 pm, Social Services Designee (SSD) was interviewed. FNP's Progress Note on Resident 1, dated 10/2/15, was concurrently reviewed with SSD. SSD stated that Resident 1's family member had not signed the papers needed to get his teeth extracted for an appointment scheduled 9/8/15. SSD stated that she was not aware that Resident 1's family member had agreed on 10/2/15 for him to get dental treatment and that he was to be scheduled (a service scheduled by Social Services). She confirmed that she should have been notified to schedule Resident 1 to see the dentist. On 2/17/16 at 5 pm, Resident 1's physician (MED) was interviewed about Resident 1's dental problems. MED stated he had not examined Resident 1's mouth since his initial exam (admitted [DATE]). MED was asked about why the facility had not treated Resident 1's dental pain. He stated he had not spoken to Resident 1's family about his dental problems and asked what we (California Department of Public Health) thought he should do. On 2/18/16 at 3 pm, Resident 1's family member (decision maker) stated that she did not want Resident 1 to be in pain and wanted him to get needed dental work done. On 2/24/16 at 11 am, the SSD was not able to explain why Resident 2's Teeth (dental pain) and Oral Surgery care plan interventions were not continued or updated. SSD stated she was not aware of Resident 1's continued tooth pain.

Based on observation, interview and record review the facility failed to ensure one of 23 residents' care was supervised by the physician, when he did not take an active role in their care. This resulted in the resident not being evaluated and treated for [REDACTED]. (Resident 1) Findings: Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The facility's minimum data set (MDS, a comprehensive assessment of each resident's functional capabilities that helps nursing home staff identify health problems), dated 1/12/16, showed his cognition (brain function) was moderately impaired. The MDS described him having Obvious or likely cavities or broken natural teeth. Social Services notes, dated 3/6/16 and 3/24/16, noted that Resident 1 experienced tooth pain. A Dental Note for Resident 1, dated 3/25/15, showed he experienced dental pain, had multiple broken teeth, and was being evaluated for tooth extractions (removal). Resident 1's Oral Surgeon for Tooth Extraction care plan, dated 3/27/15, showed the facility would monitor his intake for changes and his pain. The care plan was discontinued on 8/18/15 although his teeth were not fixed. Resident 1's Nursing Progress note, dated 8/21/15, showed he refused his lunch due to dental pain and often complains of tooth ache to the CNA (certified nurse assistant) staff. Resident 1's Weight Loss care plan, dated 2/4/16, showed he had experienced a 39 pound weight loss (21 percent) in the past 6 months. On 2/17/16 at 3:45 pm, Resident 1's physician (MED) was interviewed about Resident 1's dental problems. MED stated he had not examined Resident 1's mouth since his initial exam (admitted [DATE]). MED was asked about why the facility had not treated Resident 1's dental pain, he was not able to explain. He stated that he had over 300 patients. MED stated he had not spoken to Resident 1's daughter about his dental problems and pain or the risks versus benefits of treating his pain. MED asked what we (California Department of Public Health) thought he should do. On 2/18/16 at 8:15 am, the facility's Weight Assessment and Intervention policy, revised 4/2012, was reviewed and the Director of Nurses (DON) was concurrently interviewed. The care plan showed that Care planning for weight loss or impaired nutrition will be a multidisciplinary effort and will include the Physician, nursing staff, the dietitian, the consultant Pharmacist, and the resident or resident's legal surrogate. The DON confirmed the facility had not followed their policy. The DON also stated that the facility's Multidisciplinary Team (IDT) had not included the Physician and had not identified Resident 1's dental pain and its affects on his nutritional intake and resulting weight loss.

Based on observation, interview, and record review, the facility failed to provide necessary treatment and services to prevent the development and/or worsening of pressure ulcers (PU, skin wound related to extended pressure causing loss of blood circulation to the site and death to skin cells) when; 1. For Resident 17, care plans for existing skin problems were not developed, assessment of skin was insufficient to monitor skin conditons, and effective care was not provided to prevent the development and/or worsening of PUs. 2. For Resident 2, inadequate assessments and lack of documentation for the resident's skin condition allowed lack of care leading to the development of a PU which was not discovered until it had advanced to a Stage III (full skin loss). 3. The facility did not conduct timely and skin/wound assessments, care plan interventions were not identified, implemented, monitored and revised. This resulted in Resident 4 developing two pressure ulcers: a. On 12/01/14 a Stage II pressure ulcer was identified on the coccyx (tailbone). b. On 1/1/15 an unstageable pressure ulcer with eschar was identified on the right heel. 4. The facility failed to follow physician's orders [REDACTED]. Findings: The facility's Policy and Procedure (P&P), dated 10/2010, titled, "Prevention of Pressure Ulcers," indicated: "The purpose of this procedure is to provide information regarding the identification of pressure ulcer (PU) risk factors and interventions for specific risk factors." "Review the resident's care plan to assess for any special needs of the resident. See P&P for specific task, such as bathing, incontinence (lack of control of urination and defecation) care, repositioning." "PUs are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease in blood circulation (blood flow) to that area and subsequent destruction of tissue. The most common site of a PU is where the bone is near the surface of the body including the back of the head, around the ears, elbows, shoulder blades, backbone, hips, knees, heels, ankles, and toes. Pressure can also come from splints, casts, and wrinkles in bed linens. If PUs are not treated when discovered, they quickly get larger, become very painful for the resident, and often times become infected. PUs are made worse by continual pressure, heat, moisture, irritating substances on the resident's skin (i.e., perspiration, feces, urine...etc.), decline in nutrition and hydration status, acute illness and/or decline in the resident's physical and/or mental condition. Once a PU develops, it can be extremely difficult to heal. PUs are a serious skin condition... The facility should have a system/procedure to assure assessments are timely and appropriate and changes in condition are recognized, evaluated, reported...and addressed." "General Preventive Measures Identify risk factors for PU development. For a person in bed: Change position at least every two hours or more frequently if needed; Determine if resident needs a specific mattress..; Raise the head of the bed as little and for as short a time as possible.. For a person in a chair: Change position at least every hour; Use foam, gel, or air cushion as indicated to relieve pressure; ...Refer resident to rehabilitation program, or restorative nursing program, as indicated; encourage the resident to participate in active and passive range of motion exercises to improve circulation; Ensure that the resident drinks plenty of fluids and eats a well balanced diet; Routinely assess and document the condition of the resident's skin for any signs and symptoms of irritation or breakdown; Immediately report any signs of a developing PU to the supervisor; The care process should include efforts to stabilize, reduce or remove underlying risk factors, to monitor the impact of the interventions, and to modify the interventions as appropriate." "Risk Factor(s): Moisture...Friction and Shear...Bed-fast (person who cannot leave bed without assist),...Chair-fast...Immobility...Bowel and Bladder Incontinence... Poor Nutrition...Lowered Mental Awareness...Co-morbid conditions (other illness or injury)...(adverse effects of certain) Medications...(problems with generalized or localized) blood flow...Resident refusal of some aspects of care and treatment...Cognitive (ability to reason) impairment...A (previous) healed ulcer..." The policy and procedure continues with specific care and treatment instructions for reporting refusal of care and ongoing documentation of pressure ulcers. 1. On 1/23/15, Resident 17's record was reviewed. Resident 17 was admitted from an acute care hospital to the facility on [DATE]. [DIAGNOSES REDACTED]. An, "Interfacility Transfer Report," from the hospital, dated 9/4/14, specified that Resident 17's had a, "skin condition: pink coccyx (tailbone)." On 9/4/14, a facility Licensed Nurse (LN) documented an admission skin assessment that included front and back full body diagrams labeled with Resident 17's skin problems. Skin problems included bruises, scratches and scabs on different parts of the body, "old shingles rash," "excoriated (irritated raw, scraped, or worn off area of skin) coccyx," and "Stage I (reddening of skin) PUs," on each heel. A skin care plan dated 9/4/14, documented, "At risk for altered skin integrity related to: Cardiovascular Disease, Cognitive (ability to reason) Impairment, Severe [MEDICAL CONDITION] ([MEDICAL CONDITION], lung disease), Reduced Urinary Output. SKIN RISK SCORE: 16 (low risk of loss of skin integrity) per the Braden assessment tool used by the facility." There was no reference in the care plan specific to Resident 17's multiple existing skin problems. A facility Policy and Procedure, titled, Admission Assessment and Follow-Up: Role of Nurse, dated 4/2007, specified, "The purpose of this procedure is to gather information about the resident's physical...condition upon admission for the purpose of managing the resident, initiating the care plan, and completing required assessment instruments including the Minimum Data Set (MDS, an assessment tool)." The, facility's "Prevention of Pressure Ulcers" policy and procedure, dated 10/2010, specified, "...Once a PU develops, it can be extremely difficult to heal. Pressure ulcers are a serious skin condition for the resident...The facility should have a system/procedure to assure assessments are timely and appropriate and changes to conditions are recognized, evaluated...and addressed." With a, "History and Physical," dated 9/8/14, the Nurse Practitioner (NP) documented under, "Physical Examination...Skin/Wound:," exclusively, "no rash." There was no documentation related to any of Resident 17's skin problems of four days prior. During an interview on 1/27/15 at 4:20 pm, NP stated that she, "would not review nurse assessment notes; would address things brought (verbally) to her attention," by staff. An admission MDS dated [DATE], documented that Resident 17 had a moderate decline in cognition, needed extensive assistance to move around in bed, assistance with activities of daily living (ADLs), and no PUs or moisture-associated skin disorder (MASD). On 9/16/14, a Licensed Nurse (LN) H documented, "Left heel with area of discoloring. Bluish-purple in color...measures 3.0 X 2.4 centimeters (CM). Depth and severity can not be determined. Heel protectors applied while in bed along with existing order for skin prep daily. Foot cradle (holds blanket-weight off of feet) applied to bed frame..." There was no further documentation of assessments for Resident 17's heels when he was discharged to an acute care hospital on [DATE]. On 9/22/14, LN H documented, "Notified by Certified Nursing Assistant (CNA)...that resident had a new sore on butt. Upon assessment found open area 1.5 cm by 1.0 cm with slough (dead tissue that separates from healthy tissue after inflammation or infection)..." On 9/23/14, a wound care physician documented, "Unstageable due to necrosis of the coccyx...light serous exudate (blood-tinged drainage)... (caused by) Pressure, 1.5 cm by 1.5 cm by unmeasurable (depth)..." During the 1/27/14, 4:20 pm interview with NP U, she further stated that dates including 9/4 to 9/18/14, "Might have been during a time of transition of wound care nurses when some nurses were not as (gestured lifting hands and shoulders, with the sound of 'umph') as the wound care nurse we have now." Interdisciplinary Team (IDT, joint meetings of those in charge of multiple disciplines of care and services) notes, dated 9/24/14, documented, "Resident with unstageable ulcer to coccyx, previous area of excoriation..." During an interview on 1/27/14 at 4:30 pm, the Director of Nursing (DON) stated that a previous wound care nurse had left on 7/18/14 and that the Director of Staff Development (DSD) and the Assistant Director of Nursing (ADON) had taken over wound care until they overlapped with the current wound care nurse (LN) H started on 9/1/14. During a simultaneous interview, DSD and ADON both stated that they had no recall of having assessed or treated Resident 17's wounds. 2. On 1/22/15 Resident 2's record was reviewed. Resident 2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A MDS dated [DATE], documented that Resident 2 had severely limited cognition (ability to reason), was frequently incontinent of (unable to control) urine and feces and was dependent "extensively" on staff for all mobility and activities of daily living (ADL). The MDS documented that he had no PUs, but that he was at risk of PU development. On 1/22/15 at 9:45 am, and on 1/22/15 at 3:10 pm, Resident 2 was observed in his room, fully clothed and laying on his back in bed. A care plan dated 1/18/14, documented, "At risk for altered skin integrity related to clinical risk factors: Chronic incontinence, Cognitive impairment, Altered ADL Ability, Bowel Incontinence. Medication use of (sedating drugs). Complicating Measures: Limited Mobility/Bedfast (unable to get up from bed without assistance)...Goal: Will reduce risk for impaired skin integrity." "Approaches (to prevent harm to skin)," included, "Weekly skin check." A care plan dated 1/23/14, documented,"...resists care, ADL care, resists getting out of bed at times." "Approaches," listed ways to encourage Resident 2 to accept routine care and to, "assess resident's resistance to care." There was nothing in the care plan regarding what staff were to do when attempts to provide care were not successful. In a nursing progress note dated 4/1/14, LN T documented, "Certified Nursing Assistant (CNA) made nursing aware that resident is with a large 'sore' to back. The Resident was assessed by nurse noted to have a 5 centimeter (cm) by 5 cm a ulcer to his [MEDICATION NAME] (mid-back) spine area. The ulcer is presenting as a Stage III. The ulcer was free from any redness, or odor. Yellow slough was noted to the center of the wound. The resident states the area is sore when touched. Nurse Practitioner (NP U) in facility and made aware of wound. Resident is with new orders for Santyl (ointment for wounds) and calcium alginate (gel incorporated into a wound care dressing) daily..." In an "Observation Report...Routine Clinical Observations - Weekly Summary (for all '3 shifts')," dated 3/27/14, five days before the discovery of the PU, LN G documented, "Head to toe observation......skin intact (no wounds)." LN G also noted, "Resident had complaints of back pain...," with no additional note of assessment specific to Resident 2's back. In a nursing note dated 3/27/14, Licensed Nurse (LN) G documented, "(Resident 2) Continues on [MEDICATION NAME] (an anti-psychotic medication) for striking out behaviors. He has had 6-8 behaviors, usually on the pm (evening) shift...Resident had complaints of back pain medicated with relief." During an interview on 1/22/15 at 11:55 am, LN G stated that he, "thinks the CNAs notice them (skin changes) most...I usually do a whole body check...but sometimes they (the residents) refuse...I don't recall (Resident 2) refusing." During interviews and record reviews on 1/23/15 from 2:20 to 2:40 pm, CNA M, CNA P, CNA X, and CNA Y (two of whom worked all shifts), at Resident 2's Station One, each stated that Resident 2 had sometimes refused care, including repositioning, showers, and getting him out of bed to change soiled (clothing or bedding), especially on the evening (PM) shift. They stated that Resident 2 was scheduled for showers twice a week on the PM shift. They further stated that CNAs do look at the residents' skin during showers and note any skin problems on a, "Shower Day Skin Inspection," form. They stated that when Resident 2 has refused care, they do not document the specifics of the occurrences. They stated that, as instructed, they tell the charge nurse of the refusals. On 1/23/14, the residents' shower schedule posted at Station One, indicated that Resident 2 had been scheduled for showers on Tuesdays and Fridays on the PM shift. He should have received a shower on Friday, 3/28/14, three days prior to the discovery of the PU. During an interview on 1/23/15 at 4:30 pm, the Medical Records Director (MRD) V could not show the Shower Day Inspection Forms because they are, "tossed out when over three months old." During an interview on 1/23/15 at 2:25 pm, LN G stated that he is a charge nurse for Station One. He stated that when a CNA reports that a resident has refused care, he attempts to work with the resident. LN G further stated that, while sometimes he has not been successful in convincing the resident to accept care, he documents the refusal, "in behaviors". A "Behavior Monitoring" flow sheet dated 3/2014, listed Resident 2's behaviors as, "agitation," and "inability to relax," and instructed staff to "tally by hash marks." From 3/24/14 through 3/31/14, the day before the discovery of the PU, there were two to four hash marks on each PM shift for "agitation." There was no specific listing for the monitoring of refusal of care. On 4/3/14, NP U assessed Resident 2's, "back ulcer." NP U documented,..."It is looking worse now and staff has asked me to look at it...2 cm by 2 cm ulcer with yellowish slough mid back over largest vertebral (spine bone) prominence, surrounded by [DIAGNOSES REDACTED] (redness) and induration (abnormal hardening of tissue). Total area effect is 10 cm.... Assessment: 1) Pressure Ulcer to back, 2) [MEDICAL CONDITION] (inflammation of skin tissues commonly caused by bacterial infection), 3) Dementia." On 4/8/14, a wound care physician assessed the ulcer as, "Stage IV (a rating for a pressure ulcer that has loss of full thickness of skin, exposing bone, tendon or muscle)," with a measurement of 2.5 by 2.6 by 0.2 cm, and with "heavy serous exudate (bloody drainage)." The physician added, "The patient also has moisture associated [MEDICAL CONDITION] (skin inflammation) which is a new problem...periwound (groin, genitals area)," and "Factors complicating wound healing: [MEDICAL CONDITION]." A document titled, "Vital Report," listed the results of all of Resident 2's weight checks. On 3/25/14, seven days before the 4/1/14 discovery of the Stage III PU, Resident 2 weighed 144.2 pounds (lbs). With his next weight check four weeks later, on 4/21/14, he weighed 128.7 lbs. Resident 2 had lost 15.5 lbs, or 14.6% of his body weight in 28 days. (Refer to F 325) All IDT notes were reviewed. The first IDT note was dated 1/16/14, the second was dated 4/10/14. The first two notes documented issues related to an anti-psychotic medication, [MEDICATION NAME], being administered to Resident 2 for "paranoid [MEDICAL CONDITION] with striking out." The IDT note dated 4/10/14, made no mention of his advanced PU discovered nine days prior. The third IDT note, dated 6/3/14, documented exclusively of an incident where Resident 2 was agitated and grabbed staff, and a plan of care to address such behavior that included "behavior monitoring." None of the three IDT notes made any mention of Resident 2's having refused care or Resident 2's weight status. During an interview on 1/22/15 at 1:40 pm, DON stated that if MRD V, could not find any assessments of Resident 2's PU, "prior to 4/1/14, then there isn't one." 3. Resident 4's clinical record was reviewed. It indicated he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. It further indicated that Resident 4 was unable to make health care decisions for himself. The Skin Risk quarterly assessment, dated 12/15/14, indicated Resident 4 was incontinent at times of bladder and bowel. The assessment indicated Resident 4 was at risk for developing pressure ulcers. The policy titled "Prevention of Pressure Ulcers" revised October 2010, indicated, the facility should have a system procedure to assure assessments are timely and appropriate and changes in condition are recognized, evaluated, reported to the practioner, physician, family, and are addressed. The policy also indicated the following information should be recorded in the resident's medical record; type of skin care given, the position in which the resident was placed, any change in resident's condition, and the condition of the residents skin (the size and location of any red or tender areas). a. The weekly nursing progress note for Resident 4 dated 11/25/14, did not include documentation of a skin issue on the coccyx. Resident 4's clinical record contained documentation that indicated, on 12/1/14, a circular open area measuring 0.5 centimeters (cm) to the coccyx was identified by a Certified Nursing Assistant (CNA). On 12/1/14 there was a A physician order [REDACTED]. An Event Report, dated 12/5/14, indicated the wound was a Stage II pressure ulcer and had been referred to the wound physician. The Interdisciplinary Team (IDT) note, dated 12/12/14, did not include documentation nor evaluations regarding the coccyx pressure ulcer. Resident 4 had no Care Plan created for the coccyx pressure ulcer. The policy titled Care Plans Comprehensive revised 10/2009, indicated the IDT develops and is responsible for the development of an individualized comprehensive care plan for each resident that identifies the highest level of functioning the resident can attain. Assessments of residents is ongoing and care plans are revised as the resident's condition changes. On 1/4/15, a nursing progress note indicated Resident 4 had an excoriated buttocks described as; red with some bleeding noted, Zinc Oxide was applied. On 1/7/15 another nursing progress note indicated excoriation to buttocks. The physician order [REDACTED]. Zinc Oxide has been used for over 30 days. The progress notes for Resident 4 indicated no further or measurements of the "buttock" pressure ulcer in the weekly nursing summary and no documentation about the coccyx in the weekly wound skin reports by the Licensed Nurse (LN) H. The records for the wound care specialist evaluation did not include any assessments of the coccyx or buttock for the months of 12/2014 and 1/2015. During an concurrent record review and interview on 1/22/15 at 10 am, Assistant Director of Nursing (ADON) confirmed there was no care planning for the coccyx wound and that the treatment was not reevaluated. b. On 01/01/15, a nursing progress note indicated a CNA reported a skin wound in the area just above Resident 4's right heel. The LN G noted only the measurements (2 cm x 1 cm) of the wound and no clinical assessment of area was documented. LN G received an order for a foam dressing to float heel while in bed. The weekly nursing progress notes for Resident 4 dated 12/16/14 and 12/30/14 indicated no new skin issues related to an unstageable pressure sore with eschar identified 2 days later. On 1/3/15 a nursing progress note indicated the right heel looks like there has been some bleeding present. There was no documentation found that the wound care nurse nor the wound care specialist was aware of the change in wound status. On 1/7/15, a nursing progress note indicated the treatment nurse evaluated Resident 4's wounds on this right foot and buttocks. No nursing progress note documentation nor skin assessment documentation could be found in Resident 4's record. The was no further documentation in the nursing progress notes indicated no further assessment of the right heel wound until 1/13/15. The skin pressure ulcer report dated 1/13/15 described the right heel as an unstageable pressure covered with eschar measuring 1.0 cm x 1.5, with no new changes or interventions. The general orders indicated on 1/9/15 the order to float the right heel on pillow when in bed was discontinued by LN G and reason was condition resolved. The initial assessment by the physician on 1/13/15, indicated the right heel was a pressure wound and was unstageable due to necrosis. The recommendation by the physician was to off load the wound. The Care Plan was not updated with the physician order [REDACTED]. The Skin Risk quarterly assessment dated [DATE] indicated Resident 4 had no interventions or measures related to heel protectors, daily skin observation, and did not recommend a review in IDT. The current plan of care was continued. During an interview on 1/22/15 at 11 am, LN H described Resident 4's right heel had a blood blister and it was dark purple, she could not give a date for this observation and could not explain whether this is was a pressure ulcer or deep tissue injury. LN H further stated that it was now eschar. The records reviewed for Resident 4 did not indicate any documentation about a blood blister in the nursing skin assessments and progress notes. During an concurrent record review and interview on 1/22/15 at 10 am, the ADON confirmed there was care planning for interventions for floating the right heel, the specialty bed, protection of the heels/feet and had no specific care plan addressing skin integrity risks related to Diabetes. During an interview on 1/23/15 at 3:25 pm, the DON stated Resident 4 was spending more time in bed. The DON further explained the physician had thought about ordering a Doppler to determine arterial versus [MEDICAL CONDITION] and confirmed the right heel was identified as a pressure ulcer. 4. A review of the facility's admission records indicated that Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS, a standardized resident assessment), dated 12/2/14, indicated that Resident 3 was at high risk for developing pressure ulcers (a wound created by areas of unrelieved pressure over a defined area, usually over a bony prominence which results in inadequate blood supply, and tissue death). The facility identified Resident 3's risk factors for developing pressure ulcers as: history of previous ulcers, age greater than [AGE] years, restricted blood circulation, undernutrition, diabetes, exposure to skin irritants and wetness (e.g. urine and feces), weakness that decreases spontaneous movement, cognitive (mental) impairment, and decreased mobility (unable to walk or turn self in bed or chair). The MDS, dated [DATE], indicated that Resident 3 was cognitively impaired and required total assistance (full staff performance) for bathing, and extensive assistance (resident involved, staff provide weight-bearing support) for transfers (movement between surfaces like bed to chair), bed mobility (to and from a lying position, and from side to side), dressing, eating, hygiene (cleansing body), and locomotion (travel from one area of facility to another). Resident 3 was non ambulatory (not capable of walking) and required extensive assistance from staff for wheelchair use. Resident 3 required extensive assistance for toileting due to incontinence of bowel and bladder. On 1/21/15 at 11:45 am, an interview was conducted with Licensed Nurse E (LN E). LN E explained that Resident 3 has had a Stage III (full thickness loss of skin with extension into subcutaneous tissue but not through the underlying fascia) pressure ulcer on her left buttock in the past which had healed, and the area had recently opened and has been assessed as a Stage II (a partial-thickness loss of skin involving epidermis and dermis) ulcer. LN E stated, "Resident 3's left buttock wound heals and then it re-opens repeatedly about every six to eight weeks." A review of Resident Progress Notes, dated 1/7/15, indicated that Resident 3 had an "abrasion on the buttocks." The Event Report, dated 1/14/15, indicated "Resident 3 presented with an open area to the L buttock tonight. It measured 0.7 x 0.5 x .02" (wound size is usually measured in centimeters). A review of physician's orders [REDACTED]. and prn (as needed). The Event Report indicated on 1/21/15 a change of order to: Clean pressure ulcer to L buttock w/ NS, pat dry, apply [MEDICATION NAME] (a non-breathable dressing which adheres to the skin and allows for normal washing and bathing) dressing daily and prn. On 1/23/15 at 10:30 am, during a concurrent review of Resident 3's 1/2015 Turning Schedule record, and interview with LN D, it was noted there was no documentation that Resident 3 was turned, as ordered, on 1/2, 1/3, 1/4, 1/5, 1/9, and 1/10/15, between the hours of 4 am and 8 am. On 1/11 and 1/12/15, there was no documentation that Resident 3 was turned between the hours of 12 am and 8 am. On 1/13/15, there was no documentation that Resident 3 was turned between the hours of 12 am and 6 am. When asked to describe how, and by whom, turning of residents is documented, LN D stated, " The CNA's know the turning schedules of each resident. They do the turning and the licensed staff visualizes that the resident has been turned, and then documents on the monthly Resident Turning Schedule document." LN D confirmed Resident 3 had no documentation of being turned on the dates and times described above. On 1/22/15 at 3:07 p.m., during an observation of Resident 3's dressing change, it was observed there was no dressing in place, as ordered, over Resident 3's left buttock and surrounding area. LN H confirmed there was no dressing in place and the missing dressing was not found. LN H confirmed the dressing order, stating, "the order is to change dressing daily and prn (as needed). The dressing should be kept in place." CNA W stated, "I just came on shift, this is my first time to come in (Resident 3's) room today." CNA W stated a nurse should be told if a dressing falls off. On 1/23/15 at 10:55 a.m., an interview was conducted with CNA M. CNA M confirmed that he was assigned to care for Resident 3 during the day shift on 1/22/15. CNA M recalled knowing that Resident 3 had a dressing on her left buttock. CNA M recalled that he had changed Resident 3's disposable undergarment three times on 1/22/15, and on the last change, he noticed the dressing was not in place. CNA M stated, "I thought the wound nurse just changed it once a day and that was it. I didn't know I was suppose to tell the nurses it came off."

Based on interview and record review the facility failed to assess and provide appropriate treatment to restore urinary continence (ability to hold urine) in one of 19 sampled residents. (Resident 9) This contributed to the resident's inability to improve his continence status. Findings: Resident 9's record was reviewed. Resident 9 was initially admitted to the facility on [DATE], was discharged on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS- an assessment tool) dated 8/26/14, showed that Resident 9 was continent (in full control) of his bladder. The first MDS completed after Resident 9's readmission, dated 10/30/14, showed that he was now "frequently" incontinent of bladder (urine), a decline from the previous assessment. During an interview and concurrent record review on 1/20/15 at 9:45 am, Licensed Nurse (LN) A stated her job was to complete MDS assessments and a bowel and bladder assessment with each MDS completed. LN A stated Resident 9 did not have a bowel and bladder assessment done to evaluate his new urinary incontinence after the 10/30/14 MDS identified a new problem of urinary incontinence. The subsequent MDS dated [DATE], titled a "significant change of condition" indicated Resident 9 was "frequently" incontinent of bladder and a trial toileting program had not been attempted since urinary incontinence was noted in the facility on 10/30/14. LN A stated a bowel and bladder assessment should have been completed on Resident 9 within 14 days of readmission and again with the significant change MDS of 11/19/14, but no assessments had been done for Resident 9 since his re-admission 3 months ago. A policy titled, "Urinary Continence and Incontinence-Assessment and Management," dated 8/2006 indicated "Nursing staff will seek and document details related to continence" then "Nursing staff and physician will identify risk factors for becoming incontinent or for worsening of current incontinence... include(ing) a review of medications that might affect continence", will summarize relevant causes, risk factors and complications and categorize the residents type of continence as urge, stress, overflow etc. The policy also stated "staff will initiate a toileting plan based on assessing the category and causes of incontinence." During an interview and concurrent record review on 1/27/15 at 1:30 pm, with LN C who manages the facility bladder toileting program, stated she had not been aware Resident 9 had lost bladder function and she had not started him on any sort of scheduled or retraining program. LN C stated Resident 9 had a high level of cognition and some episodes of continence so he may have been able to benefit from a bladder program to restore function. LN C confirmed two bowel and bladder assessments were completed on 1/23/15. One assessment indicated it had been completed using data from 11/13-11/19/14 and the second indicated it had been completed using data from the MDS of 10/30/14. Both assessments showed Resident 9 scored 12 on each assessment. LN C confirmed a score of 12 indicated Resident 9 had been a candidate for a bladder program to restore function but Resident 9's incontinence had not been assessed and no program had been initiated. LN C also confirmed neither assessment contained a summary of relevant causes of Resident 9's incontinence and the type of incontinence had not been identified as their policy indicated, which would assist the facility to determine the appropriate toileting program.