Every finding on record at River Valley Healthcare & Wellness Centre, LP

Based on interview, record review, and policy review, the facility did not ensure that two of seven residents sampled (Residents 1 and 2) were treated with dignity when:1. Resident 1 was left in his bed wet after bathing.2. Resident 2 reported that his pants were missing and the facility did not address the issue for more than a month.These failures caused Resident 1 to be frustrated and caused Resident 2 to be angry.Findings:1. Review of a facility policy titled, Resident Rights revised January 1, 2012, indicated Employees are to treat all residents with.dignity and honor the exercise of resident rights.Review of Resident 1's medical record indicated he was admitted to the facility on [DATE] with diagnoses which included quadriplegia (paralysis from the neck down, including legs, and arms, due to a spinal cord injury).Review of Resident 1's Comprehensive Minimum Data Set (MDS is an assessment tool used in nursing homes) Brief Interview for Mental Status (BIMS is a screening to identify memory and judgement status) dated 5/31/26, completed by the Social Services Director (SSD) showed a score of 15 indicating he could make his own decisions and had a good memory.Review of Resident 1's MDS assessment titled, Section GG- Functional Assessment dated 5/31/26 and completed by the MDS Nurse (a nurse who completes MDS assessments) indicated that Resident 1 was dependent (helper does all the effort, resident does none of the effort to complete an activity) on staff to bathe and was not physically able to dry himself.During an interview with the Director of Nursing (DON) on 7/17/26 at 9:55 am, the DON confirmed that Certified Nursing Assistant (CNA) A had left Resident 1 in his bed wet and covered with a bath blanket after bathing him, and had not assisted him with getting dressed.During a concurrent observation and interview on 7/17/26 at 10:14 am, Resident 1 was lying in bed with his cell phone and hands propped on the over the bed table while he used his index fingers to scroll on his cell phone. Resident 1 continued to scroll on his cell phone this way for the entire interview. Resident 1 indicated that CNA A had left him in his bed wet after bathing him. Resident 1 indicated that this frustrated him and explained that he had a spinal injury and that it bothers him when he can't do something like scroll on his cell phone because of his injury. Resident 1 indicated that he could not use his cell phone while he was wet and that he waited for CNA A to return long enough that his fan dried him.During an interview with the Assistant Director of Nursing (ADON) on 7/21/26 at 2:55 pm, the ADON indicated that she had spoken to Resident 1 after CNA A left him in his bed wet after bathing him. The ADON indicated that Resident 1 was irritated about how long it took CNA A to return and that Resident 1 had requested to not have CNA A work in his room again. The ADON indicated that she had provided written educational counseling to CNA A.Review of a facility document titled, Educational Counseling dated 7/15/26, indicated that Resident 1 was left with a bath blanket while CNA A left to grab supplies and that Resident 1 did not appreciate it. The objective of the education was that CNA A ensure that he would have all supplies/equipment ready prior to starting a task so that he could complete tasks in a timely manner.During an interview with CNA A on 7/21/26 at 11:50 am, CNA A indicated that the day that he had left Resident 1 in his bed wet after bathing him, he forgot some items he needed to finish the bathing task. CNA A indicated that he left the room and while he was in the hall Licensed Nurse (LN) B told him that she needed his help because someone fell. CNA A indicated that he went to help LN B and then returned as soon as he could. CNA A indicated that when he returned, Resident 1 was mad about waiting to be dried off.During an interview with LN B on 7/21/26 at 12:05 pm, LN B indicated that she had asked CNA A to help with a resident who had fallen but that CNA A had never said anything to her that he had left Resident 1 wet in his bed or that Resident 1 was waiting form him.During an interview with the Director of Staff Development (DSD) on 7/21/26 at 1:50 pm, the DSD indicated that her expectation for CNAs was that they would have all the necessary items that they would need to give the residents a shower or bath ready before they start bathing the resident and that if the CNA must leave the resident and cannot return within a couple of minutes they should let another staff person know so that someone can go help the resident waiting.During an interview with the DON on 7/21/26 at 3:20 pm, the DON acknowledged that CNAs should have all the supplies they will need ready before they start bathing a resident and should let another CNA know when they have a resident waiting on them when they cannot return quickly so that someone else can help the resident.2. Review of a facility policy titled, Resident Rights revised January 1, 2012, indicated, These rights include.a resident's right to.K. Retain and use personal possessions to the maximum extent that space and safety permit.Review of Resident 2's medical record indicated he was admitted to the facility on [DATE] with diagnoses which included heart attack, heart failure, diabetes (high blood sugar), and anxiety.Review of Resident 2's Quarterly MDS BIMS, dated 5/7/26, completed by the Social Services Director (SSD) showed a score of 15 indicating he could make his own decisions and had a good memory.During a concurrent interview and record review on 7/17/26 at 4:04 pm, with the Social Services Assistant (SSA), Resident 2's record titled, Personal Effects Inventory Form dated 10/28/25, completed by CNA C, was reviewed, which indicated that Resident 2 had one pair of gray slacks. Resident 2's record titled, Theft/Loss Report dated 6/8/26, completed by SSA, indicated that Resident 2 reported his gray sweatpants (Jeans Gbc) missing. Resident 2's record titled, Progress Note dated 6/17/26, completed by SSA, indicated that Resident 2 wanted his missing pants replaced. The SSA indicated that he had worked with Resident 2 to pick out pants online and took screenshots of the item and gave them to the facility administrator (ADM) to approve the purchase. The SSA indicated that the ADM had left the facility recently and he was not able to provide the screenshots of the pants that he gave to the ADM.During an interview on 7/17/26 at 4:45 pm, with the DON, the DON indicated that the ADM left suddenly about a week ago and that she would discuss Resident 2's missing item with him and would be purchasing the missing item right away.During a concurrent interview and record review on 7/21/26 at 10:33 am, with the SSD, the SSD indicated that Resident 2 had reported his missing pants on 6/8/26 and that she thought they had been ordered due to the request having been submitted to the ADM but then the ADM left and no order was made. Reviewed Resident 2's document titled, Theft/Loss Report dated 7/21/26, which indicated that Resident 2's missing pants were ordered that day. The SSD indicated that her expectation when a resident's belongings are missing was that the belongings would be found or the process to replace them would be started within 48 hours of the report being made.During an interview on 7/21/26 at 3:20 pm, the DON acknowledged that it was a long time between when Resident 2 reported his pants missing on 6/8/26 and when it was addressed on 7/21/26.

Based on interview, and record review, the facility failed to submit the required Payroll Based Journaling (PBJ), staffing information to the Centers for Medicare and Medicaid Services (CMS).This failure has the potential for nursing homes to have inadequate staffing to care for residents and can lead to adverse clinical outcomes. Findings:During a concurrent interview and record review on 5/18/26 at 9:30 am, with the Administrator (ADM), the PBJ reporting data was reviewed, the PBJ indicated the CASPER report 1705D fiscal year Quarter 1, 2026 (October 1 - December 31), was not submitted for that quarter. ADM confirmed the report was not submitted due to their corporation having computer issues and they could not submit the PBJ report on time. The facility was unable to provide evidence, by the conclusion of the survey on 5/21/26, demonstrating compliance with the regulatory requirement to submit Payroll-Based Journal (PBJ) data and reports to CMS.

Based on observation, interview, and policy review the facility did not protect the rights of all residents of the facility to access and review the results of the most recent recertification survey (a recertification survey is an evaluation of the facility to ensure they are compliant with federal regulations, clinical quality, and operational standards so they can continue to receive Medicare/Medicaid reimbursement) of the facility.This failure resulted in residents of the facility not knowing where to find the results to review.Findings:Review of a facility policy titled, Resident [NAME] of Rights, dated 5/2011, indicated (g) Examination of survey results. A resident has the right to -- (1) Examine the results of the most recent survey and any plan of correction in effect with respect to the facility. The facility must make the results available for examination in a place readily accessible to residents, and must post a notice of their availability.During a facility Resident Council meeting (an independent, organized group of residents in a nursing home, who regularly meet to advocate for their rights, improve quality of life, and address their concerns with management of the facility, run by residents for residents) interview on 5/20/26 at 10:00 am, the attendees of the meeting indicated that they did not know where in the facility to find the results of surveys conducted at the facility.During a concurrent observation and interview on 5/20/26 at 10:25 am, the Receptionist (Rec) indicated that there was no survey binder on the shelf on the north side of the facility front entrance door where is was usually kept. The Rec indicated that the Administrator (Adm) might have had it.During a concurrent observation and interview on 5/20/26 at 10:27 am, the Adm confirmed that the survey binder was not on the shelf on the north side of the facility front entrance door. The Adm indicated that it was moved to a closed cabinet inside the shelf when decorations were put away after a celebration.During a concurrent observation and interview on 5/21/26 at 11:34 am, the Adm confirmed that there was not a notice posted where the survey binder was kept.

Based on observation and interview, the facility failed to maintain a clean homelike environment affecting two out of 21 resident bathrooms housing up to three residents in each room, when the shared bathroom between rooms [ROOM NUMBERS] was highly malodorous smelling of a high concentration of urine, with brown staining in the linoleum (vinyl flooring) and surrounding the front of the toilet, and what appeared to be fecal matter (poop) adhered to the toilet tank, seat, and rim of the toilet. The bathroom between rooms 19 ad 20 smelled of urine, had brown staining to the linoleum flooring in front of the toilet, and black staining spreading out behind the toilet within the linoleum.This failure had the potential to result in disease transmission, with increasing health complications and overall well-being issues to those residents utilizing the common space.During a review of the facility's policy and procedure titled, Housekeeping - Restrooms and Showers, dated January 1, 2012, indicated, the purpose was To promote the health of residents and staff by maintaining clean and sanitary conditions.(instructions include) Restrooms. clean thoroughly all surfaces of toilet.clean area around toilets and urinals thoroughly.During an observation on 5/18/26 at 11:20 am, upon entering room [ROOM NUMBER] there was a highly concentrated urine odor permeating the room. Upon review of the shared bathroom between rooms [ROOM NUMBERS], the bathroom was observed to have an overwhelming concentrated urine odor, the toilet had smears of fecal matter on the rim, the seat, and the tank, and a dark brown staining to the linoleum was expanding out around the front of the toilet and lightly ending behind the toilet. The bolt portion at the base of the toilet by the trap area with the white cap cover was ringed with urine that had dried and was gummy and encircled the white caps.During an observation on 5/18/26 at 1:30 pm, the bathroom between rooms [ROOM NUMBERS] had a strong urine smell and the linoleum on the floor was stained brown in front of the toilet expanding outward, and behind the toilet was a worn black staining of an unknown substance.During a second observation conducted on 5/19/26 at 8:30 am, of the bathrooms between rooms [ROOM NUMBERS] and 19 and 20, both bathrooms looked and smelled the same as they had when observed the day before, on 5/18/26. During an observation and interview on 5/19/26 at 9:30 an, with Director of Nursing (DON), in DON's office, photos taken by the surveyor of the bathrooms were reviewed. DON confirmed the bathrooms appear to be unsatisfactorily unclean and the flooring stained, which is not conducive to a healthy, homelike environment.

Based on observation, interview and record review, the facility failed to ensure that one of five sampled residents (Resident 33) was administered an inhaler (hand held device that delivers medication directly into the lungs), in accordance with manufacturer's instructions. This failure had the potential for the medication to be ineffective and have a negative impact on the resident's respiratory health. Findings: During a review of the facility's policy and procedure (P&P) titled, Specific Medication Administration Procedures, dated 5/2022, the P&P indicated, Oral inhalation administration purpose is to allow for safe, accurate, and effective administration of medication using an oral inhaler with or without a spacer/chamber or nebulizer. Review the packet insert if unfamiliar with the inhalation device provided: Procedure: Ask resident to breathe out as deeply as possible (do not exhale into inhaler). Position inhaler for administration: If not using a spacer: Open mouth and position the inhaler one or two inches from mouth, OR Place inhaler mouthpiece under top teeth and above tongue with mouth/lips closed around the mouthpiece. Press down on inhaler once to release medication as resident starts to breathe in slowly through the mouth over 3 to 5 seconds. (Do not spray more than one puff at a time.) With dry-powder inhalers, the dose is activated by pushing or twisting the lever/device. Also, breathing in quickly and deeply through the mouth usually yields the best results with dry-powder inhalers. Hold breath for 10 seconds or as long as possible to allow medication to reach deeply into lungs. Slowly exhale through nose. During a review of the manufacturer's instructions for the use of an inhaler titled, Instructions for Use Tiotropium [a brand of inhaler], dated 5/2025, indicated taking your full daily dose of medicine requires four main steps. Step 1: Opening your LupinHaler [the device that delivers the Tiotropium medication] device. Step 2: Inserting the tiotropium bromide inhalation capsule into your inhaler device. Step 3: Do not press the green button more than one time. Do not shake your device. Step 4: Breathe out completely in one breath, emptying your lungs of any air. Hold your head in an upright position while looking straight ahead. Raise the LupinHaler device to your mouth in a horizontal position. Do not block the air intake vents. Close your lips tightly around the mouthpiece, breathe in deeply until your lungs are full. Hold your breath for a few seconds, and at the same time take the LupinHaler device out of your mouth. Breathe normally again. Remember: To get your full medicine dose each day, you must breathe in two times from the same tiotropium bromide inhalation powder capsule. Make sure you breathe out completely each time before you breathe in from your LupinHaler device. During a review of Resident 33's admission Record, not dated, the admission Record indicated, Resident 33 was admitted to the facility on [DATE], with diagnoses that included hyperkalemia (too much potassium in the blood, a mineral for nerves and muscles including the heart), dehydration (the body does not have enough water to function properly), heart disease, high blood pressure, diabetes (too much sugar in the blood), heart failure, unspecified (the heart is not pumping blood efficiently enough to meet the body's needs), malignant melanoma of the scalp and neck (most serious form of skin cancer spreading more aggressively), epilepsy (recurring bursts of electricity that temporarily alter behavior, movement and awareness), major depressive disorder (persistent feelings of sadness, hopelessness and loss of interests), and chronic obstructive pulmonary disease (COPD, a progressive lung disease that makes it hard to breathe). During a review of Resident 33's most recent, Minimum Data Set, (MDS, a resident assessment tool), dated 5/11/26, the MDS indicated, Resident 33 had no cognitive problems (ability to think, reason and make decisions), with a brief interview for mental status (BIMS) score of 14 out of 15. During a review of Resident 33's, Active Orders, dated 5/6/26, the Active Orders indicated Tiotropium Bromide Monohydrate Capsule [brand of inhaled medication] 18 micrograms, (mcg, a unit of measure) was ordered, inhale one capsule [the capsule breaks to release the medication when inhaled into the lungs] orally one time a day for COPD. Rinse mouth after use. During an observation on 5/20/26 at 8:50 am, in Resident 33's room, Licensed Nurse (LN) B administered Tiotropium Bromide Monohydrate Capsule 18 mcg, (inhalation medication used for COPD), without providing correct steps for use to Resident 33 who is capable of following instructions. LN B handed the inhaler to Resident 33 and did not provide proper breathing instructions for breathing out before using the inhaler. Resident 33 inhaled one puff of the inhaler medication without blowing out first and did not hold the medication in lungs for 10 seconds. LN B did not instruct Resident 33 to hold the medication in as long as possible for effectiveness after inhaling the medication. During a concurrent interview and record review on 5/20/26 at 9:02 am, with LN B the, Instructions for Use Tiotropium, dated 5/2025, ordered for Resident 33's inhalation medication steps one through four were reviewed. LN B confirmed step four was not followed and no instructions were provided to Resident 33 for correct administration of an inhaler ordered. LN B stated, I confirm I did not provide any breathing directions for this medication for breathing out before taking the inhaler or trying to hold the medication as long as possible after inhaling. I will provide instructions for all inhalers moving forward. During an interview on 5/20/26 at 10:22 am, with the Director of Nursing (DON), the DON confirmed the inhalation medication for Resident 33 was not administered correctly per their medication policy and the manufacturer's instructions for use. DON stated, I will make sure specific instructions are added to the Electronic Medical Administration Records [e-MARs] for all inhalers administered, and we will provide an in-service to all nursing staff to correctly administer all inhalers for effectiveness.

Based on interview, record review, and policy review, the facility failed to manage urinary retention (the inability to empty the bladder of urine) for one of four residents sampled (Resident 1) when Resident 1 did not urinate for over 14 hours, which can be a life-threatening medical emergency.This failure resulted in delayed treatment of Resident 1's urinary retention.Findings:Review of, National Institute of Health (a nationally recognized professional resource) webpage titled, Definitions & Facts of Urinary Retention dated December 2019 indicated that acute (sudden) urinary retention (the inability to empty the bladder of urine) can be life-threatening.Review of, National Institute of Health (a nationally recognized professional resource) webpage titled, Treatment of Urinary Retention dated December 2019 indicated that the treatment for acute urinary retention is to drain the bladder using a urinary catheter (a hollow tube inserted into the bladder to drain or collect urine also known as a Foley Catheter).Review of a facility policy titled, Catheter-Intermittent (a hollow tube inserted into the bladder to drain urine from the bladder and immediately be removed and is often used to manage urinary retention) dated April 15, 2021, indicated IV. Intermittent catheterization will be used when medically necessary.Review of Resident 1's medical record indicated that he was admitted to the facility on [DATE] with diagnoses which included chronic kidney disease (the kidneys are damaged and cannot filter blood the way they should).Review of Resident 1's Minimum Data Set (MDS is a federally mandated assessment tool that measures the health status in nursing home residents) dated 12/8/25, and completed by the Social Services Director (SSD) indicated that Resident 1 had a BIMS (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 15 indicating he could make his own decisions.Review of Resident 1's record titled, Bladder Report dated 12/8/25 indicated that Resident 1's last documented urination at the facility was on 12/8/25 at 11:32 pm, more than 14 hours before the facility sent him to the acute care hospital (a healthcare facility where patients are treated for brief but severe episodes of illness or injury).Review of Resident 1's record titled, SNF/NF to Hospital Transfer Form (a form used to help convey information to the acute care hospital about why the resident was transferred to the acute care hospital) (SNF a skilled nursing facility - are places for people to live temporarily while they are getting rehabilitation and medical treatments after hospitalization for an illness or injury), dated 12/9/25 at 2:08 pm, completed by Licensed Nurse (LN A) indicated that Resident 1 was transferred to the acute care hospital. There was no mention in this form that Resident 1 had not urinated for over 14 hours.Review of Resident 1's record titled, Communication-with Physician dated 12/9/25 at 2:39 pm written by LN A, indicated .Resident has had no urine output since yesterday.Review of Resident 1's acute care hospital emergency department report dated 12/9/25 at 3:49 pm, indicated that Resident 1 had a urinary catheter inserted and the amount of urine drained from his bladder was 2 liters (2,000 milliliters), which is equal to almost 8 and a half cups.Review of the, National Library of Medicine (a nationally recognized resource for healthcare providers) webpage titled Bladder Catheterization dated August 8, 2023, indicated that The capacity of the bladder can vary between 350 milliliters - 500 milliliters which is equal to about 1.5 cups to 2 cups.During an interview on 2/10/26 at 3:35 pm, with the Director of Nursing (DON), the DON acknowledged there was no documentation of Resident 1 urinating for over 14 hours, from 12/8/25 at 11:32 pm, till 12/9/25 at 2:08 pm, when he was sent to the acute care hospital. The DON indicated that LN A could have gotten a physician's order (written instructions from a doctor detailing specific treatments, medications, or tests for a patient) for an intermittent catheter and drained Resident 1's bladder but she did not realize Resident 1 had not urinated until later.During an interview on 2/10/26 at 4:35 pm with the DON, the DON indicated that Resident 1 not urinating happened over two shifts and that the nurse on the night shift did not have 8 or more hours of Resident 1 not urinating to report to LN A at the shift change so that LN A would be aware. The DON indicated that LN A did not recognize that Resident 1 had not urinated, until almost 8 hours into her shift.During an interview on 2/11/26 at 2:20 pm, with the DON, the DON indicated that the facility does not have a urinary retention policy (a written document used in healthcare facilities that guide how healthcare is delivered, specifically in this case for urinary retention).

Based on interview and record review, the facility failed to report an outbreak of gastroenteritis (symptoms could include vomiting and diarrhea, which could be caused by an infection) to the California Department of Public Health (CDPH, responsible to protect the health of the public) in a timely manner. This failure had the potential for infection to spread to all residents, facility staff, and the community. Findings: A review of the All Facilities Letter 23-08 (a letter from the Center for Health Care Quality, responsible for regulatory oversight, that contained reminders, recommendations, or information regarding changes in healthcare requirements), dated 1/18/23, indicated, an outbreak was defined as a disease or condition that affected more residents than expected, included gastroenteritis (an illness that caused vomiting, diarrhea, and stomach pain), and Outbreaks of any condition should generally be reported. A review of the facility ' s policy and procedure titled, Unusual Occurrence Reporting, revised 5/30/24, indicated, unusual occurrences would be reported to the appropriate agencies within 24 hours. A review of Unusual occurrence for unknown gastrointestinal [involved the mouth, stomach, and intestines] outbreak, dated, 5/5/25, indicated, two residents vomited on 5/1/25, three residents vomited on 5/3/25, and five residents had vomited on 5/4/25. During a concurrent interview and record review on 5/14/24 at 11:55 am, with Infection Preventionist (IP), the LTC Acute Gastroenteritis Surveillance Line List (line list) for residents, dated 5/2/25 was reviewed. IP confirmed, the line list indicated, symptoms of gastroenteritis, that included vomiting and/or diarrhea, were experienced by 12 residents from 5/1/25 through 5/5/25 and seven residents experienced symptoms that included vomiting, diarrhea, and/or a fever, from 5/6/25 through 5/13/25. IP confirmed, CDPH was notified by the Director of Nursing (DON) on 5/5/25. During an interview on 5/14/25 at 12:51 pm, DON confirmed that the facility reported a suspicion of gastrointestinal outbreak on 5/5/25 and was not reported in a timely manner.

Based on interview and record review, the facility failed to monitor output of foley catheters (FC - a thin, flexible tube that drains urine from the bladder into a bag) per facility policy and physician orders for three of three sampled residents (Resident 1, 2, 3). This failure had the potential to endanger the residents and cause complications due to inaccuracies in fluid balance monitoring. Findings: A record review of facility policy Catheter - Care of dated 6/10/21 indicated Nursing staff will assess urinary drainage for signs and symptoms of infection, noting cloudiness, color, sediment, blood, odor, and amount of urine. A record review of Resident 1 ' s admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included obstructive and reflux uropathy (here there's a blockage in the urinary tract, preventing the normal flow of urine), atrial fibrillation (a type of irregular heartbeat where the upper chambers of the heart beat out of sync and very rapidly), and metabolic encephalopathy (a brain dysfunction caused by problems with the body's metabolism or other systemic illnesses). A record review of facility physician orders dated 3/5/25 indicated staff were to assess urinary drainage for signs and symptoms of infection, noting cloudiness, color, sediment, blood, odor and amount of urine output, every shift. A record review of Resident 1 ' s Intake and Output record dated 3/5/25 to 3/26/25 indicated no output from Resident 1 was documented. A record review of Resident 1 ' s Bladder Report dated 2/26/25 to 3/26/25 indicated no output from Resident 1 was documented. A record review of Resident 2 ' s admission record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included retention of urine (the inability to completely empty the bladder, either suddenly (acute) or over time (chronic), metabolic encephalopathy, congestive heart failure (a condition where the heart can't pump enough blood to meet the body's needs), and benign prostatic hyperplasia (where the prostate gland grows larger than normal). A record review of facility physician orders dated 1/30/25 indicated staff were to assess urinary drainage for signs and symptoms of infection, noting cloudiness, color, sediment, blood, odor and amount of urine output, every shift. A record review of Resident 3 ' s admission record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD - lung disease causing restricted airflow and breathing problems), acute respiratory failure with hypoxia (the respiratory system cannot adequately oxygenate the blood, resulting in low blood oxygen levels), irritable bowel syndrome (IBS - a functional gastrointestinal (GI) disorder characterized by abdominal pain and changes in bowel habits, such as diarrhea, constipation, or both), and constipation (where bowel movements occur less than three times a week, and stools are hard, dry, or difficult to pass). A record review of facility physician orders dated 3/18/25 indicated staff were to assess urinary drainage for signs and symptoms of infection, noting cloudiness, color, sediment, blood, odor and amount of urine output, every shift. During a concurrent interview with the Director of Nursing (DON) on 4/10/25 at 12:01 pm, DON confirmed there was no output documented for Resident 2 and Resident 3 on their facility Intake and Output reports and Bladder reports from January 2025 to April 2025. DON also confirmed physician orders for Resident 1, 2, and 3 ordered output from FC bags to be documented. DON confirmed facility policy indicated staff was supposed to document FC bag output. DON confirmed FC bag output was not documented for Resident 1, 2 and 3, per policy. DON stated facility catheter policy and physician orders were not followed, and should have been.

Based on interview and record review, the facility failed to inform one of three sampled resident's (Resident 1) representative (RP), of a change in Resident 1's condition which required the resident to have oxygen administered. This failure violated Resident 1 and her RP's right to be fully informed of a need to alter treatment before the treatment was initiated, and make choices that were consistent with Resident 1's wishes. Findings: During a review of the facility's policy and procedure (P&P) titled, Change of Condition Notification dated April 1, 2015, Change of Condition Notification indicated, The Licensed Nurse will notify the family/surrogate decision-makers of any changes in the resident's condition as soon as possible. A review of Resident 1's medical record indicated that Resident 1 was admitted on [DATE] with diagnoses that included Metabolic Encephalopathy (a problem in the brain caused by a chemical imbalance in the blood due to illness or organs not working adequately), Urinary Tract Infection, and Severe Protein Calorie Malnutrition (poor nutritional intake). A review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 10/23/24, indicated a Brief Interview for Mental Status (BIMS, an assessment of memory and decision making abilities), was 2 out of 15, which indicated Resident 1 had poor decision making skills and memory recall. During a record review of Resident 1's Medication Administration Record (MAR) for December 2024, the MAR indicated that on 12/28/24 Resident 1 was given oxygen (O2) at 2 liters (2L, a unit of measure) by nasal cannula (a tube in the nose). During an interview on 1/2/25 at 11:30 am, with Resident Representative (RP) on the phone, RP stated, The facility put oxygen on [Resident 1] without notifying me. I went in to visit and discovered [Resident 1] was wearing oxygen around her nose. [Resident 1] had never used oxygen before. I talked to [Licensed Nurse (LN 2] who apologized for not notifying me. I have asked to be notified about anything and everything. During a concurrent interview and record review on 1/2/25 at 12:00 pm, with LN 2 at the nurse's station, LN 2 reviewed Resident 1's MAR for December 2024 and confirmed Resident 1 was given O2 on 12/28/24, due to an O2 sat (reading of low oxygen in the blood by a device placed on a finger) of 88 percent (normal is between 92 to 100 percent). LN 2 confirmed that Resident 1's RP was not notified and indicated that LN 2 was responsible to notify Resident 1's RP as the desk nurse on duty. During a concurrent interview and record review on 1/23/25 at 3:00 pm, with Director of Nurses (DON) in the conference room, DON acknowledged there was no documentation to indicate Resident 1's RP had been notified when Resident 1's condition changed and she required oxygen use.

Based on interview and record review, the facility administered oxygen (02) without a physician's order to one of three sampled residents (Resident 1). This failure had the potential to lead to negative resident clinical outcomes when nurses choose to administer medications without an order to do so by a physician. Findings: During a review of the facility ' s policy and procedure (P&P) titled, Medication Administration, dated January 1, 2012, Medication Administration indicated, Medication will be administered directly by a licensed nurse and upon the order of a physician or licensed independent practitioner. A review of Resident 1 ' s medical record indicated that Resident 1 was admitted on [DATE] with diagnoses that included Metabolic Encephalopathy (a problem in the brain caused by a chemical imbalance in the blood due to illness or organs not working adequately), Urinary Tract Infection, and Severe Protein Calorie Malnutrition (poor nutritional intake). A review of Resident 1's Minimum Data Set (MDS, a standardized assessment), Brief Interview for Mental Status (BIMS, Section C an assessment of memory and decision making ability) score dated 10/23/2024, indicated Resident 1 rated 2 of 15, which indicated a severe impairment in memory and ability to make decisions. During a record review of Resident 1's Medication Administration Record (MAR) for December 2024, the MAR indicated that on 12/28/24 oxygen was administered to Resident 1 at a rate of 2 liters (L, a unit of measurement) by nasal cannula (nose applicators) for an oxygen saturation (O2 sat, a measurement of the amount of oxygen in the blood by placing a device on a finger) of 88 percent (%, normal O2 sat is considered between 92 to 100%). During a concurrent interview and record review on 1/2/25 at 12:00 pm, with Licensed Nurse (LN) 2 at the nurse ' s station, LN 2 reviewed Resident 1's MAR and Physician's Orders for December 2024, LN 2 confirmed that he applied O2 to Resident 1 on 12/28/24 and confirmed he did not get a physician's order to do so. LN 2 stated, Applying oxygen was an acceptable nursing intervention for immediate treatment. During a concurrent interview and record review on 1/23/25 at 3:00 pm, with Director of Nurses (DON) in the conference room while reviewing Resident 1's MAR and Physician's Orders for December 2024, DON confirmed that O2 is considered a medication and requires a physician's order for a nurse to administer.

Based on observation, record review, interview, and review of the Centers for Medicare & Medicaid (CMS) Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to ensure staff accurately coded a Minimum Data Set (MDS) for 4 (Residents #8, #25, #44, and #52) of 22 sampled residents. Findings included: The Centers for Medicare & Medicaid Resident Assessment Instrument 3.0 User's Manual version 1.19.1 dated 10/2024 indicated, 1.3 Completion of the RAI included Over time, the various uses of the MDS have expanded. While its primary purpose as an assessment instrument is to identify resident care problems that are addressed in an individualized care plan, data collected from MDS assessments are also used for the Skilled Nursing Facility Prospective Payment System (SNF PPS) Medicare reimbursement system, many State Medicaid reimbursement systems, and monitoring the quality of care provided to nursing home residents. The manual indicated, The RAI process has multiple regulatory requirements that require (1) the assessment accurately reflects the resident's status. The manual indicated, Given the requirements of participation of appropriate health professionals and direct care staff, completion of the RAI is best accomplished by an interdisciplinary team (IDT) that includes nursing home staff with varied clinical backgrounds, including nursing staff and the resident's physician. The manual indicated, In addition, an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. Per the manual, It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT completing the assessment. As such, nursing homes are responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate assessment. 1. An Admission Record indicated the facility admitted Resident #8 on 07/21/2024. According to the Admission Record, Resident #8 had a medical history that included diagnoses of unspecified diastolic (congestive) heart failure, type 2 diabetes mellitus without complications, other obsessive-compulsive disorder, and other abnormalities of gait and mobility. A quarterly MDS, with an Assessment Reference Date (ARD) of 07/30/2024, revealed Resident #8 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The MDS also indicated that they used another physical restraint in chair or out of bed. Resident #8's care plan did not include any information regarding the use of a restraint. An observation on 11/04/2024 at 2:19 PM, revealed Resident #8 was in their wheelchair at activities watching movies with five other residents eating from a snack bag of sour cream and onion chips. No restraints were observed. An observation on 11/06/2024 at 2:31 PM, revealed Resident #8 was in their wheelchair in their room going through some of their personal items and surrounded by personal clutter. No restraints were observed. During an interview on 11/06/2024 at 2:35 PM, Certified Nursing Aide (CNA) #11 stated that she was not aware of any type of restraint used on Resident #8. She further stated that Resident #8 transferred themself and took themself about the facility. During an interview on 11/06/2024 at 2:40 PM, the MDS Coordinator stated that the facility did not have anyone utilizing any type of restraint. After looking at Resident #8's MDS with an ARD of 07/30/2024, she stated that she must have entered restraints by mistake. She stated that it was important that the MDS be accurate because it helped guide their care plan interventions. She stated that she was responsible for ensuring the MDSs were accurate. During an interview on 11/07/2024 at 1:27 PM, the Director of Nurses (DON) stated that she expected that the MDSs be accurate. She stated that it was important for the MDS to be accurate because it needed to be an accurate reflection of the resident, a snapshot of how they were taking care of that person and what their needs were. She stated that the MDS nurse was responsible for ensuring the MDSs were accurate. She stated that her expectation was the MDS Coordinator pull the resident's diagnosis, their care plans, and orders, do a head-to-toe assessment at their bedside, and all information should match. An interview was held with the Administrator on 11/07/2024 at 1:55 PM. She said that she expected the MDSs to be accurate because it affected patient care. She stated that she expected staff to follow all facility policy and procedures and regulatory guidance. 45555 2. An Admission Record indicated the facility admitted Resident #44 on 12/12/2019. According to the Admission Record, the resident had a medical history that included diagnoses of obstructive sleep apnea and dependence on supplemental oxygen. An annual MDS, with an Assessment Reference Date (ARD) of 09/02/2024, revealed Resident #44 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS did not indicate the resident used a non-invasive mechanical ventilator. Resident #44's care plan included a focus area revised 10/06/2022 that indicated the resident used oxygen therapy. Interventions directed staff to apply supplemental oxygen as ordered and monitor oxygen saturation and liters per minute every shift. Further review revealed the resident did not have a care plan for the use of continuous positive air pressure (CPAP) therapy (a type of non-invasive mechanical ventilation). Resident #44's Order Recap [Recapitulation] Report for orders from 08/01/2024 through 11/07/2024 revealed an order dated 10/02/2024 for CPAP therapy continuous at night for sleep apnea. The order indicated the settings on the CPAP machine should be at 4-20 centimeter of water (cmH20) and the water chamber should be emptied and filled with distilled water every night at bedtime. Resident #44's Progress Notes revealed a Long-Term Care Evaluation dated 08/30/2024 that indicated the resident received supplemental oxygen via CPAP. An observation on 11/04/2024 at 10:52 AM revealed a CPAP machine on Resident #44's nightstand with the tubing and mask attached and lying on top of the machine with dried debris in the mask. During an interview on 11/07/2024 at 9:22 AM, the MDS Coordinator stated the MDS showed a picture of the person, and their care plan was based upon it. She stated the information came from the chart history and interviews with the patient, staff, and therapy. She stated she was responsible for the accuracy of the MDS. She stated if a resident used a CPAP machine, it should be coded on the MDS. She stated Resident #44 did use a CPAP machine, and it should have been coded on the MDS if they used it during that time frame. During an interview on 11/07/2024 at 1:11 PM, the Director of Nursing (DON) stated the accuracy of the MDS was important because it was a picture of what was going on with the resident and any type of assessment on the resident needed to be accurate. She stated it was a snapshot of the resident for a period of time. She stated the MDS nurse was responsible for the accuracy of the MDS. During an interview on 11/07/2024 at 1:50 PM, the Administrator stated she expected the MDS to be accurate because it affected all resident care and communication of care but deferred any specifics to the DON. She stated she expected the staff to follow all rules and regulations and their policy and procedures. 3. An Admission Record indicated the facility admitted Resident #25 on 03/16/2023. According to the Admission Record, the resident had a medical history that included diagnoses of bipolar disorder, unspecified psychosis, and major depressive disorder. An annual MDS, with an Assessment Reference Date (ARD) of 03/23/2024, revealed the resident had modified independence in cognitive skills for daily decision-making and had a short-term and long-term memory problem per a Staff Assessment of Mental Status (SAMS). The MDS indicated the resident was not considered by the state Level II Preadmission Screening and Resident Review (PASRR) process to have a serious mental illness and/or intellectual disability or a related condition. Resident #25's Preadmission Screening and Resident Review (PASRR) Level I Screening dated 03/16/2023 indicated the results of the screening were positive for suspected mental illness. Resident #25's Preadmission Screening and Resident Review (PASRR) Individualized Determination Letter, dated 03/24/2023, indicated specialized services were recommended that included services and supports that supplement nursing facility care to address mental health needs. The letter indicated recommendations included medication education and training, activities of daily living (ADL) training/reinforcement, supportive services, neuropsychology consultation, psychiatry consultation and/or follow-up care, safety monitors, and behavior monitors. The letters indicated additional functional/medical recommendations included an internal medicine consultation, pain services education, physical therapy, occupational therapy and speech therapy consultations, a dietary consultation, social services consultation, and a continence evaluation. During an interview on 11/07/2024 at 9:22 AM, the MDS Coordinator stated the MDS showed a picture of the person, and their care plan was based upon it. She stated the information came from the chart history and interviews with the patient, staff, and therapy. She stated she was responsible for the accuracy of the MDS. She stated if the resident had a Level II PASRR it was included on the MDS. The MDS Coordinator confirmed the Level II PASRR was not coded on the MDS for Resident #25 but should have been. She stated the Level II PASRR was supposed to be downloaded in the electronic health record or was kept in the back of their hard paper chart. During an interview on 11/07/2024 at 1:11 PM, the Director of Nursing (DON) stated she expected the MDS to be accurate in relation to the PASRR. She stated if the resident had a level II PASRR it should be coded on the MDS. She stated the accuracy of the MDS was important because it was a picture of what was going on with the resident and any type of assessment on the resident needed to be accurate. The DON stated the MDS was a snapshot of the resident for a period of time. She stated the MDS nurse was responsible for the accuracy of the MDS. During an interview on 11/07/2024 at 1:50 PM, the Administrator stated she expected the MDS to be accurate because it affected all resident care and communication of care but deferred any specifics to the DON. She stated she expected the staff to follow all rules and regulations and their policy and procedures. 22445 4. An Admission Record indicated the facility admitted Resident #52 on 03/30/2022. According to the Admission Record, Resident #52 had a medical history that included unspecified anxiety disorder, recurrent major depressive disorder, post-traumatic stress disorder (PTSD), unspecified obsessive-compulsive disorder, and unspecified bipolar disorder. An annual MDS with an Assessment Reference Date (ARD) of 07/08/2024, revealed Resident #52 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS did not reveal Resident #52 had a Level II Preadmission Screening and Resident Review (PASRR). The MDS revealed Resident #52 rejected care one to three days during the assessment period. The MDS revealed the resident had diagnoses that included anxiety disorder, depression, bipolar disorder, and PTSD. Resident #52's Preadmission Screening and Resident Review (PASRR) Level I Screening dated 09/13/2022, revealed Resident #52 had serious mental illness and had been prescribed psychotropic medications for mental illness. The screening revealed that due to the positive Level I PASRR, the state agency determined a Level II mental health evaluation was required. Resident #52's Preadmission Screening and Resident Review (PASRR) Individualized Determination Report, dated 10/17/2022, revealed there were personal goals recommended for specialized services for Resident #52. During an interview on 11/07/2024 at 8:55 AM, the MDS Coordinator stated that Resident #52's designation as a resident with a Level II PASRR had not been included on the annual MDS assessment and should have been included. The MDS Coordinator stated when coding the MDS she reviewed the resident's electronic medical record and the hard chart for information regarding the PASRR status. The MDS Coordinator stated she was responsible for the completion of the section of the MDS where that PASRR was coded. The Director of Nursing (DON) was interviewed on 11/07/2024 at 1:24 PM. The DON stated she expected the MDS to be accurate and record a resident's Level II PASRR in the correct area. The DON stated the accuracy of the MDS was important because the MDS painted a picture of the resident. The Administrator was interviewed on 11/07/2024 at 1:50 PM and stated she expected accuracy in documentation on the MDS due to the MDS affected resident care.

Based on interview, record review, and facility policy review, the facility failed to notify the physician when a medication was not available for administration for 1 (Resident #58) of 6 residents reviewed for unnecessary medications. Findings included: A facility policy titled, Medication Orders, dated 04/2008, specified, The prescriber is contacted for direction when the medication will not be available. An Admission Record indicated the facility admitted Resident #58 on 08/17/2022. According to the Admission Record, the resident had a medical history that included a diagnosis of bipolar disorder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/27/2024, revealed Resident #58 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. Resident #58's care plan included a focus area initiated 05/31/2023 that indicated the resident used psychotropic medications related to bipolar disorder. Interventions directed staff to administer psychotropic medications as ordered by the physician and monitor for side effects and effectiveness every shift. Resident #58's September 2024 Medication Administration Record [MAR] revealed a transcription of an order for Depakote tablet delayed release 250 milligrams (mg) with instructions to give 250 mg by mouth at bedtime for bipolar disorder. The MAR revealed that on 09/29/2024 and 09/30/2024 Depakote was coded 9 (other/see progress notes). Resident #58's Progress Notes revealed an Orders-Administration Note dated 09/29/2024 that indicated the resident's Depakote was not available in the facility. An Orders-Administration Note dated 09/30/2024 indicated the resident's Depakote was reordered and was not available in the facility. Resident #58's October 2024 MAR revealed a transcription of an order for Depakote tablet delayed release 250 mg with instructions to give 250 mg by mouth at bedtime for bipolar disorder. The MAR revealed that on 10/07/2024, 10/08/2024, 10/10/2024, and 10/12/2024 through 10/17/2024 Depakote was coded 9 (other/see progress notes). Resident #58's Progress Notes revealed an Orders-Administration Note dated 10/07/2024 and 10/08/2024 that indicated the resident's Depakote was not available in the facility. Resident #58's Progress Notes revealed an Orders-Administration Note dated 10/10/2024 that indicated the resident's Depakote was reordered and had not been received. Resident #58's Progress Notes revealed an Orders-Administration Note dated 10/12/2024 that indicated the resident's Depakote was reordered. Resident #58's Progress Notes revealed an Orders-Administration Note dated 10/13/2024 that indicated they were waiting on delivery of the resident's Depakote from the pharmacy. Resident #58's Progress Notes revealed an Orders-Administration Note dated 10/14/2024 that indicated the resident's Depakote had not been received. Resident #58's Progress Notes revealed an Orders-Administration Note dated 10/15/2024 that indicated the Depakote was unavailable. Resident #58's Progress Notes revealed an Orders-Administration Note dated 10/16/2024 that indicated they were waiting for delivery of the resident's Depakote. Resident #58's Progress Notes revealed an Orders-Administration Note dated 10/17/2024 that indicated the resident's Depakote had not been received. Resident #58's Progress Notes for the timeframe from 09/29/2024 through 10/17/2024 revealed no evidence that staff contacted the physician about the resident's Depakote not being available from the pharmacy and not being administered. During an interview on 11/06/2024 at 2:52 PM, Licensed Vocational Nurse (LVN) #2 stated if a medication were not available during the medication pass, she would fax the physician and let him know. She stated the faxes should be kept in the resident's medical record. LVN #2 stated she did not recall if she notified the physician about Resident #58's Depakote not being available but stated if she did, she would have sent him a fax and those were kept in medical records. During an interview on 11/06/2024 at 3:03 PM, LVN #3 stated she would fax the physician to notify him if a resident's medications were not available from the pharmacy to administer, and the fax should be kept in the resident's medical record. During an interview on 11/07/2024 at 11:01 AM, LVN #4 stated if a resident missed a dose of medication, she would call the physician and the responsible party, and it should be documented in a progress note. During an interview on 11/07/2024 at 11:05 AM, LVN #5 stated the physician should be notified any time a resident missed a dose of medication, and if it were due to not being available from the pharmacy, she would get an order to administer the medication when it arrived from the facility. During an interview on 11/07/2024 at 11:07 AM, LVN #6 stated if a medication was not available from the pharmacy to administer, they should call the physician and let them know, document it in a progress note, and place the resident on alert charting. She stated in Resident #58's situation, the pharmacy, physician, and the Director of Nursing (DON) should have been called, and the resident should not have gone that many days without the medication. During an interview on 11/07/2024 at 11:31 AM, the Medical Records Supervisor stated they did not have any faxes to the physician regarding Resident #58's Depakote not being available. During an interview on 11/07/2024 at 11:54 AM, the Medical Director stated he would get over 50 faxes a day and did not recall receiving information that Resident #58 did not receive their Depakote. During an interview on 11/07/2024 at 1:11 PM, the DON stated if the nurse was not able to receive and administer a medication by the end of their shift, then they should let the physician know. She stated she was not aware of Resident #58's Depakote not being available. She stated the physician should have been notified and it should have been documented. During an interview on 11/07/2024 at 1:50 PM, the Administrator stated if a medication was not available from the pharmacy, they should notify the physician and the DON but deferred any specifics to the DON.

Based on observation, interview, record review, and facility policy review, the facility failed to have a person-centered comprehensive care plan for 2 (Resident #44 and Resident #52) of 22 sampled residents. Specifically, the facility failed to include the use of a non-invasive mechanical ventilator for Resident #44 and Level II Preadmission Screening and Resident Review (PASRR) results for Resident #52 on the comprehensive care plan. Findings included: A facility policy titled, Care Planning, revised 03/01/2014, indicated, It is the policy of this Facility to provide person-centered, comprehensive and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents in order to obtain or maintain the highest physical, mental, and psychosocial well-being. 1. An Admission Record indicated the facility admitted Resident #44 on 12/12/2019. According to the Admission Record, the resident had a medical history that included diagnoses of obstructive sleep apnea and dependence on supplemental oxygen. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/02/2024, revealed Resident #44 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS did not indicate the resident used a non-invasive mechanical ventilator. Resident #44's care plan included a focus area revised 10/06/2022 that indicated the resident used oxygen therapy. Interventions directed staff to apply supplemental oxygen as ordered and monitor oxygen saturation and liters per minute every shift. Further review revealed the resident did not have a care plan for the use of continuous positive air pressure (CPAP) therapy (a type of non-invasive mechanical ventilation). Resident #44's Order Recap [Recapitulation] Report for orders from 08/01/2024 through 11/07/2024 revealed an order dated 10/02/2024 for CPAP therapy continuous at night for sleep apnea. The order indicated the settings on the CPAP machine should be at 4-20 centimeter of water (cmH20) and the water chamber should be emptied and filled with distilled water every night at bedtime. Resident #44's October 2024 and November 2024 Medication Administration Record [MAR] revealed staff documented that the residents CPAP machine was used every night shift. Resident #44's Progress Notes revealed a Long-Term Care Evaluation dated 08/30/2024, 09/06/2024, 09/13/2024, 10/04/2024, 10/25/2024, and 11/01/2024 that indicated the resident received supplemental oxygen via CPAP. An observation on 11/04/2024 at 10:52 AM revealed a CPAP machine on Resident #44's nightstand with the tubing and mask attached and lying on top of the machine with dried debris in the mask. During an interview on 11/07/2024 at 9:22 AM, the MDS Coordinator stated she did most of the care planning. She stated the care plan should include anything to let the staff know how to understand and care for a resident. She stated the use of a CPAP machine should be included on the care plan. During an interview on 11/07/2024 at 11:01 AM, Licensed Vocational Nurse (LVN) #4 stated if a resident used a CPAP machine, it should be included on the care plan. During an interview on 11/07/2024 at 11:05 AM, LVN #5 stated the use of a CPAP machine should be included on the care plan, and the care plan was the responsibility of the MDS Coordinator. During an interview on 11/07/2024 at 1:11 PM, the Director of Nursing (DON) stated she expected the use of a CPAP machine to be included on the care plan. During an interview on 11/07/2024 at 1:50 PM, the Administrator stated the use of CPAP should be included on the care plan. She stated she expected her staff to follow all rules and regulations and the facility's policy and procedures. 22445 2. An Admission Record indicated the facility admitted Resident #52 on 03/30/2022. According to the Admission Record, Resident #52 had a medical history that included diagnoses of unspecified anxiety disorder, recurrent major depressive disorder, post-traumatic stress disorder (PTSD), unspecified obsessive-compulsive disorder, and unspecified bipolar disorder. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/08/2024, revealed Resident #52 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS did not reveal Resident #52 had a Level II PASRR. The MDS revealed Resident #52 rejected care one to three days during the assessment period. The MDS revealed Resident #52 had diagnoses that included anxiety disorder, depression, bipolar disorder, and PTSD. Resident #52's Preadmission Screening and Resident Review (PASRR) Individualized Determination Report, dated 10/17/2022, revealed that personal goals were considered in making recommendations for specialized services and included increased contact with the resident's family, address the resident's weight concerns, improve the resident's dentition, improve hearing and mobility, request in home care assistance, podiatry services, improve memory, reduce depression, improve well-being, and provide a neurological assessment. Resident #52's care plan revealed no evidence of a focus area for Resident #52's Level II PASRR and the personal goals and individualized recommendations given for specialized services included on the resident's 10/17/2022 Preadmission Screening and Resident Review (PASRR) Individualized Determination Report. The MDS Coordinator was interviewed on 11/07/2024 at 8:55 AM. The MDS Coordinator stated because Resident #52 had a Level II PASRR with additional services, the Level II PASRR designation and the additional services should have been care planned. The MDS Coordinator stated she was responsible for most of the care plans, and it was her fault Resident #52's Level II PASRR had not been included in the resident's care plan. The Director of Nursing (DON) was interviewed on 11/07/2024 at 1:24 PM. The DON stated if Resident #52 had a Level II PASRR with specific recommendations from the reviewer she expected both the Level II designation, and the recommendations would be care planned.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure non-invasive mechanical ventilation equipment was cleaned and stored properly for 1 (Resident #44) of 3 residents reviewed for respiratory care. Findings included: A facility policy titled, BiPAP [bilevel positive airway pressure] and CPAP [continuous positive airway pressure], dated 09/10/2020, specified, Continuous Positive Airway Pressure (CPAP) is delivered in a single constant pressure during inhalation and exhalation. BiPAP is the Bilevel Positive Airway Pressure or Non-Invasive Positive Pressure Ventilation (NPPV) that delivers two pressures, lesser pressure delivered on exhalation and a second greater pressure on inhalation. The policy also indicated, VIII. Cleaning included A. Keep the outside of the machine free from dust and debris. Clean using a cloth and disinfectant weekly and as needed. B. Replace the hose weekly and as needed. C. Disassemble the CPAP/BiPAP mask by removing the head hear (straps) and cushion from face D. Replace head gear (straps) weekly or as needed for soiling. E. As needed, wash mask with warm soapy water (no fragrance or colored soap), rinse and dry F. Daily and/or after every use, wash humidification chamber with warm soapy water (no fragrance or colored soap) G. All equipment should be kept in a plastic bag or container labeled with the Resident's name when not in use H. Filters should be changed every two weeks or as specified by the manufacturer. An Admission Record indicated the facility admitted Resident #44 on 12/12/2019. According to the Admission Record, the resident had a medical history that included diagnoses of obstructive sleep apnea and dependence on supplemental oxygen. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/02/2024, revealed Resident #44 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS did not indicate the resident used a non-invasive mechanical ventilator. Resident #44's care plan included a focus area revised 10/06/2022 that indicated the resident used oxygen therapy. Interventions directed staff to apply supplemental oxygen as ordered and monitor oxygen saturation and liters per minute every shift. Further review revealed the resident did not have a care plan to address the use of CPAP therapy. Resident #44's Order Recap [Recapitulation] Report for orders from 08/01/2024 through 11/07/2024 revealed an order dated 10/02/2024 for CPAP therapy continuous at night for sleep apnea. The order indicated the settings on the CPAP machine should be at 4-20 centimeter of water (cmH20) and the water chamber should be emptied and filled with distilled water every night at bedtime. Resident #44's October 2024 and November 2024 Medication Administration Record [MAR] revealed staff documented that the residents CPAP machine was used every night shift. An observation on 11/04/2024 at 10:52 AM revealed a CPAP machine on Resident #44's nightstand with the tubing and mask attached and lying on top of the machine with dried debris in the mask. Observations on 11/05/2024 at 11:54 AM, 11/06/2024 at 8:32 AM, and 11/07/2024 at 9:11 AM, revealed Resident #44's CPAP machine on the nightstand had no water in the humidifier chamber, and the mask and tubing were attached lying on top of the machine with dried debris in the mask. During an interview on 11/07/2024 at 11:01 AM, Licensed Vocational Nurse (LVN) #4 stated respiratory equipment should be stored in a plastic bag that kept it free from bacteria for infection control. She stated the resident should have a holder to keep the equipment in and the equipment was changed once a week by whatever shift it was scheduled on the MAR. During an interview on 11/07/2024 at 11:05 AM, LVN #5 stated that when respiratory equipment was not in use it should be stored in a bag for infection control purposes. During an interview on 11/07/2024 at 11:07 AM, LVN #6 stated the CPAP mask should be stored inside a bag when not in use and the mask should be wiped off after each use. She confirmed that Resident #44's CPAP mask was not clean or being stored appropriately. She stated they should be using distilled water in the humidifier chamber, and it was kept in the medication room. During an interview on 11/07/2024 at 1:11 PM, the Director of Nursing (DON) stated respiratory equipment should be cleaned after each use, and the residents had microbial bags to store them in. She stated the CPAP mask should be cleaned daily after use, the whole headgear should be cleaned weekly, and the filter changed every two weeks. During an interview on 11/07/2024 at 1:50 PM, the Administrator stated the staff should be following the facility policy and procedures and thought the respiratory equipment should be stored in a bag but deferred all nursing and care related subjects to the DON.

Based on interview, record review, facility document review, and facility policy review, the facility failed to ensure medications were received from the pharmacy in a timely manner for 1 (Resident #58) of 6 residents reviewed for unnecessary medications. Findings included: A facility policy titled, Medication Ordering and Receiving From Pharmacy, dated 02/2008, indicated, Medications and related products are received from the dispensing pharmacy on a timely basis. An Admission Record indicated the facility admitted Resident #58 on 08/17/2022. According to the Admission Record, the resident had a medical history that included a diagnosis of bipolar disorder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/27/2024, revealed Resident #58 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. Resident #58's care plan included a focus area initiated 05/31/2023 that indicated the resident used psychotropic medications related to bipolar disorder. Interventions directed staff to administer psychotropic medications as ordered by the physician and monitor for side effects and effectiveness every shift. Resident #58's September 2024 Medication Administration Record [MAR] revealed a transcription of an order for Depakote tablet delayed release 250 milligrams (mg) with instructions to give 250 mg by mouth at bedtime for bipolar disorder. The MAR revealed that on 09/29/2024 and 09/30/2024 Depakote was coded 9 (other/see progress notes). Resident #58's Progress Notes revealed an Orders-Administration Note dated 09/29/2024 that indicated the resident's Depakote was not available in the facility. An Orders-Administration Note dated 09/30/2024 indicated the resident's Depakote was reordered and was not available in the facility. Resident #58's October 2024 MAR revealed a transcription of an order for Depakote tablet delayed release 250 mg with instructions to give 250 mg by mouth at bedtime for bipolar disorder. The MAR revealed that on 10/07/2024, 10/08/2024, 10/10/2024, and 10/12/2024 through 10/17/2024 Depakote was coded 9 (other/see progress notes). Resident #58's Progress Notes revealed an Orders-Administration Note dated 10/07/2024 and 10/08/2024 that indicated the resident's Depakote was not available in the facility. Resident #58's Progress Notes revealed an Orders-Administration Note dated 10/10/2024 that indicated the resident's Depakote was reordered and had not been received. Resident #58's Progress Notes revealed an Orders-Administration Note dated 10/12/2024 that indicated the resident's Depakote was reordered. Resident #58's Progress Notes revealed an Orders-Administration Note dated 10/13/2024 that indicated they were waiting on delivery of the resident's Depakote from the pharmacy. Resident #58's Progress Notes revealed an Orders-Administration Note dated 10/14/2024 that indicated the resident's Depakote had not been received. Resident #58's Progress Notes revealed an Orders-Administration Note dated 10/15/2024 that indicated the resident's Depakote was unavailable. Resident #58's Progress Notes revealed an Orders-Administration Note dated 10/16/2024 that indicated they were waiting for delivery of the resident's Depakote. Resident #58's Progress Notes revealed an Orders-Administration Note dated 10/17/2024 that indicated the resident's Depakote had not been received. A Packing Slip, dated 08/29/2024, indicated Resident #58 had 30 tablets of divalproex (Depakote) 250 mg delivered from the pharmacy and signed for by facility staff. A Packing Slip, dated 10/18/2024, indicated Resident #58 had 30 tablets of divalproex (Depakote) 250 mg delivered from the pharmacy and signed for by facility staff. During an interview on 11/06/2024 at 2:41 PM, Licensed Vocational Nurse (LVN) #1 stated if a medication were not available while passing medications, she would look for the medication in the cart and throughout the facility. She stated she would check the kit that they had for emergency medications to see if it was available. She stated if the medications were not in the facility, she would notify the resident, the resident representative, physician, and pharmacy. She stated she would call the pharmacy to find out when it was coming and let the physician know and get orders from the physician to hold the medication until it arrived. She stated if she came in the next day and the medication was still not there, she would repeat the process. She stated it would be up to the physician to determine if a new order was needed. She stated she only worked every two weeks and did not specifically remember the Depakote not being available for Resident #58 or what she did about it. During an interview on 11/06/2024 at 2:52 PM, LVN #2 stated if a medication were not available, she would look at the overflow medications and then she would check to see if it was reordered. She stated, if it were reordered, she would call the pharmacy to find out where it was and when it was going to arrive. She stated she would fax the physician and let him know. She stated the faxes should be kept in the resident's medical record. LVN #2 stated a resident should not go longer than 24 hours without receiving their medication. She stated she was having a lot of trouble getting Resident #58's Depakote from the pharmacy and had to keep calling them. She stated she did not notify any of the nurse managers or Director of Nursing (DON). She stated she did not recall if she notified the physician but would have sent him a fax, and those were kept in medical records. During an interview on 11/06/2024 at 3:03 PM, LVN #3 stated if a medication were not available, she would look in the cart and the overflow medications and check other residents' medications to make sure it did not get mixed up with them. She stated if she were not able to find the medication then she would call the pharmacy, fax the physician that the medication was not available, notify the family or responsible party, and monitor for side effects. She stated she could not remember if she notified the physician but stated if she did, the fax should be in the resident's medical record. During an interview on 11/07/2024 at 11:01 AM, LVN #4 stated if a medication was not available, she would look in the cart and the medication room, check the emergency medication kit, and call the pharmacy, and if a dose was missed, then she would call the physician and the responsible party. She stated a resident should not go longer than 24 hours without their medication and the DON should be notified right away so she could follow up on it. During an interview on 11/07/2024 at 11:05 AM, LVN #5 stated if a medication were not available during medication pass, she would look in the overflow medications, medication room, and other carts. She would check to see if it was available in the emergency kit, and if it was still not available, she would call the pharmacy to see if it was ordered and when it could be delivered. She stated the physician should be notified if the resident missed a dose and to get an order to administer the medication when it arrived from the pharmacy. She stated a resident should not go longer than a day without their medication. She stated if she had difficulty getting the medication, she would notify the DON and the physician, because they may want to change the medication. During an interview on 11/07/2024 at 11:07 AM, LVN #6 stated if a medication was not available, she would check inside the medication room, see if it was available in the emergency kit, and if it was not there, then she would call the pharmacy and have them deliver it. She stated if she came back the next day, and the medication was still not available, she would call the pharmacy back and call the physician, responsible party, and the DON to let them know. She stated a resident should not miss any doses of medications but definitely not go longer than a shift without the medication being obtained. She stated she would document the missed dose in a progress note and place the resident on alert charting to monitor for adverse effects. LVN #6 stated the DON should have been notified when the nurse was not able to get Resident #58's Depakote from the pharmacy, and the resident should not have gone that many days without the medication. During an interview on 11/07/2024 at 11:31 AM, the Medical Records Supervisor stated they did not have any faxes to the physician regarding Resident #58's Depakote not being available. During an interview on 11/07/2024 at 11:54 AM, the Medical Director stated he would get over 50 faxes a day and did not recall receiving information that Resident #58 did not receive their Depakote. He stated he did not know why the medication would not be available from the pharmacy. He stated the resident took the Depakote as a mood stabilizer and since they did not get it, they could possibly have an unstable mood. The Medical Director stated if the resident was stable after missing the doses, it would have actually been a good gradual dose reduction. During an interview on 11/07/2024 at 12:45 PM, a Pharmacy Representative stated they got a fax on 10/18/2024 for a request for the Depakote for Resident #58, and it was delivered that day. She stated otherwise they did not have a way of telling when the facility ordered a medication, only when it was delivered. During an interview on 11/07/2024 at 1:11 PM, the DON stated the process the nurses should follow when a medication was not available was to call the pharmacy, and if they were not able to get the medication during their shift, they should let the physician know. She stated they may be able to get the medication from the emergency medication kit or get the physicians to change the order to something else that was available in the emergency kit if needed. She stated a missed dose was a missed dose and should be followed up on immediately. She stated she was not aware of Resident #58's Depakote not being available and had not been notified by any of the staff. During an interview on 11/07/2024 at 1:50 PM, the Administrator stated if a medication was not available, the nurse should notify the physician and the DON but deferred specifics to the DON.

Based on interview, record review, and facility policy review, the facility failed to notify the physician of pharmacy consultant recommendations for 1 (Resident #56) of 6 residents reviewed for unnecessary medications. Findings included: A facility policy titled, Consultant Pharmacist Reports IIIAI: Medication Regimen Review, revised 01/2018, indicated, All findings and recommendations are reported to the director of nursing and the attending physician the medical director and the administrator. The policy also indicated, G. Recommendations are acted upon and documented by the facility staff and/or the prescriber. An Admission Record indicated the facility admitted Resident #56 on 07/11/2022. According to the Admission Record, the resident had a medical history that included a diagnosis of major depressive disorder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/21/2024, revealed Resident #56 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident received an antidepressant during the last seven days of the assessment period. Resident #56's care plan included a focus area revised 10/27/2024 that indicated the resident used an antidepressant medication for depression as evidenced by withdrawal from activities of interest. Interventions directed staff to administer antidepressant medications ordered by the physician and monitor and document side effects and effectiveness every shift. Resident #56's physician orders revealed an order dated 08/24/2023 for escitalopram oxalate 5 milligrams (mg) by mouth one time a day for depression. Resident #56's August 2024 Medication Administration Record [MAR] revealed staff documented that the resident received escitalopram oxalate 5 mg by mouth every day at 8:00 AM. Resident #56's Consultant Pharmacist's Report dated 08/26/2024 indicated the resident had been receiving escitalopram 5 mg by mouth every day since 07/11/2022. The report recommended evaluating this therapy to determine if symptoms, conditions, or risks could be managed by a lower dose or if the medication could be discontinued. The report indicated to document if a gradual dose reduction (GDR) or discontinuing the medication was clinically contraindicated. Further review revealed the report had not been signed or dated by the prescriber. During an interview on 11/07/2024 at 1:11 PM, the Director of Nursing (DON) stated it was her responsibility to follow up on the pharmacy recommendations. She stated they were not able to find the follow up for the recommendations for Resident #56's GDR for the month of August 2024. She stated the pharmacy consultant reviewed records monthly, and they were to be faxed to the DON the following day and then she would follow up on them immediately. During an interview on 11/07/2024 at 1:50 PM, the Administrator deferred all nursing and related subjects to the DON but stated she expected the staff to follow all rules and regulations and their policy and procedure.

Based on interview, record review, and facility policy review, the facility failed to accurately complete a Level I Pre-Admission Screening and Resident Review (PASRR) for 2 (Resident #6 and Resident #18) of 6 residents reviewed for PASRR. Findings included: A facility policy titled, P-NP04 Admission Screening Resident Review (PASRR), revised on 04/24/2024, indicated, 5. The Facility MDS [Minimum Data Set] Coordinator will be responsible for accessing and ensure updates to the PASRR are completed per MDS guidelines. 1. An Admission Record revealed the facility admitted Resident #6 on 07/21/2023. According to the Admission Record, the resident had a medical history that included diagnoses of unspecified bipolar disorder (onset date 07/31/2023), mild recurrent major depressive disorder (onset date 07/31/2023), and generalized anxiety disorder (onset date 07/31/2023). An annual MDS, with an Assessment Reference Date (ARD) of 08/07/2024, revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. The MDS indicated Resident #6 rejected care one to three days during the assessment period. The MDS also revealed the resident had diagnoses of anxiety disorder, depression, and bipolar disorder. Resident #6's Preadmission Screening and Resident Review (PASRR) Level I Screening dated 07/29/2023 revealed the screening was Negative due to No Serious Mental Illness. During an interview on 11/07/2024 at 8:40 AM, the Business Office Manager (BOM) stated residents' PASRRs were completed by the hospital and sent over with the referral or the facility was able to print the PASRR from a website. The BOM stated she was unsure who was responsible for checking the PASRR for accuracy. The BOM stated after admission it was the responsibility of the MDS nurse to check the PASRR to ensure all diagnoses had been included. The MDS Coordinator was interviewed on 11/07/2024 at 8:55 AM. The MDS Coordinator stated the PASRR was completed at the hospital prior to the resident's admission, the facility printed the PASRR, and she was responsible for making sure the PASRR was completed. The MDS Coordinator stated she was also responsible for making sure all needed diagnoses were included and accurate and if the PASRR was not accurate she completed a new one. The MDS Coordinator stated she was unsure who had put the codes for the psychiatric diagnoses into the electronic medical record after Resident #6 was admitted , but stated a new PASRR should have been completed. The MDS Coordinator stated she had not completed a new PASRR for the resident. The MDS Coordinator stated the care Resident #6 received was patient centered and knowing the resident's psychiatric diagnoses could have helped to have more resident centered approaches in caring for the resident. The Director of Nursing (DON) was interviewed on 11/07/2024 at 1:11 PM. The DON stated she expected the PASRR to be accurate and include accurate diagnoses. The DON stated if Resident #6's PASRR Level I had been accurately completed, a Level II PASRR would have been triggered. The DON stated she did not think having a Level II PASRR would have had influence in the care received by Resident #6. The Administrator was interviewed on 1107/2024 at 1:50 PM and stated she expected documentation to be accurate since the documentation affected resident care. 2. An Admission Record revealed the facility admitted Resident #18 on 05/14/2014 and most recently on 05/11/2023. According to the Admission Record, the resident had a medical history that included diagnoses of unspecified bipolar disorder (onset date 10/03/2019), recurrent major depressive disorder (onset date 10/04/2014), and unspecified anxiety disorder (onset date 10/04/2014). A quarterly MDS, with an Assessment Reference Date (ARD) of 08/18/2024, revealed Resident #18 had a Brief Interview for Mental Status (BIMS) score of 00, which indicated the resident had severe cognitive impairment. The MDS also revealed the resident had diagnoses of anxiety disorder, depression, and bipolar disorder. Resident #18's care plan included a focus area revised on 08/14/2024, that indicated the resident received an antidepressant medication related to depression as evidenced by verbalizations of sadness. The care plan included a focus area revised on 09/18/2024, that indicated Resident #18 received an antipsychotic medication for a diagnosis of bipolar disorder as evidence by the resident continuously shouted out when needs were met. The care plan included a focus area revised on 08/14/2024 that indicated the resident was on a medication for mood stabilization related to behavioral disturbances that included striking out. Resident #18's Preadmission Screening and Resident Review (PASRR) Level I Screening Document, dated 11/05/2020, revealed the screening was Negative; there was no reason documented as to why the screening was negative. Further review revealed the area to document mental illness, and psychotropic medications had not been completed. During an interview on 11/07/2024 at 8:40 AM, the Business Office Manager (BOM) stated residents' PASRRs were completed by the hospital and sent over with the referral or the facility was able to print the PASRR from a website. The BOM stated she was unsure who was responsible for checking the PASRR for accuracy. The BOM stated after admission it was the responsibility of the MDS nurse to check the PASRR to ensure all diagnoses had been included. The MDS Coordinator was interviewed on 11/07/2024 at 8:55 AM. The MDS Coordinator stated the PASRR was completed at the hospital prior to the resident's admission, the facility printed the PASRR, and she was responsible for making sure the PASRR was completed. The MDS Coordinator stated she was also responsible for making sure all needed diagnoses were included and accurate and if the PASRR was not accurate she completed a new one. The MDS Coordinator reviewed Resident #18's PASRR and stated without the resident's psychiatric diagnoses the Level I PASRR for the resident was inaccurate and therefore a Level II PASRR had not been completed. The Director of Nursing (DON) was interviewed on 11/07/2024 at 1:11 PM. The DON stated she expected the PASRR to be accurate and to include accurate diagnoses. The DON stated if Resident #18's PASRR had been accurate the resident would have triggered for a Level II PASRR to be completed. The DON stated she did not think having a completed Level II PASSR would have had influence in the care provided for Resident #18. The Administrator was interviewed on 11/07/2024 at 1:50 PM and stated she expected documentation to be accurate since the documentation affected resident care.

Based on interview and record review, the facility failed to update care plans (a plan that outlined resident goals, care needed, and support the facility staff would provide) for two out of three sampled residents (Residents 2 and 7) when Licensed Nurses (LN) did not update the care plan after Residents 2 and 7 had a fall. This had the potential for an increase in falls and injuries. Findings: A review of the facility ' s policy and procedure (P&P) titled, Fall Prevention and Management Program, revised, 8/1/14, indicated, after a resident fell , the care plan would be initiated or updated. A review of the facility ' s P&P titled, Comprehensive Person-Centered Care Planning, revised 11/1/18, indicated, Additional changes or updates to the resident ' s comprehensive care plan will be made based on the assessed needs of the resident. A review of the undated Admission Record, indicated, Resident 2 was admitted to the facility on [DATE] with the diagnoses of dementia (memory loss), epilepsy (brain disorder that caused uncontrolled seizures [uncontrolled shaking of body]), and muscle weakness. Resident 2 was not her own responsible party (RP, decision maker). A review of resident 2 ' s Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 7/20/24, indicated, Resident 2 had no previous falls in the facility and required supervision when walking 10 feet or more. A review of the undated Admission Record, indicated, Resident 7 was admitted to the facility on [DATE] with the diagnoses of syncope and collapse (fainted and fell ), amputation (removal) of left lower leg below the knee, repeated falls, and muscle weakness. Resident 7 was not his own RP. A review of Resident 7 ' s MDS, dated [DATE], indicated, Resident 7 required the use of a walker (a frame that was held onto while walking that provided support), wheelchair, or limb prosthesis (an artificial body part, used in place of Resident 7 ' s amputated left leg) to move about the facility and required substantial assistance from staff to utilize the bathroom. The MDS indicated, Resident 7 had not had any previous falls in the facility. During an interview on 10/23/24 at 1:19 pm, LN A stated, after a resident in the facility fell , the LN was responsible to initiate an Actual Fall care plan. LN A stated, the Interdisciplinary Team (IDT, group of facility staff with knowledge of the resident that met to discuss resident care needs and update care plans as needed) would meet and determine if the care plan needed to be revised and IDT made care plan changes as necessary. During an interview on 10/23/24 at 1:33 pm, LN C stated, after a resident fell , the LN was responsible to revise or initiate a care plan. LN C stated, LNs were required to utilize a fall packet (documentation that was required from the LN regarding the fall) and the fall packet included a check list for the LN to follow. A review of the undated document titled, Fall Incident Checklist, indicated, LN was responsible for initiating an Actual Fall care plan after a resident experienced a fall. During a concurrent interview and record review on 10/23/24 at 3:09 pm, with Director of Nursing (DON), Resident 7 ' s Post Fall Evaluation, dated 10/2/24 and care plans dated 2/8/24 through 10/23/24 was reviewed. DON stated, the Post Fall Evaluation, indicated, Resident 7 had an actual fall on 10/2/24. DON confirmed, after a resident experienced a fall, the LN was responsible for initiating an Actual Fall care plan and IDT would evaluate the care plan and make changes to the care plan if needed. DON reviewed Resident 7 ' s care plans and confirmed, there was no Actual Fall care plan present regarding Resident 7 ' s fall on 10/2/24 and stated, there should have been. During a concurrent interview and record review on 10/23/24 at 3:09 pm, with DON, Resident 2 ' s Post Fall Evaluation, dated 10/14/24, and care plans, dated 1/11/23 through 10/23/24 was reviewed. DON stated, the Post Fall Evaluation, indicated, Resident 2 had an actual fall on 10/14/24. DON stated, there was no Actual Fall care plan present and there should have been. DON reviewed Resident 2 ' s care plan titled, Moderate Fall Risk, dated 1/11/23 and stated, the LN could have updated the Moderate Fall Risk care plan and did not.

Based on observation and interview, the facility failed to ensure proper infection control procedures were followed when two staff members were observed not wearing proper personal protective equipment (PPE-equipment worn to create a barrier between infectious material and a person including, gloves, gown, N95 (specialized mask), and eye shields) in COVID-19 (a highly contagious respiratory disease caused by the coronavirus) positive resident rooms. This failure had the potential to spread infection among residents, visitors, and staff. Findings: During an observation in Station 1 ' s hallway on 9/23/24 at 9:10 AM, eight rooms (23, 24, 29, 31, 33, 34, 35, and 36) were observed having isolation signs outside their doors. The signs posted read Isolation room with instructions indicating that prior to entering the room, one must clean hands (hand hygiene), don (put on) gown, N95 (mask), eye protection (eye shield) and gloves. During a concurrent observation and interview, on 9/23/24 at 9:31 AM, Licensed Vocational Nurse (LVN) A was observed coming out of isolation room [ROOM NUMBER]. LVN A took off her gown, gloves and did hand hygiene. She was wearing an N95 mask but was not wearing an eye shield. LVN A indicated the residents in the room had COVID-19. LVN A indicated she was not wearing an eye shield while taking care of the COVID-19 positive residents because she did not think she needed to. During a concurrent observation and interview, on 9/23/24 at 9:34 AM, Registered Nurse (RN) B was observed coming out of isolation room [ROOM NUMBER]. RN A took off her gown, gloves and did hand hygiene. She was wearing an N95 mask and her own prescription glasses which had slid to the end of her nose. She confirmed this was an isolation room for COVID-19. She indicated she thought it was ok to wear her glasses as an eye shield. During an interview on 9/23/24 at 9:39 AM, the Infection Preventionist (IP) indicated that it was expected for staff to wear eye shields (also called face shields or goggles) in COVID-19 isolation rooms. IP stated, regular prescription glasses do not count as eye shields. IP indicated she would need to reeducate her staff on proper PPE for isolation rooms.

Based on interview and record review, the facility failed to follow their abuse policy and procedure (P&P) for an abuse allegation that involved two out of four sampled residents (Residents 1 and 2) when the facility did not provide the State Survey Agency (SA) with results of the facility ' s investigation of the alleged abuse within five (5) working days. The lack of facility oversight placed residents at risk for further potential abuse. Findings: A review of the facility ' s P&P titled, Reporting Abuse, revised 1/8/14, indicated, The Administrator, or his designee, shall provide the appropriate agencies or individuals with a written report of the findings of the investigation withing five (5) working days of the incident A review of Resident 1 ' s undated Admission Record, indicated, Resident 1 was admitted to the facility on [DATE] with the diagnoses of high blood pressure and anxiety. Resident 1 was not her own responsible party (RP, person that made decisions). A review of Resident 2 ' s undated Admission Record, indicated, Resident 2 was admitted to the facility on [DATE] with the diagnosis of memory deficit following cerebrovascular disease (memory loss due to a stroke). Resident 2 was not her own RP. A review of the Intake Information, dated 7/30/24, received by SA, the facility had reported an allegation of resident-to-resident abuse. The Intake Information, indicated that Resident 1 hit Resident 2 with a pillow. During a concurrent interview and record review on 9/11/24 with the facility ' s interim Assistant Director of Nurses (IADON), a file that contained documents regarding the alleged abuse between Residents 1 and 2 was reviewed. The IADON stated the file did not contain the 5-day investigation report. During an interview on 9/19/24 at 11:40 a.m., the facility ' s Interim Administrator (IADMIN) stated, when there was an allegation of abuse, the facility ' s Administrator (ADMIN) performed an investigation and provided the SA the results of the investigation within 5 working days. IADMIN confirmed, the facility ' s previous ADMIN had not provide the SA with a 5-day investigation report and should have.

Based on interview, and record review, the facility failed to ensure that two of 22 sampled residents (Residents 37, and 47), whose weights were not within acceptable parameters of nutritional status, received adequate evaluations, interventions, and monitoring. These failures resulted in significant weight loss for these residents, and had the potential to lead to a decline in their overall health condition. Findings: The facility's policy titled, Evaluation of Weight and Nutritional Status, dated 1/19, was reviewed, and indicated that its purpose was to ensure that residents maintain acceptable parameters of nutritional status through evaluation of their weight and diet. The facility will work to maintain an acceptable nutritional status for residents, and will do this by monitoring the following: A. The resident's nutritional status and the factors that put the resident at risk of not maintaining acceptable parameters of nutritional status. B. Analyzing the assessment information to identify the medical condition, causes and/or problems related to the resident's condition and needs. C. Defining and implementing interventions for maintaining, or improving nutritional status that are consistent with resident needs, goals and recognized standards of practice. D. Monitoring and evaluating the resident's response, or lack of response to the interventions. E. Revising or discontinuing the approaches as appropriate, or justifying the continuation of current approaches. This policy provided the following definitions: weight loss - significant weight loss 2% in one week, 5% &/or 5 lb [pounds] in one month, 7.5% in three months, or 10% in six months, as well as unplanned weight loss that occurs over time that does not meet the guidelines for significant weight loss, and does not trigger review of the Nutritional Status CAA [care area assessment]. Avoidable - the resident did not maintain acceptable parameters of nutritional status and the facility did not do one or more of the following: 1. Evaluate the resident's clinical condition and nutritional risk factors; 2. Define and implement interventions that are consistent with resident needs, resident goals, and recognized standards of practice; 3. Monitor and evaluate the impact of interventions; or 4. Revise the interventions as appropriate. Any resident weight that varies from the previous reporting period by 5% in 30 days, 7.5% in 90 days, 10% in 180 days, will be evaluated by the IDT (Interdisciplinary Team)- Nutrition & Weight Variance Committee to determine the cause of weight loss/gain and the intervention(s) required. Once weight gain, or loss as described above is identified, the IDT - Nutrition & Weight Variance Committee will: a. Identify and implement appropriate interventions; b. Update and revise the care plan, as appropriate; c. Notify the responsible party; d. Notify the Attending Physician; and e. Notify the Registered Dietitian (RD). The Centers for Medicare and Medicaid (CMS) included the following in their interpretive guidelines for this regulation; Failure to identify residents at risk for compromised nutrition and hydration may be associated with an increased risk of mortality and other negative outcomes, such as impairment of anticipated wound healing, decline in function, fluid and electrolyte imbalance/dehydration, and unplanned weight change. 1. Resident 37's medical record was reviewed. Resident 37 was admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . In the past three months (from 9/7/21 to 12/8/21), Resident 37 had a weight loss of 19.8%, or 36.9 pounds. The facility's Weights Vitals Summary form documented the following weights, and comparisons for Resident 37: 5/3/21: 186 lbs (pounds) 6/7/21: 179.6 lbs 7/6/21: 178.2 lbs 8/3/21: 184.1 lbs 9/7/21: 185.9 lbs There was no weight for 10/2021. 11/8/21: 157.2 lbs (comparison weight 9/7/21, 185.9 lbs, -16.2%, -30.1 lbs) 11/15/21: 155.8 lbs (comparison weight 9/7/21, 185.9 lbs, -15.6%, -28.7 lbs) 11/22/21: 152.7 lbs (comparison weight 9/7/21, 185.9 lbs, -17.9%, -33.2 lbs) 11/29/21: 148.8 lbs (comparison weight 9/7/21, 185.9 lbs, - 20%, 37.1 lbs) 12/8/21: 149 lbs (comparison weight 9/7/21, 185.9 lbs, -19.8%, 36.9 lbs) Further review, of Resident 37's record indicated that he had been on a Consistent Carbohydrate Diet (CCHO, focus is to eat the same amount of carbohydrates every day to keep blood sugar stable). A copy of the Activities of Daily Living (ADL, daily routine activities that people do such as eating) flowsheets, where the nursing assistants charted the amount of each meal eaten by the resident, were provided. For half of all meals for the months of 10/2021 and 11/2021, Resident 37 had refused or eaten less than 25% of recorded meals, for these two months. No additional supplements for weight loss were added until frozen shakes were added twice per day on 11/28/21 (by this time he had lost 20% of his weight, and this was three weeks since facility staff knew of the severe weight loss noted on 11/8/21). There was a draft note (note made in the electronic record but not yet signed as complete), by the RD, on 11/5/21. There were no nutritional supplements recommended at that time, as the RD noted his last weight of 185.9 lbs on 9/7/21. There was no RD evaluation, or assessment of Resident 37's weight loss, after the facility knew of the weight loss on 11/8/21. There was also no IDT note in the record relating to his weight loss. During an interview, on 12/09/21 at 1:30 pm, the Director of Nurses (DON) was asked to provide any information she had regarding Resident 37's weight loss, and nutrition provided to him for this weight loss. During an interview, on 12/09/21 at 2:30 pm, the DON said this resident had Vitamin C ordered, and given in October for his wound. She provided a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She provided a copy of the facility's December monthly weights (not part of the record) and for this resident, it indicated he had refused weights in October and November. She said he had COVID-19 (a serious respiratory virus) in October and lost weight. The weights documented in the resident's electronic record were then reviewed with the DON, which showed he did not refuse weights in November, and, in fact, had been weighed weekly, and lost 28-pounds from 9/7/21 to 11/8/21, and had continued weight loss after that. During the above continued interview, starting at 2:30 pm on 12/9/21, the DON confirmed the facility's prior RD left in mid-September 2021 and the facility's new RD started last week, on 12/3/21. She said, a corporate regional RD came to the facility twice during this period of time (mid-September to 12/3/2021). The draft note from the corporate regional RD, dated 11/5/21, which listed the September weight of 185.9 lbs, was then reviewed with the DON. DON said this note had been made by the corporate RD during one of the times she came to the facility. The DON was asked if she thought the RD may have changed, or added recommendations to her note, had she been told there was a 28-pound weight loss, documented on 11/8, three days after she made her note. The DON confirmed there was no RD evaluation after Resident 37's weight loss, and said she would check for further information. She provided a nourishment roster that indicated a sandwich was passed to Resident 37 in the morning, and at bedtime. A review of the ADL sheets indicated a space for nourishment three times each day. For November, there was documentation that he accepted nourishment 10 out of 90 possible times, but only consumed 100% of the nourishment on two days. During a concurrent record review, and interview, on 12/09/21 at 3:46 pm, the DON said she had no other information, and she had checked for physician notes that addressed the weight loss but could find none, and also no IDT notes. The nutrition care plan which was started on 4/14/21, was reviewed. The focus was updated to include weight loss on 12/8/21 (after the start of the survey) but the interventions, which had been started on 4/14/21 (when Resident 37 had been first admitted ), had not been updated. These interventions included reporting to the physician signs and symptoms of malnutrition and specified 3-pounds in one week, greater than 5% in one month, greater than 7.5% in three months and greater then 10% in six months, and RD evaluation as needed. The DON confirmed no new interventions for weight loss had been added to Resident 37's care plan. 2. Resident 47's medical record was reviewed. Resident 47's was admitted to the facility on [DATE], from an acute care hospital following a [CONDITION(S)]. She had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . On admission her height was 63 inches, weight 183 pounds (lbs). Resident 47's weight on 9/20/21 was 178.8 lbs. On 10/2/21, Resident 47 was hospitalized with pneumonia/COVID-19, and was placed on a ventilator. Resident 47 returned to the facility on [DATE]. Readmission weight dated 10/25/21, was 134.6 lbs. Her weight continued to decline, reaching 125.4 lbs on 11/29/21, an additional 9.2 pounds/ 7% loss in 6 weeks. A review of the Facility Matrix document on 12/07/21 at 9:30 am, indicated that Resident 47 exhibited excessive weight loss without a physician-ordered weight loss program. A review of the MDS (Minimum Data Set, a resident assessment tool, with information sent from facility to CMS data base) dated 12/1/21, indicated that Resident 47 had no swallowing issues, and had weight loss of 5% or more in the last month, or 10% or more in the last 6-months, and was not on a physician-prescribed weight loss regimen. During an interview with Resident 47 on 12/07/21 at 9:40 am, she stated that her usual weight was 170 pounds (lbs), Now I weigh 140 lbs. She stated she got COVID-19 at this facility, lost her sense of taste, was sent to a hospital, and was put on a ventilator. When asked about her continued weight loss Resident 47 stated, I don't like their food. It has no flavor. It is terrible. It has no flavor, and no taste. I have no teeth, and so they think everything needs to be like baby food. I don't need it pureed. I usually order out from a restaurant tacos, or pizza. The following, Weights and Vitals Summary, for Resident 47 indicated: 10/25/21 Weight 134.6 lbs 11/08/21 Weight 128.2 lbs 11/15/21 Weight 127.1 lbs 11/22/21 Weight 126.7 lbs 11/29/21 Weight 125.4 lbs This represented a 6.8% weight loss in one month which is considered severe. Resident 47's nursing notes titled, Re-Admission Note/Care Conference dated 10/21/21, noted that the facility was not using a current weight, rather utilized a weight prior to hospitalization . Progress Notes, dated 10/29/21, titled Weekly Assessment, failed to mention the 4.75 lb weight loss, since readmission. A follow up IDT note, dated 11/04/21, titled IDT Progress Note - Behavior Management, noted the current admission weight, however failed to recognize the weight loss during hospitalization . An IDT progress note, dated 11/18/21 at 9:09 am, indicated a review of a fall. There was no mention of resident's weight loss, or of poor meal intakes. Remaining Progress Notes, dated 10/18/21 through 12/8/21, made no mention of weight loss since re-admission. A review of the Dietary Profile performed by the Dietary Services Supervisor (DSS) showed Effective Date 9/2/21, Signature by the DSS on 9/22/21, and Admission 10/18/22. The DSS documented, Resident states she can tolerate regular texture, informed SLP (Speech and Language Pathologist). Review of the Nutritional Risk Assessment, completed by the Regional RD on 11/5/21 indicated: * Resident 47 had a diet order for a CCHO, mechanical soft ground texture, thin liquids diet. Meal and fluid intakes averaged 50-75%. * Estimated energy needs were 1550-1850 kcal (kilocalories)/day, and 68-74 grams protein/day. * The RRD noted Resident 47 had no swallowing difficulty, but needed mechanical soft ground texture food due to no teeth or dentures. * The RRD also commented that fasting serum blood sugars were in good control, resident would likely benefit from liberalizing the CCHO diet, and resident had specific ethnic or religious food preferences/ likes & dislikes - refer to the dietary profile . kitchen has been honoring food preferences and providing pudding as HS (evening) snack. * The RRD summarized that Resident 47 had inadequate nutrient intake related to acute illness, meal intake 25-100%, 44.2 lbs/24.7% weight loss in 16 days of hospitalization . Resident 47 was willing to be weighed and accept a nutrition supplement with her medications. * The goals for Resident 47 were to consume greater than 50% of meals, and achieve body weight 135 lbs +/- 5% for 3 months. A recommendation was made to liberalize the diet to regular (no restrictions) but continue current texture modifications, add nutrition supplement with medication pass, and record amount taken, and consider lab tests. A review of an SBAR (Situation, Background, Assessment, Recommendation) form dated 11/12/21, indicated that RD recommendation - liberalizing CCHO (diet) to Reg (Regular diet), add Med Plus 1.7 90 mL (milliliter) TID (three times a day) - record % consumes. In a response, dated 11/15/21, the doctor wrote, No, and Continues with elevated blood sugar! regarding liberalizing the diet, and OK to the Med Plus Nutrition Supplement. A verbal order for speech therapy was obtained 11/9/21. Review of the Speech Therapy SLP Evaluation and Plan of Treatment, document dated 11/9/21, and signed by the physician 11/16/21, indicated that Resident 47 had some dysphagia (difficulty swallowing) but had good rehab potential. Diet textures were not changed. Patient needs further progress in the area of oral functions and strength of swallow to improve nutritional intake. The patient is at risk for aspiration and decreased leisure task participation. Patient has severe decreased food intake and needs further evaluation in this area to determine reason for discomfort. A review of the ADL (Activities of Daily Living) Flowsheet for Resident 47 indicated in October 2021 Resident 47's meal consumption averaged 39%, of the 33 meals documented. In 11/21 21, Resident 47's meal consumption averaged 47% of the 85 meals documented. Based on the caloric content of the facility's CCHO diet, Resident 47 would have needed to consume an average of 82% to 93%, of her meals, in order to meet her estimated energy needs. The facility's policy titled, Food Intake - Recording Percentage & Nutritional Assessment, revised 1/12, was reviewed and indicated that if any resident refuses a meal, or the food eaten is less than 50%, a nourishment (snack) or meal replacement will be offered. The amount of supplement or nourishment taken as a meal replacement will be recorded on the resident food intake record after each meal. A review of the Nutrition Care Plan for Resident 47 indicated: 9/27/21 a weekly weight loss of 5.5 lbs, 3.1%, 3-month weight loss of 20.2%. The goals initiated on 9/6/21 were to maintain admission weight (183 lbs) +/- 5%, resident to consume at least 75% of meals x 3 months, resident will tolerate diet without chewing difficulty, swallowing difficulty or GI distress x 3 months. Interventions initiated on 9/6/21, were to offer substitutes if intake less than or equal to 75%, provide and honor preferences. On 11/5/21, the RRD added interventions requesting lab work and 1.7 calorie/mL nutrition supplement three times daily with nursing medication pass, record % taken. The provision of snacks were not included in the care plan. A review of the facility's policy titled, Nutritional Assessment, revised 2/1/14, was reviewed and indicated that its purpose was to ensure that residents are properly assessed for dietary needs. The Dietitian will complete the Nutritional Assessment within fourteen (14) days of admission. The Nutritional Assessment must be signed and dated by the Dietitian on the day of completion. During an interview, with the RD, and Dietary Services Supervisor (DSS) on 12/8/21 at 11:20 am, it was reported that the previous RD had been gone from this facility since mid-September, and there was no facility RD until the previous Friday, 12/3/21. The DSS stated if problems came up she would communicate with the nurse or doctor. They would consult the Regional Registered Dietitian (RRD) for more complicated residents. She was not sure who did the initial nutrition assessments. When asked how often the RRD came to the facility the DSS replied she wasn't sure. She thought the RRD maybe came every 2-weeks, but she didn't always connect with the kitchen. During an interview, with the Director of Nursing (DON) on 12/8/21 at 3:15 pm, she acknowledged their previous RD left mid-September, the new RD started Friday 12/3. The DON stated the RRD had been at the facility twice since the previous RD left in September. The DON acknowledged that nutrition needs of Resident 47 were not met when resident weight loss, and poor meal intakes were not addressed timely and per policy.

Based on observation, interview, and record review, the facility failed to evaluate, assess, and provide wound care treatments to three of eight sampled resident's (Residents 37, 42, and 211). The facility also failed to use professionally recognized standards for documenting, and staging pressure injuries. These failed practices resulted in the developing of new, or worsening of existing pressure injuries (wounds caused by unrelieved pressure on the skin) for these residents, which could lead to negative clinical outcomes. Findings: According to the National Pressure Injury Advisory Panel (NPIAP an internationally used, and professionally recognized pressure injury resource), revised 2016, Staging pressure injuries are important to ensure appropriate treatment, and the understanding of anatomy is essential when evaluating the type of tissue present in a wound. A review of the facility's policy titled, Pressure Injury and Skin Integrity Treatment, revised 8/12/16, was reviewed, and indicated the following pressure injury staging definitions. Stage 1: Non-blanchable [CONDITION(S)] (redness/warmth) of intact skin. Stage 2: Partial thickness skin loss with exposed dermis (layer of skin under the surface). Wound bed is viable, pink or red, moist, and may also present as an intact serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar (dead, black tissue) are not present. Stage 3: Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deeper wounds. Undermining, and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage, and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 4: Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament. Cartilage, or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining, and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Deep Tissue Pressure Injury: Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION(S)] separation revealing a dark wound bed or blood filled blister. This policy indicated that a licensed nurse will initiate a Pressure Injury Progress Report, when a resident is admitted with a pressure injury, or if a pressure injury develops. The Pressure Injury Progress Report will be updated weekly by the licensed nurse. A consultation from a wound care physician will be obtained upon an order from the attending physician. The resident's dietary needs will be evaluated by the Registered Dietitian on admission, and when there is a significant change in the skin condition. The diet should contain adequate calories, nutrients and fluids to support wound healing. The preventive measures may be documented on the Treatment Administration Record (TAR), the Activities of Daily Living (ADL) flowsheet, the Licensed Nurses Progress Note, or the Licensed Nurses Weekly Summary. The licensed nurse will document the status of all skin conditions at least weekly, or as otherwise indicated in the resident's care plan. The licensed nurses will document effectiveness of current treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The interdisciplinary team (IDT)- Skin Committee will document discussion and recommendations for all skin integrity problems that do not respond to treatment, worsen or increase in size. Complaints of increased pain, discomfort or decrease in mobility by a resident. The presence of exudates, odor or necrosis. The residents refusing treatment, or other problems that may hinder healing. Documentation of all notifications to the family, resident and/or responsible party when there is a change in the resident's skin condition. The resident's care plan will be updated as necessary. The policy further indicated that a risk assessment for developing pressure injuries will be completed upon admission, weekly and for four consecutive weeks after admission, quarterly and when there is a significant change in condition. Regardless of the risk score, the licensed nurse will develop an individualized care plan for the resident's risk factors in consultation with the following; attending physician, IDT, Registered Dietitian, and Director of Rehabilitation Services. The nursing staff will implement interventions identified in the care plan which may include, but are not limited to, the following; pressure redistributing devices for bed and chair, repositioning and turning, bowel and bladder training, scheduled tolieting or incontinence management programs, bed trapeze bar, draw sheets, mechanical lifts, positioning aides, to reduce friction and shear when repositioning. The nursing staff will observe for any signs of potential or active pressure injury daily while providing nursing care. The licensed nurses will document the effectiveness of the pressure injury prevention techniques in the resident's medical record on a weekly basis. Skin assessments are performed on admission, then weekly for four weeks, quarterly and when there is a significant change of condition. The resident's care plan will be initiated on admission, and updated as necessary. 1. Resident 211's medical record was reviewed. Resident 211 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 211's most recent MDS (Minimum Data Set, a standardized assessment tool), dated 11/19/21, indicated that Resident 211 was dependent on staff for bed mobility, transfers, eating, dressing, bathing, grooming, incontinent of bowel and bladder, and that she had one Deep Tissue Injury present. On 11/12/21 at 10:26 am, Resident 211's Admit/Readmit Assessment, skin assessment was done. Section C titled, Skin Integrity, contained a picture of human body with numbered pressure area sites where the nurse documents all skin concerns upon admission, including pressure injuries. This area was blank with a notation that read, See admit note for skin assessment. The Admit Note, did not included an actual assessment either. The hospital transfer record dated 11/12/21, indicated that Resident 211 did not have any pressure injuries at the time she was discharged from the hospital. Therefore, Resident 211's pressure injuries were considered acquired, in this facility. A review of Resident 211's Progress Notes, indicated that the first documented skin assessment was on 11/12/21 at 12 pm, when a licensed nurse documented that she had superficial shearing to coccyx (tailbone area). On 11/14/21 at 8:38 am, two days later, the Treatment Nurse (TN) documented that Resident 211 had a pressure injury to her sacrum [area above the tailbone] that measured 4 centimeters (cm), and the wound bed was 100% slough (a yellowish-white material in the wound bed that consists of dead cells, and delays wound healing). The pressure injury was not staged and according to the facility's Pressure Injury Prevention policy, this would have been considered an Unstageable Pressure Injury. At 11:06 am, the same day, TN identified a second pressure injury to Resident 211's right buttock that measured 1 cm x 1 cm. The TN described the wound as, shearing [from skin rubbing on sheets or sliding down in bed]. According to the policy, this was a Stage 2 pressure injury. There was only one weekly Skin/Wound, progress note, done on 12/7/21 at 7:29 am, three weeks after the pressure injuries were identified. The TN documented that the sacral wound then measured 3 cm x 3.5 cm and had started out as a sheer, but worsened because Resident 211 was scooting herself all over her bed. There were no documented or care planned interventions in place that addressed how Resident 211's constant movement impacted the healing of her pressure injuries. There were only two Weekly Skin Check, assessments done on 11/14/21, and 11/27/21. The skin assessment on 11/14/21, was still identifying shearing, to the right buttock and had not mentioned the sacrum. The skin assessment on 11/27/21, included an open wound, on the sacrum but was still not staged after two weeks. Only one Weekly Nursing Summary, was done on 12/3/21, three weeks after admission, and the general skin condition, was left blank. On 11/17, and 11/18/21, nursing progress notes, incorrectly reflected that Resident 211's skin was not being assessed when the licensed nurses documented only redness or shearing to the buttock area. On 11/16, 11/29, 12/1, and 12/3/21, the licensed nurse's documentation indicated that Resident 211 was anxious, extremely restless, in pain, agitated and constantly moving in bed. There was no evidence that the IDT had met to discuss, evaluate and develop a plan of care to resolve Resident 211's acquired pressure injuries. There was no evidence that a Registered Dietitian (RD) had evaluated Resident 211's nutritional needs, as their policy directed. A review of Resident 211's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The wound physician had not been asked to evaluate Resident 211, even though he was in the facility every Tuesday. On 11/14/21, an order to put Zinc (a thick white barrier cream like [MEDICATION(S)] diaper rash cream) on Resident 211's right buttock for shearing, but the right buttock actually had a Stage 2 pressure injury. Incorrect staging of pressure injuries can result in obtaining the wrong treatments. an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 12/08/21 at 9:00 am, an observation, and concurrent interview, of Resident 211's pressure injuries was conducted with TN. Resident 211 was asleep and lying on her left side. She was on a standard house mattress. Both the right buttock and sacral pressure injury wounds were missing their dressings. The right buttock Stage 2 pressure injury contained 100% slough therefore, it had worsened to an Unstageable pressure injury. The sacrum wound was deep and contained 25% slough and according to the pressure staging guidelines, would be considered a Stage 3. The TN stated, The wounds appear to have worsened since three days ago. TN confirmed that she still has not asked the wound physician to see Resident 211. On 12/08/21 at 4:23 pm, TN was interviewed, in the conference room. TN stated that she has been in this position since 7/2021, and only received two-days of training. The TN stated, I don't know what I am doing. I don't have a clue what I am looking at on these wounds. I stage everything as a DTI [deep tissue injury] because I don't know how to stage wounds. I wait for the wound doctor to do the rest. TN confirmed that she had not evaluated Resident 211's skin until two-days after she was admitted , and had incorrectly staged her pressure injuries, but then so did the other nurses. TN stated, that Resident 211 should have already been placed on an air bed, and seen the wound doctor by now. TN confirmed that the weekly Skin/Wound assessments were not done, I am very behind on documentation. TN confirmed that the RD had not evaluated Resident 211 for nutritional needs, and stated, we haven't had one for a few months. TN confirmed that these combined failures and her lack of knowledge most likely contributed to the worsening of Resident 211's pressure injuries. On 12/09/21 at 8:35 am, an interview, and concurrent record review, was conducted with the Director of Nursing (DON). The DON confirmed that there was no record that any physician had evaluated Resident 211's pressure injuries since she was admitted . The DON stated that a request should have been sent to the wound physician on 11/14/21, when the pressure injuries were first identified. The DON confirmed that the Admission Skin Assessment was blank. The DON confirmed that there were several missing Weekly Skin Check, Weekly Nursing Summary and Skin/Wound assessments and stated, those should have been done every week, either by the treatment nurse, or the floor nurse. The DON confirmed that it is the policy of the facility for the registered dietician to evaluate and participate in recommending dietary supplements such as vitamins, minerals and protein for residents with pressure injuries, and that was not done. The DON confirmed that there had been no wound IDT meetings to discuss Resident 211's pressure injuries, and added, up to now, I thought she just had some shearing, this is all very confusing. On 12/9/21 at 11:15 am, an observation, of Resident 211's pressure injuries and concurrent interview, was conducted with the Director of Staff Development (DSD). The DSD stated that she considered herself experienced and knowledgeable about pressure injuries, and staging. The observation revealed that the right buttock wound was covered in slough 100%, the DSD stated, that would be considered an Unstageable pressure injury because you can't tell how deep it is until the slough is gone, then it will most likely be a stage 3 or 4. The sacral wound had full thickness skin loss and exposed fat with 25% slough, the DSD stated, this would be a Stage 3. The DSD added, these wounds are definitely not DTI's, and the staff need training. 2. Resident 37's medical record was reviewed. Resident 37 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 37's Admit/Readmit Assessment, dated 4/13/21, indicated that they were total dependence for toilet use, extensive assistance required for personal hygiene, and abrasions and open areas on the skin of the left knee, right lower leg, and right foot. No wounds or skin conditions were noted on the sacral or coccyx areas. A review of a Nurses Progress Note, dated 10/30/21, at 1:42 pm, by Licensed Nurse (LN) 6, indicated that a Certified Nursing Assistant (CNA) alerted LN 6 to some redness on Resident 37's skin during perineal (groin area) care. LN 6 assessed Resident 37's coccyx area and described it as blanching redness (meaning when touched lightly the skin would turn white, then return to its previous color). LN 6 wrote that Resident 37 preferred to sleep on their back and was educated about turning off their back for skin care. Zinc oxide was ordered to apply to the coccyx skin once every shift. A review of an IDT Progress Note, dated 11/4/21, at 12:17 pm, by TN, indicated the Wound Doctor (WD) had seen Resident 37 on 11/2/21, and described a new wound as, distal (furthest from the center of the body) sacrum shear. A review of a Skin/Wound Note, dated 11/7/21, at 8:52 am, by TN, indicated the coccyx wound was macerated (moist and soft). A review of a Weekly Summary, dated 11/7/21, at 3:58 pm, by LN 2, indicated, Skin normal (assessment not indicated). A review of a Health Status Note, dated 11/13/21, at 3:22 am, by a LN, indicated Resident 37's sacral wound was greyish in appearance, malodorous, with reddened edges and painful to touch. Resident 37's laboratory report, dated 11/16/21, indicated a culture report report for the swab of the drainage from Resident 37's sacral wound. The culture produced four types of bacteria, and indicated an infected wound. A review of WD Note, dated 11/16/21, indicated a, shear wound of the distal sacrum - deteriorated due to generalized decline of patient, infection, full thickness. A review of a WD Note, dated 11/23/21, indicated, unstageable DTI of the distal sacrum - deteriorated due to generalized decline of patient, full thickness. Resident 37's WD note, dated 11/30/21, indicated, unstageable DTI of the distal sacrum - improved evidenced by decreased surface area, decreased necrotic (dead) tissue, full thickness. Review of a WD Note, dated 12/7/21, indicated, Stage IV pressure wound of the distal sacrum - improved evidenced by decreased surface, increased granulation (new tissue growth), full thickness. As per the NPIAP and the facility's policy, no staging numbers were assigned to Resident 37's sacral wound until 37-days after it had first appeared as redness, and had progressed to a Stage IV. Review of Resident 37's Care Plan showed no registered dietician evaluation among the interventions listed for the new sacral pressure wound problem. No registered dietician evaluation was completed after the wound was identified. A review of three Weekly Skin Check sheets showed the following descriptions of skin irregularities under Section Two, Condition of Skin. On 11/17/21, shear distal sacrum. On 11/24/21, DTI of the distal sacrum 8 cm x 6.8 cm. On 12/1/21, DTI of the distal sacrum 8.5 cm x 6 cm. Review of Resident 37's Treatment Administration Record (TAR) for the months of 11/21 and 12/21, indicated orders to treat the resident's distal sacrum wound. For orders that were to have been done once a shift (three times a day), there was no documentation for the following dates and shifts: 11/1/21 PM shift; 11/17/21 PM shift; 11/22/21 PM shift; 11/12/21 AM, PM, and NOC (night) shifts; 11/24/21 PM shift; 11/26/21 PM shift; 11/29/21 and 11/30/21 PM shift; 12/1/21 PM shift; 12/4/21 and 12/5/21 PM shift. During a concurrent observation, and interview, on 12/821, at 9:26 am, TN and CNA 8 repositioned Resident 37, and changed the distal sacrum wound dressing. An incontinence brief that was taped closed appeared saturated with urine. A foam dressing covered the wound. The wound was raw, open, with moist pink tissue in the woundbed, and yellow areas that appeared to be subcutaneous tissue in the woundbed. TN stated that the doctor had debrided the wound yesterday. During a concurrent observation, and interview, on 12/09/21, at 10:45 am, the DSD removed a soiled incontinence brief, and changed changed Resident 37's distal sacrum wound dressing. The gauze DSD removed was saturated with pale green-colored drainage, and the edge of the gauze contained stool. DSD stated that they didn't usually measure the wounds during dressing changes. During an interview, on 12/09/21, at 2:48 pm, the MDS Nurse answered questions about a significant change in status assessment, and whether or not Resident 37's distal sacrum wound would have triggered one to be done since its discovery in early November. MDS stated they weren't sure and were waiting to hear back from the consultant about it. 3. Resident 42's medical record was reviewed. Resident 42 was admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/7/21, another diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 42 had a left trochanter (bony prominence near the end of the thighbone) Stage 4 pressure injury for which he was receiving treatment. During an interview, on 12/08/21 at 10:05 am, the TN said a physician who specializes in wound care was treating Resident 42's wound. She said this was a long term wound greater than two-years that had shown slow improvement during that time. On 12/09/21, wound treatment records were reviewed for 9/2021 through 11/2021. Treatments had been ordered twice per day in 9/21. On 9/3/21, 9/4/21, 9/6/21, and 9/7/21, only one treatment, instead of two treatments, per day was documented as done. The order was then changed, on 9/8/21, to a weekly treatment, and no treatment was documented 9/15/21. In 10/21, treatments were changed to Tuesday, Thursday, and Saturday in 10/21. Treatments were not documented as done, on 10/19/21, and 10/23/21. Treatments were then changed to daily, on 10/24/21, and his treatment was not documented on 10/27/21. Daily treatments continued in 11/21. Treatments were not documented on 11/12/21, 11/13/21, 11/19/21, and 11/24/21. During a concurrent record review, and interview, on 12/09/21 at 11:35 am, the missing treatments were discussed with the Director of Nurses (DON) who confirmed the above. She said when the treatment nurse was not working, the nurses assigned to pass medications does the residents' treatments. The DON said if she found any more documentation or other information regarding these missing treatments she would let me know, but nothing additional was provided.

Based on interview, and record review, the facility failed to provide supervision and safety interventions for one of three residents (Resident 1) at high risk for wandering, and elopement (leaving the facility without permission). As a result of this failure, Resident 1 left the facility without staff being aware and fell out of his wheelchair, into the street where he was found by a passerby who alerted the staff. Resident 1 sustained facial, nasal (nose), and head injuries, and was taken to a nearby hospital where he died a few days later. Findings: Resident 1's record was reviewed, and indicated that he was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The facility's documentation titled, Unusual Occurrence Report, was reviewed, and indicated that Resident 1 eloped from the facility on [DATE], at approximately 9 pm. Resident 1 was found on the ground with injuries to his face, and was transferred to the hospital. A review of the hospital's records indicated Resident 1 was seen in the Emergency Department on [DATE] at 9:35 pm, with significant epistaxis (nosebleed). Resident 1 was intubated (tube placed into the lungs) and placed on a ventilator (machine that breathes for a patient) for airway control and bleeding control. The [DIAGNOSES REDACTED]. According to hospital records, Resident 1 was taken off the ventilator on [DATE], and placed on comfort care (medical care provided at the end of life designed to relieve pain and suffering). Resident 1 died on [DATE]. Resident 1's death certificate lists the immediate cause of death as acute [MEDICAL CONDITION], followed by traumatic epistaxis. The facility's policy titled, Wandering and Elopement, dated ,[DATE], was reviewed, and indicated that the Licensed Nurse in collaboration with the Interdisciplinary Team (IDT, a committee that oversees the care of a resident using a team approach) will assess residents upon admission, readmission, quarterly, and upon identification of significant change in condition to determine their risk of wandering/elopement. The resident's risk for elopement and preventative interventions will be documented in the resident's medical record, and will be reviewed and re-evaluated by the IDT upon admission, readmission, quarterly, and upon change in condition. The IDT will develop a plan of care considering the individual risk factors of the resident. The Long Term Care Ombudsman (Omb, a state sponsored elder advocate) was notified, by the facility, of Resident 1's transfer to the hospital and they conducted an investigation into the incident. During an interview, on [DATE] at 4 pm, the Omb stated a witness (unavailable for interview by this surveyor) who found Resident 1 lying in the street said it looked like his wheelchair had gone over the curb and had tossed him out into the street about five feet and provided a picture of the area where he had been laying. The Omb reported that Resident 1's Responsible Party (RP, legal decision maker) told her she had been notified of the incident by the facility. The RP was told that Resident 1's wheelchair had rolled down the ramp, out of the parking lot, then hit the curb, where he fell out. The RP was told at first that his wanderguard (a device that sounds when resident goes out the door) didn't work, then she was told that he didn't have the alarm on (the RP was unavailable for interview by this surveyor). During an interview, on [DATE] at 11:55 am, the Administrator said at the time of the elopement the front door would have been locked, so no one from the outside could enter, but persons from the inside could leave through that door. The Administrator confirmed there was no one at the front desk after 5 pm everyday. A review of Resident 1's record indicated a document titled, Wandering Risk Assessment, was completed by Licensed Nurse (LN) 1 on [DATE]. This document indicated that Resident 1 was at high risk for wandering. Resident 1's record contained no care plans or safety interventions related to wandering or elopement, and no physician orders for a wanderguard. During an interview, on [DATE] at 12:30 pm, LN 1 confirmed that Resident 1 was high risk for wandering. LN 1 confirmed there was no care plan for wandering or elopement. LN 1 said a care plan should have been initiated for all high risk residents. LN 1 confirmed that there was no physician's order for a wanderguard. During an interview, on [DATE] at 1:15 pm, the Director of Nurses (DON) said the nurses should know if a resident has wandering behaviors, and start a care plan. The DON said they try to put wanderguard on residents when the residents tries to leave the facility, but before an actual elopement occurs. During an interview, on [DATE] at 2:25 pm, LN 2 reported on the evening of the elopement, the certified nursing assistant (CNA) who brought Resident 1 back into the building said he had a wanderguard on his wheelchair, although she had not heard it alarm. During an interview, on [DATE] at 1:50 pm, LN 3 said on the night of the incident someone had come to their door, which was locked, and asked if Resident 1 belonged in our facility. LN 3 confirmed that Resident 1 was an exit seeker, but this was the first time he had gone out through the front door. LN 3 said he had a wanderguard on his wheelchair but the registry (temporary staff) CNA had placed him in the wrong wheelchair (without the wanderguard attached). During an interview, on [DATE] at 1:40 pm, the DON said there had been an alarm on Resident 1's wheelchair, but that he was placed in the wrong wheelchair. There was no order for the wanderguard, so it had not been included in the care plan, and had not been placed on the Medication Administration Record [REDACTED].

An Immediate Jeopardy (IJ) was declared on 9/25/20 at 11:30 am, related to the facility's failure to implement an effective infection control program, an immediate corrective action plan to address a punitive sick leave policy which was resulting in staff reporting into work sick was provided by the facility's administration on 9/25/20 at 5 pm, this plan was approved at 5:30 pm. The IJ was abated on 9/29/20, at 4:10 pm, after onsite verification of correction was put into place. Based on observations, interviews and record review, the facility failed to properly prevent and/or manage a significant COVID-19 outbreak within the facility. The facility also failed to: 1. Develop and implement staff leave policies that were non-punitive, and that conformed to current state requirements, which resulted in staff potentially working while they were sick. 2. The appropriate amount of Personal Protective Equipment (PPE) was not available, accessible, or being properly used by the staff. 3. The facility's weekly COVID-19 testing not being done per current guidelines. 4. The facility's line listing was not being maintained per current standards. 5. Staff education and updates were not being provided daily, as described in the facility's Mitigation Plan. These failures resulted in a significant amount of residents, and staff contracting and spreading this illness throughout the building which placed everyone at significant risk. Refer to F-835, and F-837. Findings: 1. A review of an undated facility document titled COVID Sick Pay Compensation, indicated that the company program was intended to serve as a supplement to the existing employee sick leave. The policy additionally stated that the benefit is only available for employees who have had exposure to COVID-19 at work. The policy further stated, While out on a COVID-19 related leave, employees must utilize their available sick bank first. The policy also stated that employees are not entitled to this benefit if they have no symptoms, and there is work available with COVID-19 positive residents. A review of the facility COVID-19 Mitigation Plan, revised 8/12/20, indicated that asymptomatic COVID-positive staff should not come to work unless they are needed, due to critical staffing shortage, to work only with COVID-positive residents and staff. The Plan further indicated that the sick leave policy should be non-punitive, and consistent with public health policies, and state labor laws. During an interview, on 9/23/20 at 1:30 PM, with Certified Nursing Assistant (CNA) E, CNA E stated that on 9/4/20, she began to have body aches, chills, sweats, and respiratory symptoms, but had no fever. She was tested for COVID-19, but was asked to return to work even though she had symptoms. She worked on September 6, 7, and 8. CNA E received a positive test result on 9/9/20, and did not work again until 9/23/20. CNA E stated that, sometime in August, she had worked at the facility with a registry CNA who had been positive for COVID-19, and neither of them had worn masks while providing care to the residents. During a telephone interview, on 9/24/20 at 2:45 PM, with the Infection Preventionist (IP), IP stated that he always tells the staff to go home if they feel ill, and that his recommendation to keep ill staff at home was met with some resistance from administration. During a telephone interview, on 9/24/20 at 3:40 PM, with Staffing Coordinator (SC), SC stated that staff who are out with COVID-19 are to use all sick and vacation time first before they are entitled to receive the special COVID-19 sick pay. SC stated she was unaware of the state regulations regarding special COVID-19 sick pay. During an interview, on 9/25/20 at 9:50 AM, with Payroll Coordinator (PC), PC stated that staff must use up all sick time and vacation time before being able to receive the special COVID-19 pay the company provides for staff who are ill with COVID-19, per company policy. During an interview, on 9/25/20 at 10:15 AM, with the Director of Nursing (DON), DON stated that staff had to use regular sick time before being eligible for COVID-19 sick time. DON confirmed that the company policy did not conform to current state labor regulations for COVID-19 sick pay. During a telephone interview on 9/27/20 at 10:00 am, with CNA H, CNA H stated, she started feeling sick 9/12/20, and called in to work on 9/13 and 9/14, for symptoms of COVID-19, i.e. loss of taste, lethargy, and cough. CNA H said she told the DON her symptoms, and asked if she had to work. CNA H said the DON said yes. CNA H also stated, she was surprised the IP did not tell her to stay home. CNA H was also told she had to use her sick and vacation time. CNA H was unaware of the new labor law. CNA H said she tested positive for COVID over that weekend. 2. During an observation on 9/24/20, at 7:25 am, on wing 1 and 2, the staff were not changing their PPE (gowns) between residents when providing care. During an interview, on 9/23/20, at 12:30 pm, with CNA B, CNA B said, I am wearing the same gown for each room of residents in the yellow hallways. CNA B confirmed the CNA's are not wearing different gowns for each resident in the room. CNA B stated the respirator she is wearing today is not new. The management team gives them out, and they were not in yet when she started her shift at 6 am, this morning. CNA B stated the PPE they are supposed to be wearing is not readily available. During an interview, on 09/23/20, at 1:00 pm, with CNA C, CNA C stated, that they are not changing gowns between residents in the same room. CNA C also stated another staff member don his gown that had been hung for his reuse in the residents' room. CNA C said PPE is kept locked up in Director of Staff Development (DSD) office and is not always available to staff. During a concurrent observation, and interview, on 9/24/2020 at 3:15 pm, in the wing 2 hallway, Licensed Nurse (LN I) was observed sitting at the nurse's station wearing a face shield. LN I was wearing an N-95 mask below her chin, leaving her nose and mouth uncovered behind the shield. When asked if staff were to wear their N-95 mask over the nose and mouth at the nurse's desk, LN I replied, I don't know. During an interview, on 9/24/2020 at 3:18 pm,, with IP, IP stated that staff are to wear a face shield and a N-95 mask covering the nose and mouth when at the nurse's desk and acknowledged that the facility was not following their PPE protocols. During an interview, on 09/25/20, at 1:15 pm, with CNA D, CNA D stated, they were told by the IP, to reuse gowns and wear one gown per day per resident room. CNA D confirmed the facility has had issues with gowns being available and they were told by leadership to wear surgical facemasks at start of outbreak. During an interview, on 09/25/20, at 1:40 pm, with CNA E, CNA E stated, she was wearing a surgical mask for the first hour or so of her shift because the PPE was locked up in the office, and not available prior to starting her shift. During an interview, on 09/25/20, at 2:00 pm, with DON, DON acknowledged that if staff are wearing one gown per resident room per day that the facility is not following their policy. During an interview, on 09/25/20, at 2:30 pm, with CNA F, CNA F stated that respirators are not available at start of 6 am, shift until the management team arrives. CNA F also stated staff are provided one gown per resident room and they are to reuse the same gown all day during their shift for all the residents in the same room. 3. During an interview, on 9/24/2020 at 11:30 am, with Administrator (ADM), ADM stated that staff and residents were being tested weekly for COVID-19 due to there being positive COVID-19 cases within the facility, but that she had not received results for her COVID-19 test for the week of 9/18/2020. ADM further stated that another staff member usually obtained her COVID-19 testing sample, but that on 9/18/2020, she had obtained her own COVID-19 test sample and placed this sample in a box to be sent to the lab for testing. ADM was unsure of what happened to the test sample, after leaving the test kit in the box, or why she had not received the test results. ADM confirmed that she had worked in the building despite not receiving testing results for that week, and acknowledged the facility had not followed testing policy. During review of an electronic communication received by ADM on 9/22/2020, it indicated that ADM had not received a test result for the week of 9/18/2020. During review of a facility policy titled, (Facility) Covid-19 Mitigation Plan, dated 5/29/2020, (revised 8/12/2020), indicated that when a resident or staff member tested positive for COVID-19, staff and residents would be tested every seven days until no new cases of COVID-19 were identified for two rounds of testing. Further review indicated that all COVID-19 test results must be reported within 48-hours of giving a sample. 4. During an interview, on 9/24/2020 at 11:30 am, with ADM, ADM stated that 31 residents had tested positive for COVID-19 in the facility as of 9/24/2020. ADM provided an untitled facility document, and stated that it was the most current facility line list (a document used to track if and when residents develop symptoms of a disease or test positive for a disease). During review of the facility line list, undated, indicated only eight residents' COVID-19 symptoms, and status were documented on the line list. During an interview, on 9/24/2020, at 3:00 pm, with IP, IP confirmed that the line list provided by the ADM was the most up to date list. The IP stated that he had been focused on COVID-19 testing activities, and had not been updating the line list. The IP acknowledged that the facility was not following policy on maintaining the line list. During review of a facility policy titled, (Facility) Covid-19 Mitigation Plan, dated 5/29/2020, (revised 8/12/2020), indicated that the facility would maintain a line list of residents with symptoms of COVID-19, and all residents with positive COVID-19 laboratory tests. 5. A review of the facility COVID-19 Mitigation Plan indicated that a facility objective was to communicate with staff daily. The Plan further stated that the Infection Preventionist (IP) would attend daily stand up meetings and provide updates to staff regarding Personal Protective Equipment (PPE), as well as changes in policies, or mitigation measures. During an interview, on 9/23/20 at 2:20 pm, with CNA F, CNA F stated there had been only one in-service at the facility regarding proper use of PPE. During an interview on 9/24/20 at 11:25 am, with CNA H, CNA H stated that instruction had been provided on PPE and COVID-19 precautions in July 2020. She was unable to recall any other in-services since then. CNA H stated she was instructed to use a respirator until dirty or damp, and they should be stored for reuse in a Ziploc bag. She had also been instructed to reuse gowns during a shift. The change in procedure to not reuse gowns had been provided to her this morning by another CNA. During an interview, on 9/24/20 at 11:50 am, with CNA D, CNA D stated there had been no in-services in the last six months, aside from one meeting about complaints. CNA D stated there had been no COVID-19 training aside from a written notice regarding COVID-19 precautions left at the nursing station in August. CNA D stated no one has asked for a return demonstration of correct PPE procedures. During an interview, on 9/24/20 at 11:55 am, with CNA E, CNA E stated there had been only two in-services in the last four months, including one on PPE use. CNA E stated the licensed nurses sometimes provide updates, and she learns other precautions and procedures regarding COVID-19 from other CNAs. During an interview, on 9/24/20 at 12:20 pm, with Director of Staff Development (DSD), DSD stated that she has provided two COVID-19 in-services since June 2020, when she began her employment at the facility. Copies of two in-service sign-in sheets dated 7/24/20, and 8/5/20, were provided. DSD also stated she walks through the halls and updates staff as needed. She stated she has often been assigned to work administering medications due to staffing issues, and has not been able to provide staff training full-time. She stated the IP has provided most of the COVID-19 training. During a telephone interview, on 9/24/20 at 2:40 pm, with IP, IP stated he has not provided staff education regarding COVID-19. During an interview, on 9/25/20 at 10:15 am, with DON, DON stated that the DSD is expected to provide staff education and updates, including two in-services a month, as well as informal updates at shift change. DON also stated that the DSD, and IP should talk to staff and provide education daily. She stated she was unaware that daily updates had not been provided, as specified in the facility Mitigation Plan. During an interview on 9/25/20 at 11:20 am, with DSD, DSD confirmed she has been unable to provide daily education or updates due to staffing concerns, and being assigned to administer medications.

Based on observation, interview, and record review, the facility failed to provide consistent administrative oversight to ensure the residents' received the care and services to meet their needs when: 1. Staff leave policies did not conform to current state labor regulations. Refer to F 880, Findings 1. 2. Routine staff education was not done. Refer to F 880, Findings 5. These failures resulted in a significant amount of residents, and staff contracting and spreading illness throughout the building which placed everyone at significant risk, and also contributed to an Immediate Jeopardy related to the facility not implementing and infective infection control program. Refer to F 837. Findings: 1. A review of an undated facility document titled COVID Sick Pay Compensation indicated that the company program was intended to serve as a supplement to the existing employee sick leave. The policy additionally stated that the benefit is only available for employees who have had exposure to COVID-19 at work. The policy further stated, While out on a COVID-19 related leave, employees must utilize their available sick bank first. The policy also stated that employees are not entitled to this benefit if they have no symptoms and there is work available with COVID-19 positive residents. A review of the facility COVID-19 Mitigation Plan, revised 8/12/20, indicated that asymptomatic COVID-positive staff should not come to work unless they are needed, due to critical staffing shortage, to work only with COVID-positive residents and staff. The Plan further stated that the sick leave policy should be non-punitive and consistent with public health policies. During a telephonic interview on 9/24/20 at 3:40 P.M., with Staffing Coordinator (SC), SC stated that staff who are out with COVID-19 are to use sick and vacation time first before they are entitled to receive special COVID-19 sick pay. SC stated she was unaware of State regulations regarding special COVID-19 sick pay. During an interview on 9/25/20 at 9:50 A.M., with Payroll Coordinator (PC), PC stated that staff must use up all sick time and vacation time before being able to receive the special COVID-19 pay the company provides for staff who are ill with COVID-19, per company policy. During an interview on 9/25/20 at 10:15 A.M., with the Director of Nursing (DON), DON stated that staff had to use regular sick time before being eligible for COVID-19 sick time. DON confirmed that the company policy did not conform to current state labor regulations for COVID-19 sick pay. 2. A review of the facility COVID-19 Mitigation Plan indicated that a facility objective was to communicate with staff daily. The Plan further stated that the Infection Preventionist (IP) would attend daily stand up meetings and provide updates to staff regarding Personal Protective Equipment (PPE), as well as changes in policies, or mitigation measures. During an interview, on 9/23/20 at 2:20 pm, with CNA F, CNA F stated there had been only one in-service at the facility regarding proper use of PPE. During an interview on 9/24/20 at 11:25 am, with CNA H, CNA H stated that instruction had been provided on PPE and COVID-19 precautions in July 2020. She was unable to recall any other in-services since then. CNA H stated she was instructed to use a respirator until dirty or damp, and they should be stored for reuse in a Ziploc bag. She had also been instructed to reuse gowns during a shift. The change in procedure to not reuse gowns had been provided to her this morning by another CNA. During an interview, on 9/24/20 at 11:50 am, with CNA D, CNA D stated there had been no in-services in the last six months, aside from one meeting about complaints. CNA D stated there had been no COVID-19 training aside from a written notice regarding COVID-19 precautions left at the nursing station in August. CNA D stated no one has asked for a return demonstration of correct PPE procedures. During an interview, on 9/24/20 at 11:55 am, with CNA E, CNA E stated there had been only two in-services in the last four months, including one on PPE use. CNA E stated the licensed nurses sometimes provide updates, and she learns other precautions and procedures regarding COVID-19 from other CNAs. During an interview, on 9/24/20 at 12:20 pm, with Director of Staff Development (DSD), DSD stated that she has provided two COVID-19 in-services since June 2020, when she began her employment at the facility. Copies of two in-service sign-in sheets dated 7/24/20, and 8/5/20, were provided. DSD also stated she walks through the halls and updates staff as needed. She stated she has often been assigned to work administering medications due to staffing issues, and has not been able to provide staff training full-time. She stated the IP has provided most of the COVID-19 training. During a telephone interview, on 9/24/20 at 2:40 pm, with IP, IP stated he has not provided staff education regarding COVID-19. During an interview, on 9/25/20 at 10:15 am, with DON, DON stated that the DSD is expected to provide staff education and updates, including two in-services a month, as well as informal updates at shift change. DON also stated that the DSD, and IP should talk to staff and provide education daily. She stated she was unaware that daily updates had not been provided, as specified in the facility Mitigation Plan. During an interview on 9/25/20 at 11:20 am, with DSD, DSD confirmed she has been unable to provide daily education or updates due to staffing concerns, and being assigned to administer medications.

Based on observation, interview and record review, the facility failed to have an effective governing body (GB) legally responsible for establishing and implementing management and operational policies to ensure effective administration of the facility and safe working environments for the staff. This faliure resulted in punitive sick leave policy that potenitally lead to staff working instead of calling off, which placed the residents at risk for being exposed to possible COVID-19, and also contributed to an Immediate Jeopardy related to the facility not implementing and infective infection control program. Refer to F-880, and F-835. Findings: A review of an undated facility document titled COVID Sick Pay Compensation indicated that the company program was intended to serve as a supplement to the existing employee sick leave. The policy additionally stated that the benefit is only available for employees who have had exposure to COVID-19 at work. The policy further stated, While out on a COVID-19 related leave, employees must utilize their available sick bank first. The policy also stated that employees are not entitled to this benefit if they have no symptoms and there is work available with COVID-19 positive residents. A review of the facility COVID-19 Mitigation Plan, revised 8/12/20, indicated that asymptomatic COVID-positive staff should not come to work unless they are needed, due to critical staffing shortage, to work only with COVID-positive residents and staff. The Plan further stated that the sick leave policy should be non-punitive, consistent with public health policies, and current state labor laws. During an interview, on 9/23/20 at 1:30 PM, with Certified Nursing Assistant (CNA) E, CNA E stated that on 9/4/20, she began to have body aches, chills, sweats, and respiratory symptoms, but had no fever. She was tested for COVID-19 but was asked to return to work even though she had symptoms. She worked on 9/6-8, She received a positive test result on 9/9/20, and did not work again until 9/23/20. During a telephone interview, on 9/24/20 at 2:45 PM, with Infection Preventionist (IP), IP stated that he always tells staff to go home if they feel ill, and that his recommendation to keep ill staff at home was met with some resistance from administration. During a telephoe interview, on 9/24/20 at 3:40 PM, with Staffing Coordinator (SC), SC stated that staff who are out with COVID-19 are to use sick and vacation time first before they are entitled to receive special COVID-19 sick pay. SC stated she was unaware of new state regulations regarding special COVID-19 sick pay. During an interview, on 9/25/20 at 9:50 AM, with Payroll Coordinator (PC), PC stated that staff must use up all sick time and vacation time before being able to receive the special COVID-19 pay the company provides for staff who are ill with COVID-19, per company policy. During an interview, on 9/25/20 at 10:15 AM, with the Director of Nursing (DON), DON stated that staff had to use regular sick time before being eligible for COVID-19 sick time. DON confirmed that the company policy did not conform to current state labor regulations for COVID-19 sick pay. During a telephone interview on 09/27/20 at 10:00 am, with CNA H, CNA H stated, she started feeling sick 9/12/20, and called in to work on 9/13, and 9/14, for symptoms of COVID-19, i.e. loss of taste, lethargy, and cough. CNA H said she told the DON her symptoms and asked if she had to work. CNA H said the DON said yes. CNA H also stated, she was surprised the IP did not tell her to stay home. CNA H was also told she had to use her sick, and vacation time. CNA H was unaware of the new law. CNA H said she tested positive for COVID over that weekend.

Based on observation, interview and record review, the facility failed to ensure that three of 20 sampled residents (Residents 18, 146, and 83), whose weights were not within acceptable parameters of nutritional status, received adequate interventions and monitoring; and failed to ensure that one resident of 20 sampled residents (Resident 42) received enough fluids to maintain proper hydration. 1. Resident 83 suffered severe weight loss (greater than 5% in one month and greater than 7.5% in two months) and had not received an assessment by the Registered Dietitian (RD) or Interdisciplinary Team (IDT, a team that addresses all aspects of a resident's care needs and each discipline intervenes to ensure that the resident's goals are met) and had no interventions initiated to treat the weight loss; 2. Resident 146 suffered severe weight loss and although interventions had been recommended and included in the plan of care, not all of these interventions, including supplement preference, offering of substitutes, encouragement and assistance with meals, were implemented, (Refer to F 558); 3. Resident 18 suffered severe weight loss (greater than 14% in 6 months) and had not received an assessment by the RD or IDT, and had no interventions started to treat the weight loss; and 4. Resident 42 was not assessed and her fluid intake monitored adequately, to prevent dehydration (the body doesn't have enough water and other fluids to carry out its normal functions). These failures resulted in or contributed to severe weight loss for Residents 18, 83, and 146, and dehydration for Resident 42 and a decline in their overall health condition. Findings: The facility's policy, Evaluation of Weight and Nutritional Status, dated 7/2018, was reviewed. Its purpose was: To ensure that residents maintain acceptable parameters of nutritional status through evaluation of weight and diet. I. The facility will work to maintain an acceptable nutritional status for residents by: A. Assessing the resident's nutritional status and the factors that put the resident at risk of not maintaining acceptable parameters of nutritional status. B. Analyzing the assessment information to identify the medical condition, causes and/or problems related to the resident's condition and needs. C. Defining and implementing interventions for maintaining, or improving nutritional status that are consistent with resident needs, goals and recognized standards of practice. D. Monitoring and evaluating the resident's response, or lack of response to the interventions. Revising or discontinuing the approaches as appropriate, or justifying the continuation of current approaches. II. Definitions: weight loss - significant weight loss 2% in one week, 5% &/or 5 lb (pounds) in one month, 7.5% in three months, or 10% in six months, as well as unplanned weight loss that occurs over time that does not meet the guidelines for weight loss and does not trigger review of the Nutritional Status CAA (care area assessment). Avoidable - the resident did not maintain acceptable parameters of nutritional status and the facility did not do one or more of the following: 1. Evaluate the resident's clinical condition and nutritional risk factors; 2. Define and implement interventions that are consistent with resident needs, resident goals, and recognized standards of practice; 3. Monitor and evaluate the impact of interventions; or 4. Revise the interventions as appropriate. III. B. Any resident weight that varies from the previous reporting period by 5% in 30 days, 7/5% in 90 days, 10% in 180 days, will be evaluated by the IDT - Nutrition & Weight Variance Committee to determine the cause of weight loss/gain and the intervention(s) required. i. Once weight gain or loss as described above is identified, the IDT - Nutrition & Weight Variance Committee will: a. Identify and implement appropriate interventions; b. Update and revise the care plan, as appropriate; c. Notify the responsible party; d. Notify the Attending Physician; and e. Notify the Registered Dietitian. 1. A review of Resident 83's record indicated she was admitted on [DATE], with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS, a resident assessment tool) dated 9/1/18, indicated a BIMS (brief interview for mental status) score of 10 out of a possible 15, indicating mild cognitive impairment. During an interview on 9/10/18 at 9:50 am, Resident 83 complained about the food not tasting good. The facility's Weights Summary form indicated the following weights and comparisons for Resident 83: 5/23/18 147.1 pounds (lbs) 6/07/18 143.6 6/12/18 146.2 6/20/18 146 6/27/18 147.2 7/11/18 143.5 8/07/18 142.9 8/27/18 136 7.5% change (comparison weight 6/27/18, 147.2 lbs, -7.6%, -11.2 lbs) 9/04/18 134.6 5.0% change (comparison weight 8/7/18, 142.9 lbs, -5.8%, -8.3 lbs) 7.5% change (comparison weight 6/12/18 146.2 lbs, -7.9%, -11.6 lbs) 9/11/18 134.9 7.5% change (comparison weight 6/20/18, 146 lbs, -7.6%, -11.1 lbs) A review of Resident 83's record on 9/11/18, indicated a nutritional risk assessment was completed on 6/4/18, where the RD noted the resident was on a regular diet and appeared to be meeting the low end of estimated nutrition needs, the note included, will continue to monitor weights. No other nutritional risk assessments had been completed. A dietary profile completed on 8/25/18, indicated the RD to review as planned, monitor oral intake and weekly weights. There was no other dietary assessment, no IDT note, and no notification to the physician regarding Resident 83's weight loss in the record. During a concurrent interview and record review on 9/12/18 at 7:55 am, the Director of Nurses (DON) said that all newly admitted residents were weighed every week for four weeks and if stable, then weights were done monthly, unless otherwise ordered by the physician (MD). If weight loss was greater than 5% in 1 month the RD and MD would be notified, and the resident would be included in weekly nutrition meetings which occurred on Thursdays. Residents were weighed on Tuesdays. The DON confirmed there was no note from the RD or note that Resident 83's MD was notified regarding the weight loss. She confirmed there were no IDT notes or Weight Variance Committee notes, no interventions, and no physician orders regarding the weight loss. The DON said that the RD was the one who decided which resident was on the list for the Thursday weight meetings. The facility's Weight Summary sheet was reviewed and the DON confirmed the weight loss in the three month period from 6/12/18 through 9/11/18 was 7.73% and the weight loss was 5.8% from 8/7/18 through 9/4/18 and 5.6% from 8/7/18 through 9/11/18. The DON provided a copy of the Activities of Daily Living (ADL-daily routine activities that people do: eating, bathing, dressing, toileting, walking) flowsheet where the nursing assistants charted the amount of each meal eaten by the resident. From 8/28/18 through 9/11/18, Resident 83 had eaten 50% or less, or refused meals, for 34 of 45 meals. During a concurrent interview and record review on 9/12/18 at 5 pm, the RD said that in their current weight tracking system, Resident 83's weight was missed. A review of the weight tracking document, Weekly Weights, 8/28/18, bolded residents with significant weight change form included only one weight done on 8/28/18 for Resident 83 which was 136 lbs. This Weekly Weights form dated 9/4/18, the weight of 136 lbs on 8/27/18 and 134.6 lbs on 9/4/18, reflecting a weight change of 1.4 lbs and a 1% drop in weight. There were no weights recorded on this document for any of the four weeks in 7/2018 or the first three weeks of 8/2018 for Resident 83. The RD said Resident 83 had been relatively stable since admission and the first weight she had on her list for this resident was the 8/27/18 weight of 136 lbs. She said the Director of Staff Development (DSD) nurse enters the weights onto the spreadsheet she used with all residents. The prior weights did not get entered onto her list, but now she can see there was an eight pound weight loss from 8/7/18 to 9/4/18 and the resident should have been assessed on 9/4/18. RD confirmed she was not familiar with the electronic health record used by the facility and did not feel it was reliable. 2. A review of Resident 146's record indicated she was admitted on [DATE], with [DIAGNOSES REDACTED]. The most recent MDS, dated [DATE], indicated a BIMS score of 15, indicating no cognitive (ability to think and reason) impairment. The facility's Weights Summary for Resident 146 was reviewed and indicated the following weights and comparisons: 8/23/18 118.8 lbs 8/28/18 114.4 9/4/18 111 5.0% change (comparison weight 8/23/18, 118 lbs, -6.6%, -7.8 lbs) 9/11/18 107.5 5.0% change (comparison weight 8/23/18, 118 lbs, -9.5%, -11.3 lbs) 7.5% change (comparison weight 8/23/18, 118.8 lbs, -9.5%, -11.3 lbs) A review of the record included a note sent to the physician to inform him of Resident 146's weight loss on 9/1/18 and Mighty Shakes (a nutritional supplement to provide extra calories and protein) were ordered three times per day (TID). The IDT weight variance note was dated 9/5/18 and the RD recommended: continue regular diet, weekly weights, mighty shakes TID, and staff assistance with all meals. Under supplements it was noted the resident preferred strawberry. A review of the care plan included the following interventions, Encourage 75% or greater intake of each meal, offer substitute if intake is less than 75%, provide and honor food preferences. During an interview on 9/10/18 at 11:05 am, Resident 146 complained of cold food. During an observation on 9/10/18 at 12:30 pm, lunch trays for the assisted Dining Room (DR) were brought, in a cart, then staff started passing them out to the residents who were seated in the assisted DR. Resident 146's meal was placed in front of her at 1245 pm. At 12:55 pm staff asked if she was hungry and she replied yes, I need help, then staff uncovered her tray and started to feed her. She was the last resident at her table to eat and had sat and watched the others eat before she received assistance, 25 minutes after trays first arrived on the unit. On 9/11/18 the following observations were made. At 12:30 pm, a lunch tray was served to Resident 146. The lid was left on covering the plate, and the utensils had large gray adaptive handles. At 12:45 pm, Resident 146 lifted the lid off the plate. At 12:47 pm, Resident 146 tried to grip her utensils but was unable to do so as the handles were too large for her to grasp. Her mighty shake was poured into cup by staff but no straw was placed in it. Resident 146 was unable to drink from glass since she could not grasp it with her hands. At 12:49 pm, she was able to grip her spoon enough that she was able to get some peas and small pieces of potato on it, then brought her mouth down to the plate to get the food off the spoon. Resident 146 then went to a desk in the DR and got a straw out of the top drawer then the Director of Staff Development, asked, do you need a straw? At 12:57 pm, staff then asked Resident 146 if she needed assistance as she was leaving the DR in her wheelchair and she said no, and left the DR. No assistance had been given to the resident, she had not been encouraged to drink her mighty shake, and she was not offered a substitute. Resident 146 had eaten some of the peas and potatoes on her tray, around 25% of her meal (according to observation and documentation by staff). None of the chicken had been eaten and it had not been cut up for the resident so that she could eat it on her own. During an interview on 9/11/18 at 1 pm, Resident 146 said that the Mighty Shakes were OK, but she liked ensure better. She said she liked strawberry and was told she would get it, but has not yet. Resident 146 was observed with vanilla Mighty Shakes at the lunch meal on 9/10/18 and 9/11/18. During a concurrent interview and record review on 9/11/18 at 4:25 pm, the DON agreed Resident 146 was unable to cut up food and should have received assistance with her meal today. She confirmed, per IDT note, staff were aware the resident preferred strawberry Mighty Shakes and did not know why she did not get strawberry. The DON was asked how the RD would know how much of the Mighty Shake the resident drank. The DON confirmed the Medication Administration Record [REDACTED]. During an interview on 9/12/18 at 5:30 pm, the RD said that the amount of supplement consumed should be entered, and if the order on the MAR indicated [REDACTED]. She confirmed the IDT note indicated the resident liked strawberry Mighty Shakes and that was resident preference, but said she was not sure the facility had strawberry Mighty Shakes. 3. A review of Resident 18's record indicated he was readmitted on [DATE] with [DIAGNOSES REDACTED]. Physician's orders dated 10/01/16 indicated that Resident 18, Does NOT have the capacity to understand and make decisions. During an observation on 9/10/18 at 1 pm, Resident 18 was observed in the small dining room during lunch. Resident 18 was seated in a wheelchair with a Certified Nursing Assistant who fed him 100% of his lunch and beverages. Resident 18's medical record was reviewed. According to the Weights and Vitals Summary, Resident 18's weights in pounds were as follows: 09/11/18 132.8 -10% change (Comparison Weight 04/11/18, 154.1 lbs, -13.8%, -21.3 lbs) -5% change (Comparison Weight 8/16/18, 148.1 lbs, 10.3%, -15.3 lbs) -7.5% change (Comparison Weight 6/7/18, 155.2 lbs, -11.7%, 18.2 lbs) 09/05/18 137 -10% change (Comparison Weight 3/13/18, 156 lbs, -12.2%, -19 lbs) -5% change (Comparison Weight 8/16/18, 148.1 lbs, -7.5%, 11.1 lbs) -7.5% change (Comparison Weight 6/7/18, 155.2 lbs, -11.7%, -18.2 lbs) 08/16/18 148.1 07/05/18 154 06/07/18 155.2 +5% change (Comparison Weight 5/22/18, 147.4 lbs, +5.3%, +7.8 lbs) 05/30/18 154.6 05/22/18 147.4 -10% change (Comparison Weight 12/12/17, 165.3 lbs, -10.8%, -17.9 lbs) 05/16/18 150.8 05/10/18 148.5 -10% change (Comparison Weight 12/12/17, 165.3 lbs, -10.2%, -16.8 lbs) 04/11/18 154.1 03/13/18 156 02/13/18 157.4 01/09/18 158.4 01/02/18 161 12/26/17 160.2 12/19/17 161.9 12/12/17 165.3 During a record review on 9/12/18 at 8:44 am of Resident 18's IDT progress notes dated 9/5/18 at 8:26 pm indicated, Resident with significant weight loss over the last 3 and 6 months. It indicated that Resident 18's ideal body weight was 160 pounds and his actual body weight was 137 pounds on 9/4/18. It indicated his food consumed was reviewed and appeared adequate. IDT progress note indicated, Monitor weekly weight at this time, if needed diet can be fortified. During an interview on 9/12/18 at 2:38 pm, Licensed Nurse (LN) N stated that you can see it in Resident 18's face that he had lost weight. LN N stated that LN C was responsible for monitoring for weight loss. During a concurrent interview and record review on 9/12/18 at 2:48 pm, LN C stated that the weekly weight committee consisted of RD, DSD, MDS RN, Director of Nutritional Services (DNS) and LN C. LN C stated that the RD did not record a weight in the weight log for 8/2018, which did not allow them to see his weight loss for the month. During an interview on 9/12/18 at 3:05 pm, LN B stated the facility noticed fluctuating weights with lots of residents over the past couple months. LN B stated they had the scales recalibrated to ensure accuracy and were only having certain staff weighing the residents. LN B stated that she was the only staff member who entered weights and notes on percentages for significant losses. LN B relied on the spreadsheet from the RD to Trigger for weight loss. LN B stated that RD missed entering Resident 18's weight on the log for 8/2018 causing an extra month to pass without addressing his excessive weight loss. During a concurrent interview and record review on 9/12/18 at 3:30 pm DON reviewed Resident 18's previous six months of weights. DON acknowledged that from 3/13/18 to 9/11/19 Resident 18 had a 14.87% weight loss. DON acknowledged that RD did not enter 8/2018 weight for Resident 18, so it did not trigger last month for a significant weight loss. DON acknowledged the facility was aware and charted significant weight loss for past 3 and 6 months, and stated they could be doing more to help Resident 18. DON acknowledged that monitoring weight was not an intervention, but an assessment tool. DON acknowledged that there was no evidence that a physician had assessed Resident 18 to determine the cause of his weight loss. DON acknowledged that laboratory tests to determine cause of weight loss have not been done. DON stated she did not have an answer as to why RD had not been putting interventions in place regarding weight loss. DON acknowledged that the cause of his extreme weight loss had not been addressed. DON stated we, Have a lot of work to do. DON acknowledged that care plans regarding weight had not been current since 7/2018. DON acknowledged that she was unaware that LNs were not assessing Resident 18 for weight loss and have not recorded it in the weekly assessments. MD K's progress notes did not address Resident 18's weight loss issues. DON stated how important nutrition was, especially since Resident 18 was a diabetic with wounds on his foot. During a concurrent interview and record review on 9/12/18 at 5:09 pm, RD stated it Breaks my heart that Resident 18 got missed since she did not log a weight for him for the month of 8/2018 on her spreadsheet, causing his weight loss to not trigger as a significant loss. RD stated that the current system, Isn't working and she will contact the regional dietitian for training. RD acknowledged that Resident 18's nutrition was even more important since he was a diabetic with foot wounds which made it much harder for him to heal. RD acknowledged that it was the facility's practice to not notify nursing or the physician regarding weight issues. RD stated that the physician was notified for Resident 18 requesting weekly weights on 9/6/18. RD acknowledged weight loss was a problem with Resident 18 even though he ate well. RD stated she did not know how to fix it. 4. A review of Resident 42's record revealed that she was admitted to the facility, on 7/13/17, with [DIAGNOSES REDACTED]. Resident 42's record indicated she was alert and oriented and able to make her own decisions. During observations of Resident 42 conducted on 9/10/18, at 10:30 am, she was in bed, head of the bed elevated approximately 30 degrees, her eyes closed and she was difficult to arouse. No response was made when she was greeted by the investigator. During a concurrent interview with LN O, she stated that Resident 42 had made it clear to staff when she was sleeping she did not want to be disturbed. At 2:45 pm, Resident 42 was in bed. Staff were unable to arouse her. During an interview with LN P on 9/10/18 at 2:45 pm, she stated that Resident 42's hands were cold and she has never seen her like this. LN P stated last night (pm shift 9/9/18) at bed time she had administered two pain pills to Resident 42. During a review of Resident 42's vital signs with LN P for 9/10/18 she stated her blood pressure at 10 am was 212/90 and at 3 pm was 147/81. She also stated Resident 42 has been battling a UTI (urinary tract infection) and that She normally does not take extra fluids. She just came off Bactrim (antibiotic medication) for 10 days for a urinary tract infection. LN P also noted that Resident 42 normally smoked during the day, but did not today. During an observation on 9/10/18 at 3:15 pm, with a registry Certified Nursing Assistant (CNA), CNA R and LN P Resident 42 was still laying in bed with the head of the bed elevated approximately 30 degrees. Resident 42 was difficult to arouse or responded to questions by the staff. During an interview conducted with LN G, on 9/10/18, he stated that Resident 42 has made it clear she does not want to be awakened when she was sleeping. LN G concurrently reviewed Resident 42's CNA documentation that revealed that Resident 42 had refused breakfast and lunch for 9/10/18. A concurrent review of the prior week indicated that Resident 42 usually consumed 50 - 100% of her meals CNA documentation revealed that Resident 42 had not refused any of her meals. Resident 42 was on charting for daily fluid intake that indicated on 9/9/18 she had taken in 720 ml (milliliter) of fluid and in the morning of 9/10/18 she had taken in 120 mls of fluid. There was no documentation in the CNA charting binder that the licensed nurse had been notified that Resident 42 had not eaten her meals during the day or that she had a change of condition. LN G indicated Resident 42 was not normally lethargic. A review, dated 9/6/17, of the MAYO Clinic recommendations of average fluid intake for the adult female indicated approximately 2.7 liters or 2,700 milliliters per day. A medical record titled History and Physical from the acute care hospital dated 9/11/18, indicated that Resident 42 was admitted with a history of hypertension, history of multiple [MEDICAL CONDITION] with right sided [MEDICAL CONDITION], diabetes mellitus with complications and who has had recurrent Urinary tract infections (UTI's). She had not eaten any of her meals for a 24 hour period. She was volume depleted (indicating dehydration). Laboratory values indicated Resident 42 was dehydrated. Upon admission her blood pressure was 198/94 which increased to 226/96, she was considered a hypertensive urgency/emergency. part of her altered mental status can be explained by the urinary tract infection and hypertensive [MEDICAL CONDITION]. During an interview conducted with the DSD on 9/13/18 at 9:50 am, she stated that the CNA's were trained to report refusal of meals and fluids and if the resident was lethargic to the licensed nurse. Anything not normal was supposed to be taken to nurses and they were supposed to write it down on the ADL's (documentation for the activities of daily living). She acknowledged that the CNA's documented that Resident 42 refused her breakfast and lunch, but had not notified the licensed nurse of the refusals or that Resident 42 was lethargic. During an interview with the DON (Director of Nursing) on 9/13/18, she acknowledged that Resident 42 had been in bed all day and not consumed any of her food or fluids and that she had hydration issues.

Based on observation, interview, and record review the facility failed to consistently maintain temperatures in the resident care areas of the building at a safe level, less than 81 degrees Fahrenheit (dF), over the period of 6/3/16 to 6/6/16, without adequate action to remedy the situation. This caused 9 of 11 sampled residents to suffer uncomfortable and unsafe heat levels with potential declines in health and hydration (taking in fluid to replace lost fluid). On 6/6/16, at 5:25 pm, an Immediate Jeopardy was called with the facility Administrator (Admin) due to the risk of harm to residents and the facility's failure to act related to high facility temperatures and resident complaints. Findings: A facility Dehydration Risk Assessment form, dated 6/7/16, listed the following risk factors for a determination of the potential risk of dehydration (the body does not have enough water and other fluids to carry out its normal functions). Poor fluid intake, difficulty swallowing fluids, moderate to extensive assist with fluid intake, [DIAGNOSES REDACTED]. A letter sent by California Department Of Public Health (CDPH) to all facility types (AFL 14-13), dated 5/27/14, read Facilities must have contingency plans in place to deal with the loss of air conditioning . take measures to ensure patients and residents are free of adverse conditions that may cause heat related health complications. Facilities should use portable fans and other temporary cooling devices when indicated An accompanying notice, to the letter, titled, CDPH Fast Facts Preventing Summer Heat Injuries read, Summer heat waves can be dangerous. Older people are at highest risk. People normally cool their body by sweating, but under some conditions sweating is not enough. Very high body temperatures may damage the brain and other vital organs. Some conditions that can limit the ability to regulate temperature include old age (over 65), obesity, fever, dehydration, heart disease, poor circulation, sunburns, drug and alcohol use Stay cool indoors When temperature is in the high 90's or higher, a fan will not prevent heat-related illness On 6/6/16 at 3:40 pm, upon entrance to the facility the lobby wall thermometer was observed to read 81 dF. During an interview on 6/6/16, at 3:45 pm, the facility Maintenance Supervisor (MS) stated that he was aware of a problem with the facility chiller. (A chiller is a cooling unit that uses refrigerant to cool large pipes of water that run throughout the building's attic. Air is then blown against the cool pipe at various vents, called air handler units - AHUs, located in patient rooms and halls in the building to cool the air flowing into the building.) MS stated that the problem started when he was notified 6/3/16, at about 7 pm, that the building was too hot and that some rooms were about 92 dF. MS stated that the service company for the chiller unit came out and found that the electrical breaker for the unit had tripped off. He stated it then was reset. MS also stated that the facility staff had called and complained of facility temperatures on 6/5/16, around 6 pm, but the chiller breaker was checked and was okay at that time, but no building temperatures where recorded. MS stated, I have been checking them, but not writing them down. MS was unable to provide evidence of the facility recording environmental temperatures or chiller maintenance. He was unable to provide a policy on checking environmental temperatures and what to do in the event of an air conditioning failure. He stated that he had last checked the chiller breaker at 11 am on 6/6/16, and it was okay. MS stated that the chiller and some air handlers were in need of repair and that the facility was Waiting for parts. MS provided proposed quotes for chiller maintenance service from EMCOR Services. The quotes were dated 4/1/16 and 4/5/16, and identified proposed maintenance needed for the chiller unit that had not yet been done. On 6/6/16, at 3:50 pm, the facility tour began in the Main Dining room with MS providing temperature checks. During a concurrent interview with Resident 1 who was present in the dining room at the time of the tour, Resident 1 stated, The building temperatures have been too warm for the past two weeks. MS identified that it was 86 dF where Resident 1 was sitting in the Main Dining room. Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 1 took medications for his blood pressure and depression that placed him at higher risk for dehydration. Resident 1 was greater than [AGE] years old. During the rest of the facility tour, The following resident area facility temperatures and observations were verified by MS: Corridor to Wing II 83 dF; Resident room [ROOM NUMBER] was 82 dF; Resident room [ROOM NUMBER] was 80 dF; Resident room [ROOM NUMBER] was 82 dF; Nursing Station Wing II 80 dF, with a large air fan running; Resident room [ROOM NUMBER] was 84 dF; Hall near Nursing Station II 81 dF; Resident room [ROOM NUMBER] was between 83 to 86 dF, the cooler air vent was blowing in air at 96 dF Resident rooms [ROOM NUMBERS] had temperature readings between 89 and 97 dF depending on the direction the laser temperature sensor was pointed. During an interview on 6/6/16, at 3:55 pm, Certified Nursing Assistant (CNA) A stated that Resident 2 had been complaining of the heat in the building. Resident 2's record was reviewed. Resident 2 was admitted [DATE] with [DIAGNOSES REDACTED]. Resident 2's care plan for nutrition, dated 5/19/16, read that she was at risk for dehydration. Resident 2 was greater than [AGE] years old. During an interview on 6/6/16, at 4 pm, CNA B stated that he had Many resident complaints about the heat in the building. He stated that the facility was providing increased fluids and wet towels for residents. During an interview on 6/6/16 at 4:10 pm, Resident 4 stated, With my room's cooler going all the time it is still very warm at 82 (dF), her room temperature, at the time of the interview, taken by MS was 84 dF. Resident 4's record was reviewed. Resident 4 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident 4 was taking more than one psychotropic (relating to or denoting drugs that affect a person's mental state) medication. Resident 4 was greater than [AGE] years old. During an observation on 6/6/16, at 4:15 pm, Resident 5 yelled out loudly, It's too warm. Resident 6 appeared in distress, and was restlessly moving about in her chair near the nursing station. Resident 5's record was reviewed. Resident 5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 5's age was greater than 65. The temperature in the area taken by MS was 81 dF. During an interview on 6/6/16, at 4:30 pm, Resident 8 stated It's been so hot I have been unable to eat and was observed with a dry, red flushed face. Resident 8's intake records showed that she refused her dinner on 6/6/16 and drank approximately 50 percent of her fluids. Resident 8's record was reviewed. Resident 8 was readmitted on [DATE], with [DIAGNOSES REDACTED]. Resident 8 was currently being treated for [REDACTED]. Resident 8 was bed bound and a higher risk for heat related illness due to her conditions. Resident 8's age was greater than [AGE] years old. During an interview and observation on 6/6/16, at 4:35 pm, MS verified that the chiller breaker had tripped off again and the facility chiller unit was not functioning. It was observed that the chiller was not cooling water and the water flow into the building was at 92 dF. MS stated that normal cooling water flow into building, when the chiller was functional, was about 40 to 42 dF. This resulted in open vents blowing air into the facility in excess of 90 dF. MS stated that he was told the chiller circuit breaker was getting too hot. He stated that the breaker had been replaced in recent years. MS stated that the chiller unit and some of the air handlers in the building still had problems but the main issue was the chiller circuit breaker. MS stated that he had not had an electrician evaluate the panel or breaker. During an interview on 6/6/16, at 5:40 pm, Resident 9 complained that on 6/3/16 and 6/6/16, It was like an oven in her room, my daughter had to bring in a fan, I have an extra hard time breathing because of the heat. Resident 9's record was reviewed. Resident 9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 9 was being treated for [REDACTED]. During an interview on 6/7/16, at 3:05 pm, Resident 3 stated It was horrible when the facility was not able to maintain temperatures. Resident 3's record was reviewed. Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 3 was greater than [AGE] years old. On 6/7/15, at 3:45 pm, the Speech Therapist (ST) stated that that Residents 6 and 7 refused their therapy due to the heat. ST stated that on 6/6/16, she could not get any further with Resident 7's treatment because the resident was complaining, I'm hot! I'm hot! ST stated that she worked the evening of 6/3/16, when the facility was hot everywhere. On 6/7/16, the facility provided an EMCOR work order summary, dated 6/3/16 that was reviewed and indicate, Chiller down, BLD (building) too warm Main 800 amp (ampere - the standard unit for measuring electrical current) circuit breaker in switchgear panel had tripped (in off position). Breaker was reset and the chiller initiated startup sequence After chiller ran for some time and pulled down water temp, the building had cooled down 5 degrees Several AHUs on the north and south were not discharging cold air. These units need to be investigated AHUs in patient rooms need to be checked for water flow and fan operation. When I left the site the building had pulled down to 84 degrees . primary cause of chiller going down was related to loss of power supply from tripped circuit breaker in the buildings electrical panel. The breaker is located in the electrical box on the west side of the building and is exposed to direct heat from the sun. On 6/7/16, another EMCOR service report dated 6/6/16, was reviewed and read, This call was related to loss of power supply from the buildings breaker panel. On 6/7/16, at 4:33 pm, the IJ was abated (removed) with the Administrator and Vice President Of Operations when an acceptable plan of action and evidence that the plan had been implemented was observed with purchased air conditioning units placed throughout the building.

Based on observation, interview and record review, the facility failed to maintain acceptable parameters of nutritional status when they did not recognize, evaluate and address decreased intake and severe weight loss for one of 16 sampled residents (Resident 5) and failed to follow its weight management policies. These failures contributed to Resident 5's continued severe weight loss and had the potential to result in further weight loss due to a delay in the implementation of measures to correct the weight loss, delayed healing of a pressure ulcer (bedsore), and an overall decline in her health condition. Findings: A review of Resident 5's record disclosed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was assessed as having nutritional problems and was started on nutritional supplements that included "Boost" three times per day with meals and "Med Pass 2.0" two times per day. A review of the facility policy titled, "Weight committee," dated 7/2013, indicated the facility would review residents with a weight loss of 5 pounds (#) or more in 30 days, and a loss of 7.5% body weight over 3 months. It also stated identified residents were reviewed by the Interdisciplinary Team (IDT) to determine the reason for the weight variance and plan new interventions to prevent further weight change and improve weight status. The facility policy titled, "Weight management system," dated 11/2012, indicated each resident would maintain acceptable parameters of nutritional status as indicated by clinical measures such as body weight. It also indicated supplements are documented as % consumed. The clinical record indicated Resident 5's weight on 2/1/14 was 127.5 # indicating a decrease of 8.8# from her prior monthly weight of 136.3# on 1/5/14. A "Dietary/nutritional progress note," dated 2/11/14 indicated Resident 5 was eating approximately 50% of meals. No notation was made that indicated the 8.8# significant weight loss was identified or evaluated for possible causes by the facility . Resident 5's weight on 3/1/14 was 122.4#, indicating a weight loss of 5.1# from her prior monthly weight of 127.5#. A "Dietary/nutritional progress note," dated 3/25/14, three weeks after the loss, indicated no change in Resident 5's percentage of meal intake and a goal for Resident 5 to gain weight was identified. No notation was made that indicated that the 5.1# significant weight loss was identified or evaluated by the facility. No notation was made indicating any interventions were placed or assessed to assist Resident 5 to achieve the goal of gain weight. On 4/1/14, Resident 5's weight had decreased to 120.3#, indicating a severe weight loss of 11.7% in 90 days. A "Dietary/nutritional progress note," dated 4/8/14, indicated Resident 5 was "not eating well." No notation was made indicating that the severe weight loss was identified or evaluated by the facility or any interventions placed or assessed to assist Resident 5 to achieve the goal of weight gain. There were no IDT notes that addressed weight loss for the months of 2/2014 and 3/2014. There was one IDT note for 4/2014 that mentioned the weight loss. An IDT note dated 4/22/14, indicated Resident 5 was "eating very poorly." No notation was made indicating that the severe weight loss was identified or evaluated by the facility or any interventions placed or assessed to assist Resident 5 to achieve the goal of weight gain. The "amount eaten" worksheets were where staff documented the meal percentages and supplements consumed by Resident 5. These worksheets were reviewed and showed that from 4/1 - 4/14/14, Resident 5 ate 25% or less for 27 of 42 meals and ate greater than 75% for only one meal. From 4/17 - 4/30/14, Resident 5 ate 25% or less for 31 of 42 meals and ate greater than 75% for only one meal during this period. During an observation on 4/29/14, at 12:30 pm, Resident 5 was observed lying in bed sleeping. Resident 5's lunch tray was on the over bed table, uneaten. The document titled, "Amount eaten," was reviewed and indicated Resident 5 had a 0-25% intake for that meal. During an observation and concurrent interview on 4/30/14, at 7:45 am, Resident 5 was in her wheelchair in the small dining room. The Certified Nurse Assistant (CNA) E, assisting Resident 5 stated the resident was done with breakfast and had refused all solid food and had taken a liquid supplement. The document titled, "Amount eaten," indicated Resident 5 had a 0-25% intake for that meal. The section titled supplement was blank. During an interview with Licensed Nurse D on 5/2/14, at 8:30 am, he stated the nurse signature on the Medication Administration Record [REDACTED]. The "Amount eaten'" worksheets for 1/1/14 - 5/1/14 had no documentation under the heading of "supplements." Despite the severe weight loss Resident 5 had experienced since 1/2014, and the decrease in meals consumed, a document titled, "Dietary profile," dated 4/21/14, indicated "Resident stable with good po (oral) intake...weight stable." During an interview with the Director of Nurses (DON) on 4/30/14, at 9:30 am, she confirmed Resident 5 had a significant weight loss monthly for the past three months and the facility did not assess or develop new interventions. The DON further stated she would "expect to see other nutritional interventions" developed and implemented for Resident 5 after her significant weight loss. During an interview with the Registered Dietician (RD), on 5/2/14, at 8 am, she stated part of her duties was to monitor monthly weights and identify Residents who have had a significant weight loss including a 5# loss in 30 days and a 7.5% loss in 90 days. The RD confirmed the interventions the facility had in place for Resident 5 prior to 2/1/14 were not effective to prevent her weight loss. The RD stated the process was for her to bring residents who have had a significant weight change to the next weekly IDT meeting for evaluation and assessment for potential new interventions. The RD confirmed this had not been done for Resident 5 when she had a significant weight loss in 2/14, 3/14 and 4/2014 as their policy dictates because "she (Resident 5) got missed." The RD stated she evaluates residents intakes, documents her findings and assesses adequacy of intake. The RD stated she was "not sure how (meal) percentage was calculated," but she did not think it included liquid supplements.

Based on interview and record review, the facility failed to: Promptly notify Resident 1's physician and obtain treatment for [REDACTED]. Registered Nurse (RN) E, identified that Resident 1's left leg was swollen and suspected it to be fractured on [DATE]. RN E delegated the responsibility of following-up on her findings to the day shift Charge nurse, Licensed Vocational Nurse (LN) A, who took no action, and the pm shift nurse, LN B, waited until the next day before taking action that resulted in treatment. Resident 1 was confirmed to have a significant left femur (long bone of the leg) fracture on [DATE], and was transferred to the emergency room (ER). Resident 1's broken femur could not be repaired and she was put on Hospice (end of life care) and bedrest and died six days later; and Provide adequate supervision to prevent avoidable falls when on [DATE], Resident 1 sustained multiple injuries from falling out of her wheelchair, and on [DATE], when she slid out of a shower chair, in the presence of two staff members both times. Evaluate and analyze the hazards of using a Hoyer lift to transfer Resident 1 to and from bed, (a mechanical lifting device where the resident is placed in a "sling" and is suspended in air while being transferred). When the facility's Interdisciplinary Team (IDT) identified that the Hoyer sling had contributed to repeated skin tear injuries and bruises to Resident 1, they continued to use it; and Ensure that staff were educated on the Hoyer "sling use" and the "safe handling" of Resident 1, that the Incident/Accident Investigation Follow-Up Recommendation team, which consisted of the Director of Nursing (DON), the Administrator, and a nurse, had repeatedly recommended after identifying that the sling of the Hoyer lift and the way the staff were "handling" Resident 1, had contributed to her multiple bruises and skin tear injuries; and Follow their "Investigating Unexplained Injuries" policy and procedure (P&P) and investigate an injury that Resident 1 sustained on [DATE], when a bruise was found on her left inner thigh. These failures resulted in repeated avoidable bruises and skin tear injuries, two avoidable falls, one with multiple injuries, two emergency hospital transfers, and a broken leg, and compromised Resident 1's ability to maintain her highest practicable level of well-being. Findings: Resident 1 was admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS, an assessment tool), dated [DATE], reflected that Resident 1 had severely impaired cognition, upper and lower extremity joint contractures (a permanent shortening of a muscle) , and was totally dependent on one to two staff members, for all activities of daily living (ADLs), including eating. On [DATE], a document review was conducted of the facility's "Incident/Accident Reports" that involved Resident 1 from [DATE] through [DATE]. The Incident/Accident Reports contained an Interview Record, Investigation Follow-Up, Description of Situation, Summary of Investigation, Past Interventions Attempted, and Recommendations/New Interventions, and reflected the following: On [DATE] at 7 am, a light purple bruise below Resident 1's left eyebrow was found. The DON documented in the "Summary Of Investigation" section, "May be related to transfer. Resident has fragile skin and is noted to bruise easily." The Investigation Follow-Up team recommended, "1. Re-educate staff on safe handling during transfers." On [DATE] at 10 am, two CNAs transferred Resident 1 to a shower chair which she began to slide out of and the two CNAs lowered Resident 1 to the floor, uninjured. The Investigation Follow-Up team recommended, "Staff education on safe handling..." On [DATE] at 1 pm, blood was noticed on Resident 1's left sock and her little toe was found to have been scraped. The Investigation Follow-Up team recommended, "Use caution when moving Resident through hallways and doorways. Keep feet on foot holding." On [DATE] at 2:55 pm, a nurse documented in the Nurses notes that she had been informed by a CNA that Resident 1 had a bruise to her left inner thigh "after shower" and "looks like may have been caused by a sling." There was no description of the bruise, and no documented nursing assessment of Resident 1's condition. There was no evidence of an Incident/Accident Report Investigation and one could not be produced by the DON upon request. The IDT documented on [DATE], "likely caused by sling for mechanical lift." On [DATE] at 9:15 pm, CNAs C and D were getting Resident 1 ready for bed and had removed the lap tray (a device that was attached to the front of Resident 1's wheelchair chair to prevent her from falling). In the "Interview Record" CNA C stated that she had remained with Resident 1 while CNA D left the room to get a nightgown and Resident 1 "sat straight up causing her to fall..." Resident 1 sustained; a 1 x 1 (length times width) centimeter (cm-2.5cm is equal to one inch) bruise to her left leg, a 0.5 x 0.8 cm bruise to her left lower leg, a 2.5 x 0.5 cm skin tear to her left lower leg, a 1 x 0.5 cm skin tear to her left knee, a 10 x 6 cm bruise to her left thigh, a 0.5 x 0.7 cm bruise to her left wrist, a 5 x 2 cm mid upper back to armpit bruise, a 4 x 5 x .05 cm (when three measurements are used-the last number is the depth of the wound) laceration to her forehead, a 2 x 1 cm right elbow skin tear, a 1 x 5 x 1 cm skin tear to her upper right arm, a 1 x 2 cm skin tear to her nose, a 0.2 x 1.5 cm bruise to the top of her right hand, and a 3 x 2 cm bruise to her right hand. Resident 1 required a transfer to the ER for an evaluation of her condition and stitches to repair the laceration on her forehead. The Investigation Follow-Up team recommended, "no new interventions/recommendations." On [DATE] at 7 am, a skin tear that measured 0.9 x 1.5 cm was found on Resident 1's right shin, when a CNA "pulled back the covers" to change her. The Investigation Follow-Up team recommended, "Educate staff on safe handling." The IDT documented on [DATE], "likely caused during mechanical lift transfer, staff education on safe handling." On [DATE] (no time), a bruise that measured 2.5 x 2.5 cm was found on the back of Resident 1's left knee. There was no evidence of assessment, documentation, intervention, or monitoring of Resident 1's condition after the injury was known, and there was no documentation, treatment, or monitoring on the ,[DATE], Treatment Record (TAR). The Investigation Follow-Up team's recommendations were, "Monitor and treat until resolved" and "Educate staff on sling use and ensure it does not put pressure behind a resident's knees." The IDT documented on [DATE], "Probable cause may be sling from Hoyer lift. Monitor till resolved." The IDT had not recognized that assessment, documentation, or monitoring had not been done. On [DATE], RN E documented on the Interview Record that on the "afternoon of [DATE]" she had observed that Resident 1's left thigh/leg was increased in size, in comparison to the right leg. RN E documented that she, "Advised the Charge nurse to call MD (Doctor) and obtain an x-ray of left leg (thigh)." RN E had not documented her findings in Resident 1's clinical record or showed evidence of a full assessment of the injury and the physician was not notified. There was no evidence that the day shift "Charge nurse" (LN A), had followed through and assessed Resident 1's condition or notified the physician. At 8:30 pm on [DATE] (after office hours on a Friday night), with no evidence to support that Resident 1's condition was stable, LN B faxed a request for an x-ray to Resident 1's physician. There was no further physician contact, assessment of Resident 1's condition, documentation, monitoring, or interventions for Resident 1's injury until the next day on [DATE] (Saturday) at 3 pm, when LN B obtained an order for [REDACTED]. A review of the x-ray report that was done on [DATE], revealed that Resident 1 had an "oblique (diagonal) intertrochanteric (round processes at the top of the femur) fracture of the left proximal (toward the top near the hip joint) femur, with significant superior (high) displacement (bone that separates from it's normal position, as the muscles pull the bone up and out of place) of the left femoral shaft component (the long straight portion of the femur)." A review of the ER physician's (Physician A) History and Physical, dated [DATE], was conducted. Physician A documented that "the Patient has quite a bit of swelling, tenderness and ecchymosis (bruising) along her left lower extremity...with transitions from purple to green...This bruising, I would guess, would be at least ,[DATE] days old...she has a fairly impressive intertrochanteric fracture of the left femur...I do not really feel like the patient is a surgical candidate...made comfort care...set her up for hospice...the patient has a very severe injury...because of the claimed time of injury versus the appearance of the bruises we felt it was necessary to file an APS (Adult Protective Services) report." Nursing note documentation reflected that Resident 1 returned to the facility on [DATE] just before 1 am, and was placed on permanent bedrest. Hospice services were initiated on [DATE], and Resident 1 died on [DATE] at 4:45 pm. A review of the facility's P&P titled, "Investigating Unexplained Injuries" revised [DATE], directed the following: "1. Should a resident be observed with unexplained injuries (including bruises, abrasions, and injuries of unknown source), the Nurse Supervisor on duty must complete an accident/incident form and record such information into the resident's clinical record." "2. "Injury of unknown source" is defined as an injury that meets both of the following conditions: a. The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and b. The injury is suspicious because of: * the extent of the injury; or * the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma); or * the number of injuries observed at one particular point in time; or * the incidence of injuries over time." On [DATE] at 10:25 am, an interview and concurrent record review was conducted with the Director of Staff Development (DSD). Inservice training logs from [DATE] through [DATE], were reviewed and revealed that no education or training had been provided to staff regarding the "sling use" or "safe handling" for Resident 1. The DSD stated, "I was never told to conduct an inservice or provide training" to staff that were directly responsible for Hoyer lift transfers, sling use, or the "safe handling" of Resident 1. On [DATE] at 12 pm, an interview and concurrent record review was conducted with the DON. The DON was unable to explain why the facility failed to prevent Resident 1's multiple and repeated injuries and avoidable falls, when she was totally dependent on staff for all of her care needs. The DON stated that Resident 1's falls out of her wheelchair, when the lap tray was removed on [DATE], and out of the shower chair on [DATE], were "avoidable." The DON confirmed that staff had not been re-educated on the Hoyer "sling" use or the "safe handling" of Resident 1, as the Investigation Follow Up team and IDT had recommended. The DON confirmed that the facility had not investigated the unexplained bruise to Resident 1's left inner thigh on [DATE], per policy. The DON confirmed that on [DATE], when Resident 1 was suspected as having a left leg fracture, at least three staff nurses staff had not followed the facility's policy and implemented procedures for unexplained injuries and treatment was delayed.

Based on observation, interview, and record review, the facility failed to identify a pressure ulcer (bedsore) that a resident developed while in the facility. The facility failed to show that the pressure ulcer's development was unavoidable. The facility failed to identify the pressure ulcer, develop a care plan to heal the pressure ulcer, complete accurate skin assessments, follow its skin care policy, and demonstrate that all ordered treatment was done in a timely manner for one of 17 sampled residents. This resulted or had the potential to result in a worsening of the pressure ulcer, delay in healing, pain, and a decreased level of well being. (Resident 3) Findings: A review of Resident 3's record disclosed that she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 3's quarterly Minimum Data Set (MDS), a resident assessment tool that reflects resident needs, dated 12/8/11, contained no documentation of any pressure ulcer on the coccyx even though treatment records showed dressings to the area started on 11/15/11. A significant change MDS, dated [DATE], also contained no documentation of any pressure ulcer on the coccyx even though treatment records showed a different type of dressing to the coccyx had been started on 12/25/11. The Care Area Assessment (CAA) summary documented triggered areas of concern and whether a care plan had been developed. Since the coccyx pressure ulcer had not been documented in the MDS, it did not appear as an area of concern and as a result, no care plan had been developed. During an interview on 4/17/12 at 7:55 am, the MDS Nurse stated the skin sheets had been reviewed prior to completion of the MDSs. There was no coccyx pressure ulcer noted on the skin sheets so he had not known about the coccyx pressure ulcer and did not document its presence on the MDS. On 4/18/12 at 7:50 am, wound care was observed and Resident 3's coccyx pressure ulcer was still present but was healing. The facility's "Skin and Wound Management Program" policy, dated 6/23/06, was reviewed. It read as follows, "a thorough assessment of the resident's skin is completed on admission, re-admission, quarterly and when a change of condition occurs. Wounds determined to be pressure ulcers will be monitored using the weekly pressure ulcer healing record while non-pressure wounds will be monitored using the non-pressure skin condition report form. Body checks will be performed by CNAs (Certified Nursing Assistants) daily. Observations will be reported to the charge nurse and documented on the CNA daily skin check. Charge Nurses will perform weekly skin evaluation and document the findings on the weekly skin review. In the event a pressure ulcer develops, the Interdisciplinary Team (IDT) will convene to determine whether the pressure ulcer was avoidable or unavoidable. The IDT will be intricately (in a very detailed way) involved with all aspects of prevention, planning, and implementation of interventions. All treatment orders for pressure ulcers must include site, stage, size (length, width and depth) and timed for review every two weeks. The wound is also measured and documented fully on the weekly pressure ulcer healing record." The treatment records for Resident 3 were reviewed for dressing changes for the months of 9/11 through 12/11. A type of barrier ointment had been ordered to be applied to the buttocks, gluteal cleft and coccyx every shift starting on 9/27/11. This was changed on 11/15/11, to include cleansing with normal saline followed by a [MEDICATION NAME] dressing (provides protection and cushion) to the left buttocks to be changed every three days. This treatment continued until 12/25/11. During that period between 11/15/11 to 12/25/12, two dressing changes were not documented as being done. The treatment was changed to applying silver alginate (antimicrobial dressing) then [MEDICATION NAME] dressing to the coccyx to be changed every other day from 12/25/11 through 1/12/12. During this time, one dressing change was not documented as being done. On 1/17/12 the treatment was changed to, "Santyl" (a [MEDICATION NAME] agent) then a [MEDICATION NAME] dressing to the coccyx wound to be changed daily. From 1/17/though 1/23/12, one dressing change was not documented as being done. During an interview and concurrent treatment record review on 4/18/12 at 1:20 pm, DON G confirmed the missing treatments and stated she did not know whether the treatments had been missed or if they were done but not charted. There was an order from the admitting physician, dated 1/17/12, for another physician (Physician I) to do a debridement on the "coccyx excoriation." There was nothing in the record to indicate that this debridement had been done prior to Resident 3's transfer to the hospital on [DATE]. During an interview on 4/17/12 at 7:55 am, the MDS Nurse stated that the wound care physicians who saw the facility's residents came weekly on Wednesdays. He reviewed a calendar and confirmed that 1/17/12 was on a Tuesday, indicating that the debridement should have occured on Wednesday 1/18/12. During an interview on 4/16/12 at 4:40 pm, Director of Nurses (DON) G confirmed there had been an order on 1/17/12 for a physician to do a debridement on the coccyx, "excoriation" for Resident 3. She stated that the pressure ulcer had to be at least a Stage III (full thickness tissue loss) for the physician to do a debridement. DON G confirmed that there was no staging or measurements of the pressure ulcer, no weekly skin sheets, and no physician progress notes [REDACTED]. She stated she was unable to give a reason why the skin sheets had not completed because she had not worked at the facility at that time. There was a high risk pressure ulcer prevention care plan initiated on 9/21/11 for Resident 3. It was updated with the following on 1/19/12, "excoriation at top of gluteal cleft" with the intervention written as, "treatment as ordered". There were no other revisions made to this care plan and/or a new care plan was not developed. During an interview on 4/17/12 at 5 pm, the Regional Clinical Director confirmed that the first time the coccyx wound was addressed in the care plan was on 1/19/12. During an interview on 4/18/12 at 8:30 am, the Regional Clinical Director confirmed that the facility policy had not been followed when staff did not complete a pressure ulcer assessment, there was no care plan for the coccyx pressure ulcer, no IDT notes regarding the coccyx pressure ulcer, there were no weekly skin sheets for either pressure ulcer wounds or non-pressure ulcer wounds by the nurses and no daily sheets by the CNAs that referred to the coccyx pressure ulcer. Resident 3 was transferred to an acute care hospital on [DATE] to have a PEG (tube placed into the stomach for feeding through the abdominal wall) inserted as she had stopped taking in fluids. The facility's transfer form contained the following documentation, "excoriation (torn or worn area on surface of skin) full thickness wound" with an arrow pointing to the coccyx (tailbone). Upon presentation to the acute care hospital on [DATE], photographs of Resident 3's coccyx pressure ulcer were taken and showed an unstageable pressure ulcer. An unstageable pressure ulcer is defined as a full thickness loss in which the base of the ulcer is covered by slough (yellow, tan ,gray, green or brown) and/or eschar (tan, brown, or black) in the wound bed. While at the hospital for the PEG tube placement, the physician debrided (removal of necrotic tissue) the pressure ulcer on 1/26/12 and it was then assessed by a wound care nurse, as a Stage IV pressure ulcer (a full thickness tissue loss with exposed bone, tendon, or muscle). Resident 3 was discharged back to the facility on [DATE]. Resident 3 was admitted to the facility on [DATE] without a pressure ulcer. Upon transfer to the hospital on [DATE] she had an unstageable pressure ulcer that was determined to be a Stage IV pressure ulcer, two days later. Although treatment for [REDACTED]. As a result of the failure to identify the pressure ulcer, skin assessments and measurements were not done according to facility policy. The facility was unable to demonstrate when the coccyx wound was first identified and if wound treatment was assessed for effectiveness. The facility was unable to show that all pressure ulcer treatments were done. There was no explanation for the delay in the debridement of the coccyx wound ordered on [DATE].