Every finding on record at Sunny Ridge

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure medications available for residents were not expired and kept in a temperature-controlled environment; this was true for 2 of 2 medication carts and 1 storage room observed. This failure created the potential for residents to receive medications with decreased efficacy. Findings include:The facility's Medication Labeling and Storage policy revised 2/2023, documented: If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items.1. On 1/22/26 at 8:00 AM, the East Hall medication cart was inspected with LPN #1 present. The following medications were observed:One tube of Glucose Gel 15 mg, expired 4/25One bottle of Aspirin 81 mg, expired 10/25One bottle of Fexofenadine HCI 60 mg, expired 11/25One bottle of TUMS, expired 12/25One bottle of Vitamin D 1,000 (10mcg), expired 12/25One bottle of Aspirin 325 mg, expired 12/25One bottle of Gen-dryl (diphenhydramine) 25 mg, expired 12/25On 1/22/26 at 8:05 AM, LPN #1 stated, she did not know who was responsible for making sure medications were not expired in her medication cart. 2. On 1/22/2026 at 8:10 AM, the [NAME] Hall medication cart was inspected with RN #1 present. The following medications were observed:One bottle of Zinc 50 mg, expired 11/25One bottle of Aspirin 325 mg, expired 12/25One bottle of Vitamin E 180 mg, expired 12/25On 1/22/2026 at 8:20 AM, RN #1 stated he was unsure of who was responsible for ensuring the medications were not expired in his medication cart.3) On 1/22/26 at 8:30 AM, the facility's medication storage room was inspected with RN #1 present. One bottle of Zinc 50 mg was observed expired 11/25.On 1/23/26 at 1:05 PM, the DON stated the expired medications in the medication carts and the medication storage room should have been removed by the nursing staff.4) On 1/22/26 at 8:35 AM, the facility's medication storage room was inspected with the ADON present. The following refrigerator temperature logs had not been updated since 1/18/26 morning shift:specimen refrigeratorvaccine refrigeratormedication refrigeratorOn 1/22/26 at 8:40 AM, the ADON confirmed the temperatures had not been checked since the morning of 1/18/25. The ADON also stated the temperature logs for the refrigerators are the responsibility of the cart nurse to check and record every shift.

Based on observation, the SOM Appendix PP, review of the FDA Food Code, and staff interview it was determined the facility failed to provide a clean and sanitary environment required for food safety, as well as cleaning and sanitizing dishes used by facility residents. This was true for 31 of 32 residents who received food prepared by the facilities kitchen. These deficient practices created the potential for harm by placing residents at risk for potential foodborne illnesses and adverse health outcomes. Findings include:1. The FDA Food Code Section 2-402.11 Effectiveness documented, food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens.On 1/20/26 at 8:15 AM, during an initial observation of the facility kitchen Dietary Aide #1 was observed walking through the kitchen without wearing a hair net.On 1/20/26 at 8:18 AM, Dietary Aide #1 stated he should have been wearing a hair net while walking through the kitchen.2. The FDA Food Code Section 3-401.11 Raw Animal Foods, documented raw animal foods such as eggs shall be cooked to heat all parts of the food to a temperature of 145 degrees F for 15 seconds for raw eggs that are broken and prepared for immediate service.The FDA Food Code Section 3-501.19 Time as a Public Health Control, documented a food establishment serving a highly susceptible population may not use time for hot holding foods for 4 hours as the public health control for raw eggs.On 1/22/26 at 7:36 AM, [NAME] #1 was observed frying eggs on the griddle, removing them without checking a temperature, with visibly runny yolks.On 1/22/26 at 8:10 AM, [NAME] #1 confirmed he was using unpasteurized eggs to make over easy eggs, stating yolks are served runny.On 1/22/26 at 8:12 AM, the DM stated eggs should not be served over easy.At 8:54 AM, the last of the resident's breakfast food trays were delivered. The over easy eggs were not served for immediate service.3. The FDA Food Code Section 4-302.12 Food Temperature Measuring Devices documented the presence and accessibility of food temperature measuring devices is critical to the effective monitoring of food temperatures. Proper use of such devices provides the operator or person in charge with important information with which to determine if temperatures should be adjusted or if foods should be discarded.On 1/22/26 from 7:15 AM through 8:45 AM, food temperatures for the steamtable foods were not observed being taken or recorded, when [NAME] #1 added more hashbrowns to the serving line.On 1/22/26 at 7:50 AM, [NAME] #1 stated he recorded the temperatures and kept the measurements in his mind, recording them at the end of tray line service.On 1/22/26 at 7:52 AM, the DM stated temperatures should be taken and recorded prior to tray line service.4. The FDA Food Code Section 4-602.11 Equipment Food-Contact Surfaces and Utensils documented surfaces of equipment contacting food that is not time/temperature controlled for food shall be cleaned. On 1/22/26 at 8:12 AM, [NAME] #1 was observed using a dry-cleaning cloth from on top of the food cutting board to wipe the edge of a resident's plate and then set the cleaning cloth back on the cutting board he had used to cut the breakfast sandwiches.On 1/22/26 at 8:14 AM, [NAME] #1 moved the cleaning cloth off the cutting board into a newly made sanitation bucket. [NAME] #1 was not observed getting a new cutting board.On 1/22/26 at 8:20 AM, [NAME] #1 chopped breakfast meat on the cutting board.On 1/22/26 at 8:28 AM, [NAME] #1 stated the cleaning cloths should have been placed in the sanitation bucket prior to tray line service starting.5. The FDA Food Code Section 3-304.15 Glove, Use Limitation documented single-use gloves shall be used for only one task, used for no other purpose, and discarded when damaged, soiled, or when interruptions occur in the operation.From 7:35 AM through 8:24 AM, [NAME] #1 grabbed egg sandwiches with his gloved hands, placing the sandwiches on resident's plates. He was observed grabbing resident's plates, plating the food, using a sanitation cloth to wipe the edge of residents plates, and touching the diet paper slips without changing gloves.At 7:47 AM, after removing the over easy eggs from the griddle onto a plate, [NAME] #1 picked up an over easy egg with his gloved hands and placed it on a resident's plate.At 8:25 AM, [NAME] #1 grabbed a hashbrown with his gloved hand and placed it on a resident's plate.On 1/22/26 at 8:28 AM, [NAME] #1 stated he should have used tongs to grab the egg sandwiches and hashbrowns. He stated gloves are changed between tasks like after he cracked the eggs for cooking.6. The FDA Food Code Section 4-501.12 Cutting Surfaces documented cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms (organisms that cause diseases like bacteria, viruses, and fungi) transmissible through food may build up or accumulate. These microorganisms may be transferred to foods that are prepared on such surfaces.On 1/23/25 at 1:37 PM, the clean cutting boards were observed with residue in the scratched and scored areas.On 1/23/25 at 1:39 PM, the DM stated the cutting boards should be replaced when residue cannot be cleaned.7. The FDA Food Code Section 4-501.114 Manual Chemical Sanitization - Temperature, pH, and Concentration documented sanitizing solution should have a concentration as indicated by the manufacturer's use directions included in the labeling.On 1/23/26 at 1:13 PM, the sanitation bucket used to clean surfaces after lunch tray line tested for less than 200 parts per million (ppm).On 1/23/26 at 1:15 PM, Dietary Aide #2 stated she had made the sanitation bucket 20 minutes before and it had not registered at the required 200 ppm, but she continued to use the sanitation bucket to clean the surfaces of the kitchen. Dietary Aide #2 stated she should have made a new sanitation bucket with at least 200 ppm or more prior to use.8. The SOM Appendix PP revised 7/23/25, documented equipment can become contaminated in various ways including improper sanitation.a. 0n 1/23/26 at 1:23 PM, the ice machine was observed to have a thin line of black residue on the interior white separation plate.On 1/23/26 at 1:25 PM, the DM confirmed there was black residue in the ice machine and that maintenance had cleaned the ice machine two months prior. She stated more frequent cleaning should be done if the ice machine needed it.b. On 1/23/26 at 1:35 PM, dirty dishes were observed stacked on a kitchen preparation table above the clean cutting boards used for food preparation.On 1/23/26 at 1:40 PM, the DM and Dietary Aide #1, explained dirty dishes are taken through the clean side of the dish room and washed appropriately, before being put away. The DM stated she did not believe the dishwashing procedure to get dirty dishes through the clean side to the dirty side was incorrect as dirty dishes should not be taken through a clean kitchen.c. On 1/23/26 at 1:45 PM, cooking skillets were observed with the coating scratched and visibly peeling in the interior portion where food would be cooked.On 1/23/26 at 1:48 PM, the DM stated these skillets should have been replaced and not used for cooking.

Based on record review and staff interview, it was determined the facility failed to help in developing an advance directive for health care decisions. This was true for 1 of 7 residents (Resident #18) reviewed for advance directives. This deficient practice created the potential for harm if residents' instructions for their healthcare were not followed in the event of a life-threatening outcome. Findings include:Resident #18 was admitted to the facility on [DATE] with multiple diagnoses including right side paralysis following a heart attack, Parkinson's Disease, cognitive communication deficit, depression, and anxiety. A Comprehensive MDS assessment dated [DATE] documented Resident #18 was cognitively intact.A record review of Resident #18's Progress Notes did not document he was offered the opportunity to create an advanced directive.Resident #18's IDT Care Conferences dated 4/17/25, 5/15/25, 7/28/25, 9/17/25, and 12/16/25 did not document that Resident #18 was offered information to formulate an adavanced directiveOn 1/22/26 at 11:22 AM, the Administrator confirmed there was no documentation Resident #18 was provided information to formulate an advanced directive.

Based on record review and staff interview, it was determined the facility failed to ensure the MDS assessment accurately reflected resident's status. This was true for 2 of 13 residents (#3 and #6) whose MDS assessments were reviewed. This deficient practice had the potential for negative outcomes if the resident was not assessed and/or monitored due to inaccurate assessments. Findings include:1. Resident #3 was initially admitted to the facility on [DATE] and readmitted on [DATE] after a short hospital stay with multiple diagnoses including schizophrenia - bipolar type and anxiety.Resident #3's Significant Change MDS assessment dated [DATE], documented under A1500 in Section A, no for the question, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? However, there was a PASRR level II documented in her electronic medical record, dated 9/14/25.On 1/21/26 at 3:24 PM, the MDS Coordinator #2 stated Resident #3's Significant Change MDS assessment was coded that the resident did not receive a PASRR Level II, and it should have been coded yes.2. Resident #6 was admitted to the facility on [DATE] with multiple diagnoses including end stage renal disease with dependence on dialysis.Resident #6's Quarterly MDS assessment dated [DATE], documented under section H-A, a response of yes for the question, Indwelling catheter. On 1/20/26 at 10:40 AM, observed Resident #6 in her room and she did not have a foley catheter. On 1/21/26 at 3:20 PM, the MDS coordinator #2 stated Resident #6's Quarterly MDS dated [DATE] was coded that she had a foley catheter in error.

Based on record review, observation, and interview, the facility failed to ensure comprehensive resident centered care plan included the care and services for their toenails. This was true for 1 of 13 residents (Resident #32) whose comprehensive care plan was reviewed. This deficient practice created the potential for Resident #32 to receive inadequate or inappropriate care. Findings include: Resident #32 was admitted to the facility on [DATE], with multiple diagnoses including stroke with hemiplegia and hemiparesis (paralysis and weakness on one side on the body).A Comprehensive MDS assessment dated [DATE], documented Resident #32 was dependent on staff for her activities of daily living.Resident #32's ADLs care plan, revised 12/15/25 did not include care for her toenails.On 1/21/26 at 9:44 AM, Resident #32's toenails were observed with the ADON. The ADON was asked to describe Resident #32's toenails. The ADON stated it looked like Resident #32 might have fungal infection on her toenails, brittle, thick and of off color. When asked what he meant of off color, the ADON stated it was brownish in color.On 1/21/26 at 9:56 AM, the ADON reviewed Resident #32's care plan and stated he did not see the condition of her toenails were addressed in her care plan. The ADON stated Resident #32's care plan should have included the care for her toenails.

Based on record review, observation, and staff interview, it was determined the facility failed to ensure residents who were dependent on staff for activities of daily living assistance received services for their toenails. This was true for 1 of 1 resident (Resident #32) reviewed for nail care. This placed Resident #32 at risk of embarrassment which could affect her socially due to the appearance of her toenails. Findings include: Resident #32 was admitted to the facility on [DATE], with multiple diagnoses including stroke with hemiplegia and hemiparesis (paralysis and weakness on one side on the body).A Comprehensive MDS assessment dated [DATE], documented Resident #32 was dependent on staff for her activities of daily living. On 1/20/26 at 3:34 PM with CNA #1 present, Resident #32's toenails were observed to be thick and whitish to yellowish in color.On 1/21/26 at 9:44 AM, Resident #32's toenails were observed with the ADON. The ADON was asked to describe Resident #32's toenails. The ADON stated it looked like Resident #32 might have fungal infection on her toenails, brittle, thick and of off color. When asked what he meant of off color, the ADON stated it was brownish in color. The ADON stated a Podiatrist visits the facility to look after the residents' toenails. When asked if Resident #32 was seen by the Podiatrist, the ADON stated he would find out and let the Surveyor know.On 1/21/26 at 12:42 PM, the ADON stated the Podiatrist visits the facility every three months and was last at the facility on 11/6/25. When asked if Resident #32 was seen by the Podiatrist, the ADON stated she was not seen by the Podiatrist. When asked why Resident #32 was not referred to the Podiatrist, the ADON was unable to provide an answer. When asked if Resident #32 should have seen by the Podiatrist, the ADON stated, Yes, she should have been referred to the Podiatrist.

Based on record review and interviews, it was determined the facility failed to ensure professional standards of practice were followed for 1 of 13 residents (Resident #49) reviewed for standards of practice. Resident #49's psychotropic medication was not clarified for its indication of use. These practices had the potential to adversely affect or harm residents whose care and services were not delivered to accepted standards of clinical practice. Findings include:Resident #49 was admitted to the facility on [DATE], with multiple diagnoses including diabetes, protein calorie malnutrition, and dysphagia (difficulty swallowing).A Hospital Progress Note dated 12/12/25, documented Resident #49 underwent a procedure for gastrostomy tube (a tube inserted through the wall of the abdomen directly into the stomach, used to provide nutrition) placement.A Hospital Discharge Summary Note dated 12/19/25, documented Concerned lack of sleep and depression as cause as [Resident #49] has increased stress and sleep difficulties with ongoing medical issues. Psychiatry was consulted, [Resident #49] was started on Mirtazapine (antidepressant) nightly.Resident #49's January 2026 MAR, documented she received Mirtazapine 7.5 mg via her G-tube at bedtime for appetite stimulant.On 1/21/26 at 1:10 PM, the DON reviewed Resident #49's hospital progress notes and stated Resident #49's Mirtazapine was for her insomnia and depression.

Based on observation, record review and interviews, it was determined the facility failed to ensure residents were adequately assessed for their dietary needs and provided their nutritional needs as ordered by the physician. This was true for 1 of 4 residents (Resident #32) reviewed for weight loss. Resident #32 had the potential for harm when she experienced a 5% weight loss in 30 days. Findings include: Resident #32 was admitted to the facility on [DATE], with multiple diagnoses including stroke with hemiplegia and hemiparesis (paralysis and weakness on one side on the body), dysphagia (difficulty swallowing), hepatitis C and alcohol abuse.A physician's order dated 12/31/25, documented Resident #32 was to be served with regular diet: mechanical soft texture, regular consistency, no plain eggs, bacon or milk products, extra gravy, sauces, yogurt to breakfast tray, ice cream to lunch or dinner tray.A Dietary Profile dated 10/2/25, documented Resident #32's preferred orange juice for her beverage. The dietary profile did not document what she likes and dislikes to eat.A Skin & Weight Note dated 10/30/25, documented Resident #32 had significant weight loss of 5% since her admission to the facility. Her oral intake was 26 -75%. The physician and dietitian were notified of Resident #32's weight loss. The dietitian recommended to add strawberry health shake two times a day to Resident #32's lunch and dinner trays, appetite stimulant was increased on 10/21/25.A Skin & Weight Note dated 11/6/25, documented Resident #32 had significant weight loss of 5% in 30 days. The physician and dietitian were notified of Resident #32's weight loss. The Skin & Weight Note documented the following interventions: regular diet, pureed texture with extra gravy and sauces. Add yogurt to breakfast tray and ice cream to lunch or dinner tray, health shake two times a day strawberry, appetite stimulant increased on 10/21/25.A Skin & Weight Note dated 12/18/25, documented Resident #32 had significant weight loss of 6% in one month. Resident #32 weight continued to drop which was unavoidable due to her disease progression. Her intake was poor to fair but does usually drink a health shake. Resident #32's representative declined for her to have an enteral nutritional support and would like to do comfort measures at this time. Weight was stable since last review.Resident #32 was observed eating in the Restorative Dining Room on:1/20/26 at 12:16 PM, there was no ice cream or health shake observed on her lunch tray.1/22/26 at 8:15 AM, there was no yogurt or health shake observed on breakfast tray.On 1/22/26 at 11:00 AM, Resident #32 was lying in her bed, when asked what she likes to eat, she stated she likes peanut butter. When asked what else she would like to eat, Resident #32 closed her eyes.On 1/22/26 at 1:24 PM, the DM stated Resident #32 used to be served with milk shakes, yogurt and ice cream, but on 12/31/25 she received a communication note from the Speech Language Therapist which documented no eggs, no bacon, no milk products. The DM stated they were told Resident #32 had diarrhea with milk products. The DM stated Resident #32 was not served with health shake as it was milk based. When asked if the facility had non-dairy products supplements for their residents who required it, the DM stated, No. When asked if she informed her supervisor regarding the unavailability of non-dairy products in the facility, the DM stated she did not inform the Administrator. When asked if she should have informed the Administrator regarding the unavailability of non-dairy products in the facility, the DM stated, Yes, I should have informed the Administrator.The DM was also asked regarding Resident #32's Dietary Profile dated 10/2/25, which did not document Resident #32's likes and dislikes to eat. The DM stated sometimes residents were unable to give an answer. When asked if she asked Resident #32's representatives of her likes and dislikes to eat. The DM stated she did not ask Resident #32's representative.

Based on observation, CDC guidance, interview, and record review, it was determined the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to prevent the transmission of communicable diseases and infections when the facility failed to perform hand hygiene and don gloves during medication administration, and Resident #49's graduated cylinder and syringe were not changed as ordered by the physician. These failures increased the risk of infection and its associated complications. Findings include: The Centers for Disease Control and Prevention (CDC) web page titled, Clinical Safety: Hand Hygiene for Healthcare Workers, updated 2/27/24 accessed on 1/27/26, documented hand hygiene should be performed: Immediately before touching a patient. Before performing an aseptic task such as placing an indwelling device or handling invasive medical devices. Before moving from work on a soiled body site to a clean body site on the same patient. After touching a patient or patient's surroundings. After contact with blood, body fluids, or contaminated surfaces. Immediately after glove removal. The following was observed for hand hygiene and Personal Protective equipment (PPE): 1) On 1/22/26 at 7:12 AM, LPN #1 was observed preparing a resident's insulin and transdermal patches at the medication cart. She picked up the resident's insulin pen and patches and walked to his room, knocked on the door and entered the room. No hand hygiene or donning of gloves was observed. LPN #1 placed the insulin pen on the bedside table next to a bedside urinal with no barrier between the insulin pen and the table. She then opened the transdermal pain patch and applied it to the resident, rubbing the patch onto his skin with her ungloved hand. LPN #1 then donned gloves without performing hand hygiene and proceeded to administer the resident's insulin injection. She removed her gloves, performed hand hygiene and applied the transdermal nicotine patch to the resident with an ungloved hand. On 1/22/26 at 7:40 AM, LPN #1 stated she was not aware she needed to place a barrier between the insulin pen and the bedside table. When asked about performing hand hygiene when entering a patient's room and prior to donning gloves, LPN #1 chose to remain silent. 2) On 1/22/26 at 8:46 AM, RN #1 was observed preparing a resident's oral medications at the medication cart. He picked up the resident's cup of oral medications and walked to her room, knocked on the door and entered the room. No hand hygiene or donning of gloves was observed. RN #1 handed the resident her medications cup with a cup of water and observed her swallow them. On 1/22/26 at 11:00 AM, the DON stated the expectation for her nurses would be that they perform hand hygiene upon entering a resident's room and donning gloves prior to administering insulin or transdermal patches of any kind. 3) Resident #49 was admitted to the facility on [DATE], with multiple diagnoses including diabetes, protein calorie malnutrition, and dysphagia (difficulty swallowing). A Hospital Progress Note dated 12/12/25, documented Resident #49 underwent a procedure for gastrostomy tube (a tube inserted through the wall of the abdomen directly into the stomach, used to provide nutrition) placement. A Physician's order dated 1/12/26, directed staff to change and date Resident #49's syringe and graduated cylinder every night shift. On 1/21/26 at 3:15 PM, Resident #49's graduated cylinder and syringe were observed on top of her dresser. The graduated cylinder was dated 1/18/26 and the syringe was undated. On 1/21/26 at 3:20 PM, the Surveyor and ADON went to Resident #49's room to look at her graduated cylinder and syringe. The ADON stated the graduated cylinder and syringe should be change every night and dated. On 1/22/26 at 10:23 AM, the DON stated the graduated cylinder and syringe were ordered to be changed every night for infection control purposes.

Based on record review, CDC guidance, and staff interview, it was determined the facility failed to ensure COVID-19 vaccinations were administered to the residents. This was true for 1 of 5 residents (Resident #32) whose COVID-19 vaccination was reviewed. This deficient practice placed residents at risk of severe illness, hospitalization, and death due to SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus - the virus that causes the COVID-19 illness) and had the potential to affect all residents in the facility. Findings include: The CDC website article titled: Staying Up to Date with COVID-19 Vaccines dated 11/19/25 and accessed on 1/26/26 documented:Protection from COVID-19 vaccine decreases over time.Immunity after COVID-19 infection decreases with time.The 2025-2026 vaccine is especially important if you: a. Never received a COVID-19 vaccine, b. Are ages 65 years and older c. Are at high risk for severe COVID-19 d. Are living in a long-term care facility.Resident #32 was admitted to the facility on [DATE], with multiple diagnoses including systemic lupus erythematosus (a chronic autoimmune disease where the immune system mistakenly attacks healthy tissue). Resident #32 was over the age of 65 at the time of admission.Resident #32's COVID-19 Vaccination consent form dated 9/30/25, documented her POA signed an informed consent for her to receive the COVID-19 vaccine.A Progress Note dated 10/25/25 at 1:33 PM, documented the COVID-19 vaccine was not available and pharmacy contacted.Resident #32's record did not include documentation the COVID-19 vaccine was administered.On 1/22/26 at 3:26 PM, the DON and the Regional Resource Nurse reviewed Resident #32's record and did not find documentation the COVID-19 vaccine was administered. The DON stated the Progress Note documented the vaccine was not available and could not see that the vaccine had been rescheduled.

Based on record review and staff interviews, it was determined the facility failed to ensure that physician-ordered medications were administered as prescribed for 2 of 3 residents (Resident #1 and Resident #2) reviewed for medication administration. This failure resulted in missed doses of essential medications and created the potential for adverse outcomes, including ineffective treatment and exacerbation of medical conditions. Findings include:1. Resident #1 was readmitted to the facility on [DATE], with multiple diagnoses including bipolar disorder, depression, and migraine disorder.A review of Resident #1's medication administration record (MAR), dated 8/4/25 - 8/22/25, documented the following physician orders had not been administered and coded (9) (code 9 meaning see progress note): Cyanocobalamin solution (Vitamin B12) inject 1 milliliter (mL) intramuscular one time a day for increased immune function for 4 days into shoulder, thigh, or buttocks started 8/5/25, documented code 9 for 3 of 4 administrations. Lysine (an amino acid) oral tablet 500 milligrams (mg) give 1 tablet by mouth one time a day for supplementation started 8/5/25, documented code 9 for 8 of 8 administrations. Lysine oral tablet 500 milligrams (mg) give 1 tablet by mouth one time a day for supplementation started 8/19/25, documented code 9 for 1 of 4 administrations. Topiramate (an anticonvulsant medication used to treat migraines) oral tablet 50 mg give 1 tablet by mouth in the morning for migraine started 8/19/25, documented code 9 for 2 of 4 administrations. Topiramate tablet 50 mg give 1 tablet by mouth one time a day for migraine headaches started 8/5/25, documented code 9 for 1 of 8 administrations. Topiramate tablet 50 mg give 1 tablet by mouth one time a day for migraine headaches started 8/18/25, documented code 9 for 2 of 4 administrations. Venclexta (a medication used to treat specific types of blood cancers) oral tablet 50 mg give 1 tablet by mouth one time a day for leukemia started on 8/5/25, documented code 9 for 8 of 8 administrations.On 8/29/25 at 1:25 PM, the Director of Nursing (DON) stated during a review of Resident #1's progress notes dated 8/4/25 - 8/22/25 the medication was not administered because it was not available to administer.2. Resident #2 was admitted to the facility on [DATE], with multiple diagnoses including heart disease, urinary tract infection, and chronic obstructive pulmonary disease (COPD).A review of Resident #2's medication administration record (MAR), dated 6/12/25 - 6/30/25, documented the following physician orders had not been administered and coded (9) (code 9 meaning see progress note): Breztri Inhaler (a combination inhaler used to treat COPD) inhale 2 puffs orally two times a day for COPD started 6/12/25, documented code 9 for 3 of 19 administrations. Methylprednisolone oral (a steroid used to treat inflammation) oral tablet 4 mg give 1 tablet by mouth four times a day for lumbosacral radiculopathy (a condition causing pain on the back and hip that radiates down the leg) for 1 day started 6/12/25, documented code 9 for 2 of 4 administrations. Cefdinir (an antibiotic) oral capsule 300 mg give 1 capsule by mouth two times a day for UTI for 5 days started 6/19/25, documented code 9 for 1 of 10 administrations.On 8/29/25 at 1:30 PM, the DON confirmed medications were coded 9 indicating Resident #2 did not receive the medication because it was not available.

Based on record review and staff interview, it was determined the facility failed to provide adequate supervision and functioning devices to prevent resident's fall. This was true for 1 of 3 residents (Resident #143) reviewed for accidents and falls. Resident #143 was harmed when he was being transported to the restorative dining room, and sustained a laceration on his head when he fell . Findings include: Resident #143 was admitted to the facility on [DATE] with multiple diagnoses including Parkinson's disease, heart disease, osteoarthritis, cognitive decline, and depression. An MDS significant change assessment, dated 4/16/24, documented Resident #143 was cognitively intact. Resident #143's care plan, initiated 10/12/22, documented Resident #143 was at risk for falls due to impaired mobility, Parkinson's disease, weakness, unsteady gait, medications, and poor safety awareness. Interventions included foot device to wheelchair for positioning, revised 3/21/24. This intervention was not followed. An I&A report, dated 5/2/25, documented Resident #143 was being transported to the restorative dining room. Resident #143 legs were out stretched from a seated position. Resident #143 suddenly dropped his feet to the floor, causing him to fall. His face hit the floor before CNAs were able to catch him. The report documented he was bleeding profusely from his head. EMS (Emergency Medical Services) was called and Resident #143 was transported to the hospital for treatment. A hospital report, dated 5/2/24, documented Resident #143 had a 3.5 centimeter laceration repair to his scalp, closed with 6 staples (a surgical staple used to close a wound), due to a fall from a wheelchair where he fell on to his knees and head. A facility incident investigation report, dated 5/8/24, documented a CNA stated Resident #143 had been transferred to the dining room without his foot pedals before without incident. The CNA stated Resident #143 had refused to use his foot pedals. There was no documentation in Resident #143's record that he had refused to use his foot pedals. On 1/10/25 at 10:26 AM, the Administrator stated Resident #143 had Parkinson's disease, and he did not like the foot pedals due to the jerking which caused him pain in the ankles and potential pressure ulcers. The Administrator stated the facility could have ensured wheelchair safety measures were followed such as going slower or using a wheelchair seatbelt while resident was in motion. The facility took the following actions in order: -The resident was transferred to the hospital. -The State Agency Long Term Care portal was notified. -The physician was notified. -Resident #143's respresentative was notified. -Resident #143 was monitored for his injury. -Staff were interviewed. -The staff were educated regarding wheelchair safety: Proper transfer technique, ensuring proper fit and adjustments, navigating different terrains safely, preventing accidents and injuries, maintaining wheelchair stability, checking for wear and tear, and the importance of regular inspections. -The care plan was updated to ensure Resident #143's feet were on the padded pedals during wheelchair mobility, and if Resident #143 refused, to reapproach and encourage him to use the foot pedals during transport for safety. This finding represents past non-compliance with this regulatory requirement. Resident #143 had no falls since this incident, and no other incidents were found regarding other residents being injuried during transfer. At the time of the survey the facility was in substantial compliance and therefore does not require a plan of correction. There was sufficient evidence the facility corrected the non-compliance as of 6/8/24.

Based on observation, residents and staff interviews, it was determined the facility failed to maintain or enhance residents' dignity during dining when residents seated at the same table were served their meals at different times. This was true for 2 of 14 residents (#94 and #96) observed in the main dining room and 1 of 7 (Resident #30) observed in the assisted dining room. This failure had the potential to cause a decrease in residents' sense of self-worth and psycho-social well-being. Findings include: 1. On 1/6/25, the following were observed in the Main Dining Room: a. Resident #7, Resident #9, and Resident #96 were seated at the same table. Resident #7 and Resident #9 were served their meal tray at 8:10 AM and 8:13 AM respectively and started eating. Resident #96 did not receive her tray until 8:29 AM (19 minutes from when the first meal was delivered to their table). b. Resident #93, Resident #94 and Resident #95 were seated at the same table. Resident #93 and Resident #95 were observed eating their meals at 8:21 AM. Resident #94 did not receive her meal tray. - at 8:50 AM, Resident #94 was heard saying to Resident #93 and Resident #95 Maybe I am getting my lunch. Resident #94 smiled at the surveyor and stated, Maybe they thought I am on a diet. - at 8:57 AM, CNA #1 stated she did not know why Resident #94's meal tray did not arrive. CNA #1 asked LPN #2 to get Resident #94's meal tray because she could not leave the dining room. - at 8:59 Resident #94 was served her meal tray (38 minutes from when Resident #93 and Resident #95 started eating). On 1/6/25 at 2:06 PM, the DON stated residents seated at the same table should be served their trays at the same time. She said there was a confusion in the dining room this morning. The DON stated the kitchen was told Resident #94 was not going to eat her breakfast, I don't know where that information came from. The DON stated she did not know why Resident #96 also did not receive her meal tray at the same time as Resident #7 and Resident #9. The DON stated we have been trying to place the residents' meal tray at the same order as they sat at the table. 50603 2. On 1/6/25, the following was observed in the Assisted Dining Room: -at 8:07 AM, 6 out of 7 residents were served and already eating their meals. Resident #30 was seated at the same table with Resident #17, had not been served her meal. -at 8:16 AM, Resident #30 received her meal (15 minutes after the meals were handed out to the other residents). On 1/6/25 at 8:58 AM, CNA #2 explained, Resident #30's meal tray was late because she had changed dining rooms over the weekend and the kitchen still had her registered at the Main Dining Room. The meal cart for the Main Dining Room is delivered 15 minutes after the assisted dining meal cart, so Resident #30 would receive her meal later. On 1/8/25 at 12:32 PM, the Dietary Director stated nurses will let the kitchen know when a resident changes dining rooms. The location is input into the residents' chart and the meal tickets are then printed out. If the meal is still going to the Main Dining Room, then the resident's chart has not been updated. On 1/9/25 at 2:51 PM, the Administrator and the Clinical Resource Nurse stated the kitchen was not made aware of the change over the weekend and they should have been input into Resident #30's medical record.

Based on record review, review of the Incidents and Accidents (I&As) report, residents and residents' representatives interview, staff interviews, and residents' group interviews, it was determined the facility failed to ensure there were sufficient numbers of staff available at all times to provide nursing and related services to meet the residents' needs. This was true for 3 of 41 residents (#19, #30, and #36) reviewed for staffing concerns and had the potential to affect all residents in the facility. This deficient practice created the potential for physical and psychosocial harm if residents did not receive appropriate care or received delay of care. Findings include: a. Residents and their representatives were interviewed and stated the facility did not have sufficient staff to meet their needs. - On 1/6/25 at 11:16 AM, Resident #144's representative stated, Staff is good and care for residents, but during meal times there are not enough staff to respond to immediate needs and he is waiting for help if he needs it. - On 1/6/25 at 1:29 PM, Resident #34 who was cognitively intact according to her annual MDS assessment, dated 12/7/24, stated, They are short handed to get [her] ready for bed. They also take longer during meal times. - On 1/7/25 at 11:37 PM, Resident #5 who was cognitively intact according to her annual MDS assessment, dated 12/9/24, I don't have anyone come quickly with the call light when I need my depends changed. During meal times when I need help to poop, they won't help me as they need to pass meals. - On 1/7/25 at 2:30 PM, Resident #16's representative stated, I come at lunch and he is ready to get into bed. There is lot of lunch chaos and they aren't able to help [him]until after the lunch rush. - On 1/7/25 at 2:32 PM, Resident #95 stated she pressed her call light and waited. Resident #95 stated she was holding her bladder and when she was unable to hold it she urinated into her bed. b. A Resident Council Meeting was held on 1/7/25 at 9:37 AM. Ten residents attended the meeting. Seven residents stated it took up to an hour before their call lights were answered. One male resident stated, a 10 - 15 minute waiting time was reasonable. The male resident stated, It was so uncomfortable, I needed to be changed. A female resident verified she had to wait up to an hour before getting help. c. I&As documented the following incidents: 1. Resident #19 was admitted to the facility on [DATE], with multiple diagnoses including stroke and Parkinson's disease. An MDS assessment, dated quarterly MDS assessment, dated 11/20/24, documented Resident #19 was moderately cognitively intact. An I&A report, dated 11/17/24 at 10:45 PM, documented Resident #19 was found on the floor of his room. When asked how he ended up on the floor, Resident #19 stated I crawled out of bed to get help. Resident #19 was found to be have been incontinent. An I&A report, dated 12/22/24, documented Resident #19 was found on the floor of his room. Resident #19 stated, I was trying to go to the bathroom. 2. Resident #30 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including bladder disorder, asthma and bipolar disorder. A quarterly MDS assessment, dated 12/5/24, documented Resident #30 was cognitively intact. An I&A report, dated 12/17/24, documented Resident #30 was found on the floor of her bathroom. Resident #30 stated Had my call light on but nobody came and I was worried I would wet myself. Resident #30 stated she was needing to go to the restroom, but staff was not coming fast enough. 3. Resident #36 was admitted to the facility on [DATE], with multiple diagnoses including diabetes, urinary tract infection and kidney failure. An MDS assessment, dated 11/5/24 documented Resident #36 was cognitively intact. A care plan, initiated 10/29/24, documented Resident #36 required one person assist for toileting. An I&A report, dated 12/22/24 at 7:00 PM, documented Resident #36 was found on the floor in his room. Resident #36 stated he fell when was walking back from the restroom. On 1/10/25 at 9:48 AM, the DON with the Clinical Resource Nurse stated the resident census is stable, so we keep the same number of staff for each of the shifts. We follow the PPD for staffing levels required in the facility. On 1/10/25 at 10:25 AM, the DON with the Clinical Resource Nurse stated she started in the position as DON about three weeks ago. The DON stated Resident #36 kept going to the restroom without using his call light for assistance. She stated the residents' care plan were updated to toilet them after meals and before laying down. When asked if staff were educated regarding residents' toileting program and what was done regarding residents' concerns about their call lights not being responded in a timely manner, the DON stated she would look for the documentation of education provided to the staff. On 1/10/25 at 11:41 AM, the DON with the Clinical Resource Nurse stated she was unable to find documentation staff were educated regarding residents' toileting program as indicated in their care plan. The DON also stated she could not find documentation other residents were interviewed regarding call lights waiting time when Resident #30 stated she had her call light on but nobody came and was worried she would wet herself, and toileted herself to the bathroom and fell . 50603

Based on record review, review of facility policies and procedure, review of Incidents and Accidents (I&As), and staff interview, it was determined the facility failed to ensure residents were free from significant medication errors. This was true for 3 of 3 residents (#4, #16, and #145) reviewed for medication administration. This failure created the potential for harm if the resident's medications were not administered according to the physician's order. Findings include: The facility's Administering Medications policy, revised 2/24, documented: -The Director of Nursing Services supervises and directs all personnel who administer medications and/or have related functions. -Medications are administered in accordance with prescriber orders, including any required time frame. The facility's Medication and Treatment Orders policy, revised 7/16, documented: -Drug and biological orders must be recorded on the Physician's Order Sheet in the resident's chart. 1. Resident #4 was admitted to the facility on [DATE], with multiple diagnoses including fibromyalgia (a chronic condition that causes widespread pain and tenderness in the muscles and soft tissues of the body), pain in the left shoulder, atherosclerosis (a hardening of the arteries), chronic fatigue, and hypothyroidism. A physician's order, dated 3/15/24, directed staff to give Oxycontin (opioid pain medication) ER (extended release) 80 mg two times per day. An I&A report, dated 4/9/24, documented Resident #4 accidentally received a second dose of Oxycontin on 4/8/24 after she had already taken her prescribed dosage. Resident #4 was monitored for signs and symptoms of overdose. The physician and family were notified. A nursing progress noted, dated 4/8/24 at 3:49 PM, documented Resident #4 had slight slow and slurred speech, but could response to questions appropriately. On 4/18/24, a competency assessment for the nurse who provided the second dose was completed. On 1/10/25 at 10:04 AM, the DON acknowledged the incident did happen, but she was not the DON at the time. She stated the two nurses involved in the incident were no longer employed in the facility. 2. Resident #145 was admitted to the facility on [DATE], with multiple diagnoses including COPD (chronic obstructive pulmonary disease), respiratory failure with hypoxia (low levels of oxygen in the body's tissues), and chronic kidney disease with heart failure. A physician's order, 3/29/24, documented Resident #145 was to receive the following medications: - Miralax 17 grams every day - Culterelle daily - Citracal/D3 - Vitamin C two times per day An I&A, dated 4/5/24, documented the facility did not administer Resident #145's Miralax, Culterelle, Citracal/D3, and Vitamin C as ordered by her physician. An undated handwritten note documented Hospice informed the facility on Tuesday Resident #145 did not receive her Miralax daily or three of her supplements. Hospice had faxed the orders to the facility, which were found in the staff's email from Monday. The orders were printed out and provided to the nurse who was directed to input the orders into Resident #145's record. On 4/4/24, physician orders for Miralax 17 grams every day, Culterelle daily, Citracal/D3, and Vitamin C two times per day were placed into Resident #145's medication orders. The I&A documented a staff inservice, dated 4/9/24, was provided regarding the facility's Medication and Treatment Order policy. On 1/10/25 at 10:00 AM, after reviewing the record with the DON, she stated Resident #145 did not receive the above medications as ordered. The DON stated she was not the DON at the time. She stated the nurse involved was no longer employed at the facility. 3. Resident #16 was admitted to the facility on [DATE], with multiple diagnoses including dementia, PTSD (post traumatic stress disorder), and major depressive disorder. A physician's order, dated 10/7/24, directed staff to administer Resident #16 Clindamycin (antibiotic) HCL (hydrocloride) 300 mg four times per day for 10 days. An I&A, dated 10/8/24, documented the day shift nurse missed giving two doses of Clindamycin HCL 300 mg on 10/7/24, the physician was notified of the error. The nurse involved had their clinical competencies reviewed on 10/19/24. On 1/10/25 at 10:07 AM, the DON verified the error in medication administration for Resident #16 did happen, and due to the multiple medication errors , the nurse was no longer employed at the facility. The facility did the following: -Notified the residents' physician and/or representatives of the medication errors. -Corrected the error and monitored the residents' signs and symptoms. -Provided competency evaluations for the nurses. -Provided in-service trainings. -The staff involved were no longer employed at the facility. This finding represents past non-compliance with this regulatory requirement. Resident #4, #16, and #145 had no further medication errors since this incident. At the time of the survey the facility was in substantial compliance and therefore does not require a plan of correction. There was sufficient evidence the facility corrected the non-compliance as of 11/19/24.

Based on observation, policy review, Food Code review, and staff interview, it was determined the facility failed to ensure the kitchen equipment and environment was maintained, clean, and food was stored in a safe and sanitary manner. These deficiencies had the potential to affect the 41 residents who consumed food prepared by the facility. This placed residents at risk for potential food contamination and adverse health outcomes, including food-borne illnesses. Findings include: 1. Food Receiving and Storage: The FDA Food Code Section ,d+[DATE].12 Food Storage Containers, Identified with Common Name of Food documented, Except for containers holding food that can be readily and unmistakably recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food. The FDA Food Code Section ,d+[DATE].17 Ready-to-Eat, TCS (time/temperature control for safety) food, date marking, documented, Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded. The Facility's Food Receiving and Storage policy, dated 2001, documented: . -Staff to label and date (use by date) dry foods that are removed from original packaging and stored in bins. -All foods stored in the refrigerator or freezer are covered, labeled, and dated (use by date). -Functioning of the refrigeration and food temperatures are monitored daily, and at designated intervals throughout the day by the food and nutrition services manager or designee, and documented according to the state-specific requirements. -Refrigerators must have working thermometers and are monitored documented for temperature according to state-specific guidelines. On [DATE] at 7:35 AM, the following was observed with the Dietary Director: -The temperature log on the resident snack and personal refrigerator and freezer was incorrectly dated and did not have daily temperatures recorded. -The following items were opened and undated in the dry storage area: mashed potato flakes, steel cut oats, Panko breadcrumbs, packaged rice, corn starch, Oreo cookie crumbles, and grape juice mix. -Spices were expired: hot sauce (expired [DATE]), dry pepper (expired [DATE]), poultry seasoning ([DATE]). -Large plastic bins containing white substances were not labeled with item or use by date. -Mixed vegetables in the refrigerator were opened and undated. On [DATE] at 7:45 AM, the Dietary Director stated she was unaware why there were opened, undated, and expired packages of food and spices in the dry food pantry. She stated food labels and dates are normally placed on the plastic food bins. The Dietary Director stated her staff was trained to label and date opened food items, and she did not know why they were not doing it. On [DATE] at 3:15 PM, a follow-up kitchen inspection was conducted with the Dietary Director. The following was observed: -Expired spices were stored in the food preparation station: cloves (expired [DATE]), pepper (expired [DATE]), white pepper (expired [DATE]), chicken flavor (expired [DATE]), and thyme (no date). -Opened, undated, and an iced covered package of hot dogs on the shelve directly under the freezer condenser. -Breaded chicken patties were opened and undated. -Ranch dressing, salad mix, and mixed vegetables in the refrigerator were opened and undated. -The temperature log on the resident snack and personal refrigerator and freezer was incorrectly dated and did not have daily temperatures recorded. On [DATE] at 3:30 PM, the Dietary Director stated she was unaware why there were expired spices in the cook's area, or why the foods were not dated and labeled. She stated all staff receive food services training and should know how to date food and throw away expired spices. At 3:50 PM, in a joint interview with the DON and Dietary Director, neither could verify who was supposed to be recording the temperatures on the resident refrigerator, but acknowledged someone should be doing it. 2. Cleaning, Sanitation, and Food Shelves: The FDA Food Code Section ,d+[DATE].12 documented packaged food may not be stored in direct contact with ice or water if the food is subject to the entry of water because of the nature of its packaging, wrapping, or container or its positioning in the ice or water. The FDA Food Code Section ,d+[DATE].11(A) documented food should be protected from contamination and stored in a clean, dry location where it was not exposed to splash, dust, or other contamination; and at least 6 inches above the floor. The FDA Food Code Section ,d+[DATE].12 Cleaning, Frequency and Restrictions, documented cleaning of the physical facilities is an important measure in ensuring the protection and sanitary preparation of food. A regular cleaning schedule should be established and followed to maintain the facility in a clean and sanitary manner. Primary cleaning should be done at times when foods are in protected storage and when food is not being served or prepared. The FDA Food Code Section ,d+[DATE].14 (A) documented cleaning ventilation systems intake and exhaust air ducts shall be cleaned so they are not a source of contamination by dust, dirt, and other materials. The facility's Sanitization policy, revised [DATE], documented all equipment, food contact services and utensils are cleaned and sanitized using heat or chemical sanitizing solutions. When cleaning fixed equipment (which cannot be immersed in water), the removeable parts are washed, sanitized, and non-removable parts cleaned with detergent and hot water, rinsed, air-dried, and sprayed with a sanitizing solution (at the effective concentration). The facility's Food Receiving and Storage policy, dated 2001, directed staff to: -Food in dry storage areas must be kept at least 6 inches off the floor. On [DATE] at 7:35 AM, an initial kitchen inspection was conducted with the Dietary Director. The following was observed: -Ice build-up from condensation in the freezer created water droplets that covered two boxes of unopened sausages. -Dust build-up, with large particles, were accumulated on the refrigerator fan covers. On [DATE] at 3:15 PM, a follow-up kitchen inspection was conducted with the Dietary Director. The following was observed: -Dish cloth sanitization buckets located in the ware washing room were noted to be less than 50 parts per million. -Dust was accumulated on the shelves near the oven where dried cooking sheets were stored. -Dust build-up, with large particles, were accumulated on the refrigerator fan covers. -Ice build-up from condensation in the freezer created water droplets that covered two boxes of unopened pork sausages. -Opened, iced covered package of hot dogs on the shelve directly under the freezer condenser. -A shelf in the dry food pantry, storing various dried foods, measured 4 inches from the floor. -Resident snack refrigerator had a burnt-out light bulb, and the door shelf was cracked. The handle to the refrigerator door was missing. On [DATE] at 3:15 PM, Dietary Aid #1 stated he changes the dish sanitization buckets every shift, and he was unaware it needed to be done more frequently. The Dietary Director clarified sanitation buckets are normally monitored and changed at least every three hours. At 3:30 PM, the Dietary Director stated equipment storage shelves are deep cleaned at least one time per month. She did not have a record when the shelves had last been cleaned. Additionally, the Dietary Director stated the condenser fans in the freezer and refrigerator are cleaned and maintained by Maintenance. She was not sure when they had last serviced them but believed it to be within the previous month. The Dietary Director verified the shelf in the food pantry should be at least 6 inches off the floor. On [DATE] at 10:37 AM, the Administrator stated there were no maintenance requests for the freezer fan cleaning, or freezer, and resident fridge repairs. The facility was not aware of when the freezer and refrigerator fans were last cleaned. At 11:47 AM, the Administrator and Dietary Director provided the temperature logs for [DATE], but were unable to find additional temperature logs for the previous months.

Based on record review, policy review, and staff interview, it was determined the facility failed to ensure informed consent was obtained prior to initiation of medications for 1 of 5 residents (Resident #144) reviewed for unnecessary medications. This deficient practice placed residents at risk of receiving medications without knowledge of the reason why medication was prescribed, the expected benefits, and the risks associated with the medications. Findings include: The facility's Psychotropic Medication Use policy, dated July 2022, documented residents (and/or representatives) have the right to decline treatment with psychotropic medications. The staff and physician will review with the resident/representative the risks related to not taking the medication as well as appropriate alternatives. Resident #144 was admitted to the facility on [DATE], with multiple diagnoses including stroke, hemiplegia (paralysis) affecting the right side, and bipolar disorder (a mental illness that causes extreme mood swings). A review of Resident #144's medical record documented a physician's order, dated 12/26/24, for Trazodone (antidepressant), 1 tablet via PEG-Tube (percutaneous endoscopic gastrostomy tube) at bedtime for Bipolar disorder. A signed consent for Trazodone was not found in Resident #144's medical record. On 1/9/25 at 8:00 AM, the surveyor requested a copy of Resident #144's signed consent for Trazodone. On 1/10/25 at 10:09 AM, the Clinical Resource Nurse stated she was unable to find a signed consent form for Trazodone.

Based on record review and staff interview, it was determined the facility failed to ensure transfer notices were provided to the ombudsman. This was true for 1 of 2 residents (Resident #6) reviewed for transfers to the hospital. This deficient practice had the potential for harm if residents were not aware of or able to exercise their rights related to transfers. Findings include: The State Operations Manual, Appendix PP, revised on 8/8/24 documented, Before transfers or discharges of a resident, the facility must notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. Resident #6 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including end stage renal disease, diabetes, and congestive heart failure (a chronic progressive condition affecting the pumping power of the heart muscle). Resident #6's annual MDS assessment, dated 5/23/24, documented Resident #6 was cognitively intact. A review of Resident #6's medical record documented she had two unplanned hospitalization s on 10/26/24 and 12/14/24. Documentation of Ombudsman notification was not found. On 1/9/25 at 8:00 AM, the surveyor asked for copies of hospital transfer notification to the Ombudsman. On 1/9/25 at 11:23 AM, the Administrator stated the Ombudsman was not notified of Resident #6's transfers to the hospital and she should have been.

Based on record review, policy review, and staff interview, it was determined the facility failed to ensure a bed hold notice was provided to the residents or their representatives upon transfer to the hospital. This was true for 2 of 2 residents (#6 and #40) reviewed for transfer. This deficient practice created the potential for harm if residents were not informed of their rights to return to their former bed/room at the facility within a specified time. Findings include: The facility's Transfer or Discharge policy, dated 10/2022, documented a notice of facility Bed-Hold and Return policies are provided to the resident and representative within 24 hours of emergency transfer. 1. Resident #40 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including acute cholecystitis (inflammation of the gallbladder) and diabetes. A nursing progress note, dated 9/23/24 at 8:09 PM, documented Resident #40 complained of on and off abdominal pain for the past three days. Resident #40's representative stated the surgeon told her that if ever Resident #40 had abdominal pain or fever she was to go to the hospital. Resident #40's representative took Resident #40 to the hospital. A nursing progress note, dated 9/24/24 at 8:13 AM, documented Resident #40 was admitted to the hospital. Resident #40's record did not include documentation that a Bed Hold notice was provided to her or to her representative when she was admitted to the hospital. On 1/9/25 at 3:02 PM, the DON stated she was unable to find a Bed Hold notice was provided to Resident #40 or to her representative. When asked if Bed Hold notice should have been provided to Resident #40 or to her representative, the DON stated Yes Bed Hold notice should have been provided to Resident #40 or to her representative. 50603 2. Resident #6 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with multiple diagnoses including end stage renal disease, diabetes, and congestive heart failure (a chronic condition that occurs when the heart cannot pump enough blood to meet the body's needs). Resident #6's annual MDS assessment, dated 5/23/24, documented Resident #6 was cognitively intact. A review of Resident #6's medical record documented she had two unplanned hospitalization s on 10/26/24 and 12/14/24, as follows: a. A nursing progress report, dated 10/26/24, documented Resident #6 complained of increased pain and pressure to the area surrounding the colostomy. Resident #6 stated she felt more weak and shaky, and agreed to go to the ER (emergency room ) for further evaluation. A hospital report, dated 10/26/24, documented Resident #6 had an operation to incise and drain an abdominal wall abscess. b. A nursing progress noted, dated 12/14/24, documented Resident #6 approached facility staff and stated, I need to go to the emergency room , my ostomy site hurts really bad. The ostomy site was assessed and noted to have swelling and redness, tender to the touch. Resident #6 was transported to the hospital. A hospital report for 12/14/24 was not provided to surveyor upon request. There was no documentation Resident #6 or her representative was provided bed hold paperwork. On 1/9/25 at 11:23 AM, the Administrator stated bed hold paperwork was not provided to Resident #6 or her representative for either hospitalization , and it should have been provided.

Based on record review and staff interview, it was determined the facility failed to ensure residents' Minimum Data Set (MDS) had correct assessment information. This was true for 1 of 12 residents (Resident #16) whose records were reviewed for accuracy. This deficient practice had the potential for negative outcomes if residents were not assessed and/or monitored due to inaccurate assessments. Findings include: The Resident Assessment Instrument (RAI), revised 10/1/24, documents if a PASARR (Preadmission Screening and Resident Review) Level II determines a resident has a serious mental illness then section A1500 of the MDS should be marked yes. Resident #16 was admitted to the facility on [DATE], with multiple diagnoses including dementia, PTSD (post traumatic stress disorder), and major depressive disorder. Resident #16's medical record documented a PASSAR level II, dated 1/11/22 and 6/17/22, was completed. Resident #16's admission MDS assessment, section A1500, dated 1/18/22, documented Yes, Resident #16 did have a PASSAR level II. Resident #16's annual MDS, section A1500, dated 12/23/22, 12/6/23, and 11/29/24 documented No Resident #16 did not have a completed PASSAR level II. On 1/8/25 at 2:30 PM, the MDS Coordinator stated Resident #16 had a PASSAR level II completed on 1/11/22. However, his PASSAR level II, dated 6/17/22 included an exemption that a level II was no longer needed, as he now only needs a PASSAR level I. The MDS Coordinator stated since Resident #16 no longer needed a PASSAR level II, she would not mark that in the MDS, and his original PASSAR level II would not carry forward. The MDS Coordinator verified Resident #16's admitting diagnoses had not changed.

Based on policy review, record review, review of the State Survey Agency's Long-Term Care Reporting Portal, resident interview, and staff interview, it was determined the facility failed to protect residents' rights to be free from physical and verbal abuse. This was true for 6 of 10 residents (#2, #7, #35, #36, #37, and #136) reviewed for abuse. This failure resulted in harm to Resident #2 and Resident #136. This failure also placed residents at risk of ongoing abuse and potential physical and psychosocial harm. Findings include: The facility's Abuse Prevention Program policy, revised 12/2016, stated the facility would protect residents from, as well as prevent, all types of abuse, neglect, misappropriation of property, and exploitation by anyone including staff and other residents. The policy defined the following: Verbal Abuse - The use of oral, written or gestured language that willfully includes disparaging and derogatory terms to resident or their families, or within their hearing distance; regardless of their age, ability to comprehend or disability. Physical Abuse - Includes hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment. This policy was not followed. 1. Resident #2 was admitted to the facility on [DATE], with multiple diagnoses including hemiplegia (paralysis on side of the body) and hemiparesis (weakness on one side of the body) following stroke, and heart failure. A quarterly MDS assessment, dated 3/26/22, documented Resident #2 was cognitively intact. A facility reported incident investigation, initiated 4/10/22, documented RN #2 and LPN #1 heard Resident #2 yell at someone to stop hitting her. RN #2 entered the activity/dining room and saw Resident #38 hitting Resident #2 on her left arm and yelling at her to move from where she was seated. RN #2 separated the two residents by moving Resident #38 and placing her next to a medication cart. Resident #2 was assessed and found to have a bruise to her left arm and left hand. Resident #38 had no injuries identified. The incident report documented the SSD interviewed Resident #2 on 4/14/22. Resident #2 stated Resident #38 approached her and said, This is my place, you don't belong here, get out of my chair. Resident #2 stated Resident #38 then started to hit her on the back of her neck, her back, and all over. The SSD also interviewed Resident #38. Resident #38 stated she did not hit anyone. The incident report documented the following interventions: - Resident #2 and Resident #38 were separated. - Resident #38 was placed on 15-minute checks for 72 hours for increased supervision. - Head to toe assessments were completed for both residents. Resident #2 was found to have a bruise to her left forearm and left hand. Resident #38 had no injuries were identified. - Resident #2's bruises were monitored until healed. - The SSD conducted psychosocial monitoring for both residents. - The physician was notified and reviewed Resident #38's medications. A new order was received for Resident #38 to discontinue Trazodone (antidepressant) 50 mg in three days and start Zyprexa (antipsychotic) 5 mg daily for dementia and behavioral disturbance. - Resident #38's care plan was reviewed and updated. A psychosocial note, dated 4/14/22 at 12:25 PM, documented Resident #2 was visited by the SSD. Resident #2 stated she was fine and knew Resident #38 was old and had problems. Resident #2 stated she was okay, and the incident was over. On 2/6/23 at 10:03 AM, Resident #2 stated about three months ago, Resident #38 hit her all over her upper body. Resident #2 stated, I had black and blue marks all over me and I was hurt. Resident #2 stated the staff intervened and took Resident #38 away from her and she was kept safe by the staff. On 2/8/23 at 3:59 PM, the DON stated Resident #38 hit Resident #2 while they were in the dining room. The DON stated Resident #38 had no history of prior altercations with another resident and it was the first time Resident #38 had an outburst with another resident. The DON stated Resident #38 was monitored for 72 hours after the incident and there were no concerns observed. The facility failed to ensure Resident #2 was free from physical abuse. 2. Resident #35 was admitted to the facility on [DATE], with multiple diagnoses including amyotrophic lateral sclerosis (a fatal type of motor neuron disease characterized by progressive degeneration of nerve cells in the spinal cord and brain) and adult failure to thrive. A quarterly MDS assessment, dated 7/22/21, documented Resident #35 was cognitively intact. A facility reported incident investigation, initiated 7/21/21, documented Resident #35 reported to the facility CNA #3 was rude to him, threw his arm out of her way, and left his room without placing his blankets back on him. The report documented during the facility's investigation, two other residents (#36 and #136) reported they experienced abuse as follows: a. Resident #36 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including COVID-19 and diabetes mellitus with diabetic neuropathy (nerve damage). A quarterly MDS assessment, dated 1/19/21, documented Resident #36 was cognitively intact. When Resident #36 was interviewed, she stated she felt ignored by staff and they just throw blankets on her and don't ask if she needs anything else. b. Resident #136 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease (COPD - inflammatory lung disease that causes obstructed airflow from the lungs), and type 2 diabetes mellitus with diabetic neuropathy. A quarterly MDS assessment, dated 12/26/22, documented Resident #136 was cognitively intact. The investigation report documented when Resident #136 was interviewed, she stated she felt uncomfortable asking LPN #2 for medications since she was rude to her and she felt LPN #2 viewed her as a medication-seeker when she told her, You better watch the Percocet [a narcotic pain medication], because it is very addicting. The investigation report summary documented the allegation of abuse was unsubstantiated by the interdisciplinary team. The report also stated, However, lack of customer service was substantiated. The investigation report documented the following interventions: - Resident #35's arm was assessed, and no injuries were observed. His psychosocial needs were assessed, and none were noted. His physician was notified, and he was offered counseling services, which he declined. - CNA #3 was suspended for 2 days during the investigation and received counseling related to customer service and compassionate care expectations. - LPN #2 received education related to her approach and perception of being rude and or labeling residents related to their medication regimen. - Education related to professional conduct was added to the annual in-service abuse training for all staff. On 2/10/23 at 11:10 AM, the Administrator and the DON stated no further disciplinary actions were documented for LPN #2 and CNA #3 after the incident and annual in-service abuse training was conducted for all staff in 2021 and 2022. The Administrator stated she was not working at the facility at the time of the incidents or during the investigation. She said she would not have addressed the incident as customer service issues, but as issues with unacceptable behavior and a mild type of verbal abuse. Both the Administrator and the DON felt the current staff were appropriately trained regarding abuse. The facility failed to ensure Residents #35, #36, and #136 were free from physical and verbal abuse. 3. A facility reported incident investigation, dated 11/5/22, documented LPN #1 reported the following allegations of abuse by CNA #2: - On 11/5/21, LPN #1 asked CNA #2 to assist Resident #36 out of her wheelchair and into her bed. After CNA #2 went into Resident #36's room, LPN #1 overheard her tell Resident #36, I told you, you needed to wait and if you keep leaning forward in the wheelchair, I won't get you up tomorrow. LPN #1 spoke with CNA #2 about the inappropriateness of her conversation. CNA #2 verbalized understanding. - On 11/6/21, LPN #1 gave Resident #7 her nectar-thickened coffee per her request. LPN #1 overheard CNA #2 ask Resident #7, Who gave you this coffee? You can't have it, it's not thickened. LPN #1 returned to where Resident #7 was and noted she did not have her coffee and was visibly upset and waving her hands and pointing to where her coffee used to be. LPN #1 spoke to CNA #2 about the inappropriate action of taking things away from residents and telling them they cannot have them. CNA #2 replied she would ask first next time. - On 11/6/21, LPN #1 entered Resident #37's room and noted she was visibly upset. When asked what was wrong, Resident #37 told LPN #1, I have never been treated so badly in my life. When asked what happened, she stated she asked CNA #2 for her toiletry bag so she could brush her teeth, CNA #2 responded, Can't you do it yourself? When Resident #37 asked her again, CNA #2 told her, You can do it yourself. She then set up Resident #37's oral care supplies on her bedside table instead of near the sink. LPN #1 went to speak with CNA #2 about the incident and CNA #2 walked away from LPN #1. The incident report summary documented the following interventions: - CNA #2 was suspended from working atht the facility. - Resident #7's, #36's, and #37's physicians were notified. - Additional residents were interviewed and did not voice abuse issues. - Psychosocial assessments were conducted, and follow-ups were performed for 7 days for Residents #7, #36, and #37 by the SSD and no concerns were identified. - Abuse education was conducted for all staff on 11/8/21. On 2/10/23 at 11:10 AM, the Administrator and the DON stated CNA #2 was an agency nurse and was suspended during the investigation and terminated on 11/8/21. Her agency was informed of the incidents and terminated CNA #2's contract on 11/12/21. The facility failed to ensure Residents #7, #36, and #37 were free from abuse. 40733

Based on observation, staff interview, record review, policies and recipes, it was determined the facility failed to ensure physician-ordered pureed diets and thickened liquids were the appropriate consistency when served to residents. This was true for 1 of 2 sampled residents (#24) with orders for thickened liquids and diet texture alterations. Resident #24 was in immediate jeopardy (IJ) of serious harm, impairment, or death when: a. Resident #24 was provided nectar thick liquids rather than spoon thick (pudding-like) liquids; b. Resident #24 received pureed food items inconsistent with physician orders; and c. Resident #24 was positioned inappropriately during liquid intake and after meals. On 2/22/18 at 7:26 pm, the facility's Administrator and DON were notified verbally and in writing of the IJ situation. Specifically, the facility failed to: * Ensure physician orders [REDACTED]. * Ensure the food prepared and delivered to residents was consistent with physician's dietary orders prior to residents eating or drinking food and/or beverages. * Ensure thickened liquids were provided at the consistency ordered by the physician. * Ensure aspiration precautions were implemented. The combined effect of the above failed systems placed Resident #24, and all other residents on thickened liquids and/or altered textured diets, at immediate risk for serious harm, impairment, and/or death. Findings include: The Idaho Diet Manual for Health Care Facilities, 11th edition, 2015, documented the ideal puree consistency should resemble whipped topping or mashed potatoes and occasionally pureed foods may be a thinner consistency to meet an individual's needs. In addition, the Idaho Diet Manual documented that foods with high water content must be drained or have additional fluid thickened to the correct consistency. The Idaho Diet Manual referenced the National Dysphagia Diet: Standardization for Optimal Care guidelines. The National Dysphagia Diet: Standardization for Optimal Care 2002, documented a pureed diet was for people who had moderate to severe dysphagia with poor oral phase abilities and reduced ability to protect their airways. A puree diet consists of pureed, homogenous, and cohesive foods and should be pudding-like. The American Speech-Language-Hearing Association at http://www.asha.org/public/speech/swallowing/Swallowing-Disorders-in-Adults, documented a 2004 study that identified signs and symptoms of swallowing disorders included coughing during that or right after eating or drinking, wet or gurgly sounding voice during or after eating or drinking, extra effort or time needed to chew or swallow, and food or liquid leaking from or getting stuck in the mouth. The study noted treatments for those with swallowing disorders included positioning and strategies to help the individual swallow more effectively. The facility's 11/28/16 Dysphagia Diet -Liquids Policy and Procedure (P&P) documented nectar-like liquids were fluids that poured like buttermilk, honey-like liquids were fluids that poured like honey or tomato sauce, and spoon thick liquids were fluids that held their shape on a spoon like pudding. The P&P documented nectar-like and honey-like fluids were commercially bought and spoon thick liquids were prepared and served by the kitchen. The above standards of practice were not followed. Examples include: 1. Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly MDS assessment, dated 2/5/18, documented Resident #24 had a severe cognitive impairment and no behaviors. The MDS documented Resident #24 was being followed by the Speech Language Pathologist (SLP) as of 1/30/18. The February 2018 Order Review History Report documented Resident #24's current and discontinued dietary orders were as follows: i. Active: * Pureed diet texture with spoon thickened (pudding) liquids, ordered 2/14/18. * Strict aspiration precautions, ordered 1/30/18. * 1/2 tsp bites with foods and liquids, ordered 1/30/18. ii. Discontinued: * Pureed diet texture with honey thick liquids, ordered 1/30/18 and discontinued 2/14/18. * Pureed diet texture with nectar-like liquids, ordered 8/28/17 and discontinued 1/30/18. The care plan titled, Impaired Swallowing, dated 2/5/18, documented Resident #24 coughed during meals. The care plan documented staff were to provide Resident #24 with a puree diet texture and spoon thick liquids. The care plan documented Resident #24 was to be upright at 90 degrees when swallowing food or drink and required one staff member to assist with meals. The care plan documented staff were to stop assisting Resident #24 with food or liquids if he started coughing. The care plan titled, Nutrition at Risk, revised 9/22/17, documented Resident #24 was nutritionally at risk related to dysphagia and dementia. The care plan documented Resident #24 required 1/2 tsp bites when eating. The care plan documented staff were to follow strict aspiration precautions. The care plan did not define what strict aspiration precautions meant. On 2/21/18 at 8:55 AM, Resident #24 was being assisted with his breakfast meal by the LSW (who was also a CNA). Resident #24 started coughing and his cough had a wet vocal quality to it. On 2/21/18 at 8:59 AM, the LSW stopped assisting Resident #24 with his breakfast meal. On 2/21/18 at 9:13 AM, CNA #2 and CNA #5 assisted Resident #24 into bed. Resident #24 was positioned on his back with a pillow wedged under his left side. The head of the bed was elevated to approximately 30 degrees or less. On 2/21/18 at 9:20 AM, Resident #24 was observed coughing and his cough had a wet vocal quality to it. On 2/21/18 from 9:20 AM through 11:21 AM, Resident #24 coughed intermittently. On 2/21/18 at 2:29 PM, LN #2 administered medications to Resident #24. Resident #24's head of bed was elevated to appromimately 60 degrees. Resident #24 was coughing after LN #2 administered the medications. The LN lowered the bed to approximately 15 degrees or less after administering the medications. On 2/21/18 at 2:31 PM, Resident #24 was in bed and was coughing with wet vocal quality. On 2/22/18 from 8:33 AM to 8:47 AM, Resident #24 was being assisted with his breakfast meal by CNA #8. Resident #24 was observed coughing while CNA #8 continued to provide Resident #24 with food. CNA #8 did not stop assisting Resident #24 with his breakfast meal when he was coughing. At 8:48 AM, Resident #24 was moved to his room. On 2/22/18 at 9:02 AM, CNA #8 and CNA #6 assisted Resident #24 into bed. Resident #24 was positioned on his back with a pillow wedged under his left side. The head of the bed was elevated to approximately 15 degrees or less. Resident #24's neck was slightly hyper-extended. On 2/22/18 from 9:11 AM through 10:06 AM, Resident #24 remained in the same position until LN #1 looked at his wound. On 2/22/18 at 2:40 PM, the SLP stated Resident #24 did not open his mouth very wide and he required small 1/2 tsp bite sizes while eating. The SLP stated Resident #24 was safest on pureed diet texture and spoon thick (pudding-like) liquids. The SLP stated Resident #24 coughed during meals which was what alerted her to needing an assessment. The SLP stated when diet changes occurred she filled out an order for [REDACTED].#24 should be on standard aspiration precautions. The SLP stated the care plan did not define aspiration precautions because, Staff know what aspiration precautions are. The SLP stated in normal circumstances residents would remain upright for minimally 30 minutes after meals. The SLP stated Resident #24 had MASD to his coccyx and he was the last one up before meals and the first one down after meals. The SLP stated when Resident #24 was assisted in bed directly after meals, he should be elevated to approximately 45 degrees or more for at least 30 minutes. The SLP stated Resident #24 should be elevated to 90 degrees for all food and beverage intake. The SLP stated she had educated staff on residents' swallowing needs or aspiration precautions on a 1:1 basis. The SLP stated she would search for any educations she had provided to staff in regards to Resident #24's diet requirements. On 2/22/18 at 2:50 PM, the DON stated aspiration precautions meant residents should be provided the safest diet order as specified by the SLP and/or physician. The DON stated residents should be left up-right in a chair for minimally 30 minutes after meals and if they were placed in bed before the 30 minutes, then the bed should be elevated to minimally 45 degrees. The DON stated residents should be sitting up-right for all food and beverage intake. The Resident Alert - Diet: Pureed & Nectar Thick liquids, dated 9/1/17, documented Resident #24 required Aspiration precautions and feeding strategies, verbal cue patient during meals: 1) to clear his throat, 2) to swallow again (second dry swallow), 3) give nectar liquid every 1-2 bites, 4) feed slowly, 5) 1/2 tsp bites, 6) if pt (patient) coughs stop feeding until cough stops & voice is clear. The facility could not provide evidence further diet change educations were provided to staff regarding Resident #24's diet changes to honey and then spoon thick liquids. On 2/22/18 at 2:55 PM, the DON stated sometimes there was a lack of communication between therapy and nursing when residents' diets were changed. 2. On 2/22/18 at 2:55 PM, the DON stated she could not locate spoon thick liquids in the residents' refrigerator. The DON stated she would call the kitchen to prepare spoon thick liquids. On 2/22/18 at 3:05 PM, CNA #1 was observed pouring nectar thick water into a cup and entered Resident #24's room. As surveyor entered the room, Resident #24's head of bed was raised approximately 20 degrees and CNA #1 had her hand behind his neck which hyper-extended his neck. She had the cup tilted towards his open mouth and a drop of the nectar thick liquids entered his mouth. CNA #1 was asked to stop providing the fluids and was asked what fluids she was providing Resident #24, CNA #1 stated, Nectar thick water. When asked what Resident #24's orders documented CNA #1 stated, Nectar thick. CNA #1 attempted to provide additional fluids and was stopped and asked to check the order. LN #1 was asked to come and assist CNA #1. LN #1 examined the fluids in the cup and stated, This is wrong. LN #1 verified Resident #24's diet order, care plan, and Kardex with CNA #1, which all documented spoon thick liquids. CNA #1 stated, Well, I messed up. CNA #1 stated the fluids on Resident #24's dinner meal tray were consistently nectar thick. CNA #1 stated Resident #24 received nectar thick liquids all the time. CNA #1 stated she had not checked Resident #24's care plan or Kardex before providing Resident #24 with fluids. On 2/22/18 at 3:11 PM, DA #1 was carrying Resident #24's thickened liquids towards the residents' refrigerator that she had prepared. The thickened liquids were dropped off with LN #1. The liquids were observed dripping readily off of a spoon and swished easily around the cup. LN #1 stated the liquids were not spoon thick viscosity, and were not appropriate for Resident #24. On 2/22/18 at 3:15 PM, the CDM in Training was shown the thicken liquids prepared for Resident #24. The CDM in Training was asked what spoon thick liquids meant and she was not sure. The CDM in Training was asked what pudding thick liquids meant and she stated, Like pudding. The CDM in Training stated she did not realize spoon thick and pudding thick liquids were the same thickness. The CDM in Training was asked if the fluids in the cup were spoon thick or pudding-like and she stated, No. The CDM in Training left with the beverages to add more instant thickener. On 2/22/18 at 4:53 PM, Cook #2 stated she though spoon thick liquids viscosity was between nectar and honey thick liquids. Cook #2 stated she did not realize spoon thick and pudding thick liquids were the same thickness. On 2/22/18 at 4:58 PM, the facility provided copies of the instant food thickener and a second document of a different food thickener directions. The label on the instant food thickener used in the facility directed staff to stir the liquid for 10-20 seconds and allow it to sit for 1-4 minutes until the right consistency was reached. The facility provided a second instant food thickener label which contained directions for a product not stocked in the facility. The directions directed staff to use different amounts of food thickener and directed staff to stir for 15-30 seconds and allow fluids to sit for 1-5 minutes. The CDM in Training stated staff utilized the directions on the second instant food thickeners label to prepare thickened liquids. The CDM in Training did not realize there was a difference between the two documents and the amount of thickener needed. 3. Resident #24's dinner meal was the incorrect consistency and viscosity. The Puree Chicken and Dumpling recipe and the Puree French Cut Green Beans recipe documented staff were to prepare per recipe, place the needed portions into a food processor, and blend until smooth. The recipe documented if the mixture was too thick, staff were to add low sodium broth and if the mixture was too thin, staff were to add instant food thickener. The recipe documented the food should resemble a soft whipped cream consistency. On 2/22/18 at 5:17 PM, the CDM in Training was assessing the temperatures of the food. When the CDM in Training assessed the temperature of the Puree Chicken and Dumplings, the thermometer's probe was inserted into the puree, and the puree did not cling to the probe and readily dripped off of the tip. The puree was observed thin and did not appear like whipped topping or mashed potatoes. The Puree French Green Beans appeared like apple sauce consistency when temperature was obtained. On 2/22/18 at 5:29 PM, the CDM in Training plated Resident #24's dinner meal with the Puree Chicken and Dumplings and the Puree French Cut Green Beans. On 2/22/18 from 5:37 to 5:49 PM, CNA #1 set Resident #24's dinner meal up in front of the resident. CNA #1 provided Resident #24 with 1/2 tsp bites inconsistently throughout the observation. CNA #1 was asked if the pureed food was the correct consistency and she stated, No. CNA #1 was observed using a spoon in the green beans and the puree dribbled off the spoon. CNA #1 used a fork to stir the Chicken and Dumplings, and when she lifted the fork out of the puree, it readily dripped off of the fork. CNA #1 stated the way the food was prepared was how it was always prepared. CNA #1 stated in the past she had sent the food back, however, nothing changed. CNA #1 was asked if she was going to continue providing Resident #24 with food even when she was aware that it was the wrong consistency, and CNA #1 stated, Yes. On 2/22/18 at 6:02 PM, the CDM provided a test tray of the Puree Chicken and Dumplings and the Puree French Cut Green Beans. The Chicken and Dumplings dripped readily off the spoon, and the green beans were not a homogenous, and cohesive food that was pudding-like. The CDM stated some puree foods would be thinner depending on the water content, and agreed Resident #24's puree should be minimally spoon thick or pudding-like because of his thickened liquid order. When asked if the purees were the correct consistency, she stated, The Chicken and Dumplings appears barely off. The CDM stated the consistency of the French Cut Green Beans was fine. When asked if Resident #24 should be consuming the puree she stated, No. The CDM was asked to remove the puree from Resident #24's plate and she did so. The CDM stated the CDM in Training should have noticed the incorrect consistency when she was plating the food. The CDM stated she would then expect nursing staff to not serve the food to the resident if they noticed the food was the incorrect consistency. On 2/22/18 at 6:09 PM, the DON was shown the pureed food items and stated the purees were thin and were not the correct consistency. NOTIFICATION AND REMOVAL OF IMMEDIATE JEOPARDY: On 2/22/18 at 7:26 PM, the facility's Administrator and DON was notified verbally and in writing of the IJ situation, and of the need to formulate and implement a plan of removal. On 2/23/18 at 4:00 PM, the facility provided evidence that an acceptable plan to remove the immediacy had been developed and implemented. Resident #24 was evaluated by the nursing for signs and symptoms of aspiration. All residents with orders for a pureed diet and/or thickened liquids were assessed and evaluated for aspiration precautions and records assessed for accurate orders, care plans, and Kardex. The removal plan included re-education of dietary staff on following recipes, ensuring thickened liquids were correct, and ensuring pureed foods were of pudding-like consistencies. The removal included the dietary manager or designee were educated to ensure the trays were appropriately assessed prior to distribution to the nursing staff. The nursing staff were educated on thickened liquids and ensuring pureed foods were of pudding-like consistencies and to return incorrect consistency foods and beverages to the kitchen. The nursing staff was educated on aspiration precautions. The above actions were verified and the Immediate Jeopardy removed prior to the survey exit conference completed on February 23, 2018.

Based on resident and staff interviews; record review, review of abuse policies and procedures, and review of abuse investigation reports, it was determined the facility failed to thoroughly document an investigation of a resident complaint of staff misconduct. This was true for 1 of 10 (#10) sampled residents. Resident #10 experienced psychosocial harm when the resident became tearful and expressed fearfulness that her reports of staff misconduct would result in a forced room change, or cause staff to be fired. The facility did not investigate each time the resident reported conflict with a specific staff member. Findings included: Resident #10 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple [DIAGNOSES REDACTED]. The resident's most recent Annual Assessment, dated 3/3/15, documented the resident was cognitively intact with a BIMS score of 15 and had minimal depression. The resident needed extensive assistance of one person for bed mobility, transfers, locomotion on unit, dressing, toilet use and bathing. The resident needed supervision and set up for eating and personal hygiene. The resident's care plan for the focus of distressed mood symptoms as evidenced by anxiety, tearfulness, fretful, excessive worrying related to anxiety and [MEDICAL CONDITION], initiated 9/10/14, documented the following interventions: *Allow time for expression of feelings with empathy and reassurance; *Allow time for verbalization of feelings/needs and attempt to resolve area of being upset; *Empower (name of resident) by involving in all aspects of care; *Encourage (name of resident) to seek staff support when fearful; and, *Non-pharmacological intervention: Provide 1:1 visits for support, reassurance, and allow her time to verbalize feelings, escort her to her room to reduce stimuli, offer to lie her in bed or sit her in recliner. On 5/7/15 at 1:10 PM, Resident #10 told the surveyor CNA #16 had complained to the resident she (the resident) was not getting ready fast enough in the morning. The resident thought CNA #16 was teasing and told this to CNA #2. The resident stated she realized CNA #16 was not teasing when CNA #2 backed up what CNA #16 said. The resident teared up and stated she was told she could get CNA #16 fired and would have to move out of her room. On 5/8/15 at 12:40 PM, the SSD stated, This resident requires a lot of attention and tries to manipulate the staff. She stated CNA #16 and Resident #10 would have a great relationship for a while, then the resident will get upset over something and they will switch CNA #16 out for another CNA to work with Resident #10. However, within a week the resident will ask for CNA #16 to come back to assist her. The SSD stated CNA #16 and the resident have had an up and down relationship and this situation had repeated itself. The SSD stated she told CNA #16 to take another CNA with her when going into Resident #10's room as a way to protect herself. The SSD stated this particular situation, as described by Resident #10 on 5/7/15, happened a couple of weeks ago, and the SSD had been made aware of it at that time as CNAs #16 and #2 had come to her office to inform her of the incident right after it occurred. The SSD stated she spoke with Resident #10 about the incident and told her, As a last resort we might need to move her to a different room so she had different aides. The SSD stated she told the resident she wanted her to be happy, comfortable and for her needs to be met. Resident #10 then told the SSD she was just kidding and that they got along fine. The SSD stated she told Resident #10 the staff were very concerned about losing their jobs. The SSD stated she brought the CNAs back to Resident #10's room and had the resident apologize to them. The SSD could not explain how her approach of telling the resident she may have to move to a different room, informing the resident staff could lose their jobs due to her reports, or how asking the resident to apologize to the staff were consistent with the resident's care plan. The SSD stated, since the CNAs had reported the incident immediately, and she had spoken with the resident about the incident, she felt she had taken care of the situation. When asked to provide documentation of her discussion or investigation of the incident, the SSD stated she did not document the incident or fill out an incident report since she had immediately taken care of the situation. However, the SSD did not explain how the CNA's actions were consistent with the resident's care plan. The SSD stated she felt her actions constituted a thorough investigation of the resident's concerns. The facility's Abuse Prohibition Policy, dated 7/1/13, documented: (Corporate Name) will prohibit abuse, mistreatment, neglect, involuntary seclusion, and misappropriation of property for all patients through the following: Screening of potential hires; training of employees (both new employees and ongoing training for all employees); Prevention of occurrences; Identification of possible incidents of allegations which need investigation; Investigation of incidents and allegations; Protection of patients during investigations; and Reporting of incidents, investigations, and Center response to the results of their investigations. Additionally, the policy documented: Process 1. The Administrator, or designee, is responsible for operationalizing policies and procedures that prohibit abuse, neglect, involuntary seclusion, injuries of unknown origin, and misappropriation of property. On 5/8/15 at 2:30 PM, the Administrator stated, In hindsight, 20/20, we know these residents and know if they feel intimidated, or have concerns. If we filled out an incident report for every grievance, we would have a book this big (lifting his right arm off his desk approximately 20). We talk to residents and then go from there. Confirmed grievances and/or incidents and accidents related to concerns of abuse are not always filled out. We take concerns of abuse very serious here. However, the Adninistrator could not show how Resident #10's concerns had been documented or addressed. On 5/8/15 at 4:00 PM, with the Administrator in attendance, the SSD stated she did not feel the aforementioned incident was an event, since this was the resident's normal routine. The SSD agreed this incident should have been documented, and stated, That was my slip up, and I should have, but I know my residents. On 5/8/16 at 6:25 PM, the Administrator and DON were made aware of the aforementioned concern. No further information was provided by the facility.

Based on observation, staff interview, resident interview, record review, and CMS definition of Pressure Ulcer review, the facility failed to prevent reoccurring pressure ulcers to 1 of 2 residents (5) reviewed for pressure ulcers. This deficient practice caused actual harm to Resident #5, when the facility failed to ensure preventive interventions were implemented to prevent the resident from developing a reoccurring pressure ulcer to her coccyx. The resident developed a Stage 2 pressure ulcer that was identified during the survey to the area of the resident's coccyx where she had a previous Stage 3 pressure ulcer. Additionally, the facility failed to ensure preventive interventions that were in the care plan, were being implemented to protect the resident's heels. Findings include: *The CMS "definitions for the stages of pressure ulcers identified below are from the Long-Term Care Facility Resident Assessment Instrument User's manual, Version 3.0." -"Stage I" - An observable, pressure-related alteration of intact skin, whose indicators as compared to an adjacent or opposite area on the body may include changes in one or more of the following parameters" 1. Skin Temperature (warmth or coolness); 2. Tissue consistency (firm or boggy); 3. Sensation (pain, itching); and/or 4. A defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues. -"Stage II" - Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister. -"Stage III"- Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling. Resident #5 was originally admitted to the facility on [DATE], and readmitted on [DATE] with [DIAGNOSES REDACTED]. The resident's Significant Change MDS (Minimum Data Set), dated 9/22/13, recorded: *BIMS score- 15 Cognition intact *Rejection of Cares- Behavior not exhibited *Bed Mobility- Extensive 2 person physical assist *Toilet Use- Extensive 1 person physical assist *Functional limitation in ROM(Range of Motion)- Lower extremity impairment on both sides *Risk of Pressure Ulcers- Yes *Unhealed Pressure Ulcer-Stage 1 or higher- Yes Stage and number of pressure ulcers -Stage 1 =2, Stage 2=0, Stage 3=1. The resident's Quarterly MDS, dated [DATE], recorded: *BIMS score- 13 Cognition intact *Rejection of Cares- Behavior not exhibited *Bed Mobility- Extensive 2 person physical assist *Toilet Use- Extensive 2 person physical assist *Functional limitation in ROM- Lower extremity impairment both sides *Risk of Pressure Ulcers- Yes *Stage and number of pressure ulcers- Zero (NOTE: Pressures sore were recorded as healed on the Quarterly assessment.) The resident's Braden Scale -For Predicting Pressure Sore Risk, dated, 9/15/13, 9/24, 10/1, 10/8, 12/16/13, scored the resident at an 18- mild risk for developing pressure sores. The resident's Doctor orders for January 2014 documented: *Braden Scale assessment. On Admission/Readmission weekly x 4, quarterly and with anticipated decline. *Pressure reducing mattress to bed. *Encourage res(resident) to change positions Q 2 hr. Every shift Everyday. *Float heels with pillows when in bed. Every shift Everyday. *Pressure redistribution cushion to chair. *Standard convoluted suspension boots to reduce pressure. Every shift Everyday. *Turn Q 2 H (every 2 hours) while in bed. Night hours -Night Shift Everyday. *Weekly skin check by licensed nurse, Y=Skin Intact, N=Skin not Intact. -Day Shift Specific days of the week. Thu. On 1/24/14, the Doctor's orders documented: "Okay to D/C (discontinue) "Float heels or pillows while in bed" as wears convoluted suspension boots to reduce pressure while in bed." The resident's TAR for January 2014 documented: *Standard convoluted suspension boots to reduce pressure, every shift everyday. The LN initialed through 1/29 for Day and Night shift. The Evening shift LN initialed through 1/27, and recorded circles around the initial on 1/5, 1/6, 1/7, 1/8, 1/12, 1/13, 1/14, 1/15, 1/19, with no recordings for 1/28 or 1/29. *(NOTE: For 11 of 29 days the documentation provided for the 2 pm to 10 pm shift, recorded the boots were not in place. It was not clarified in the resident's chart whether the resident was up for 8 hours in her wheelchair or in bed without the boots in place.) *Encourage res to change positions Q 2 hrs. Every shift, everyday. The LN initialed every shift, every day of the month, except on Evening shift 1/28 and 1/29 the column was left blank. *Float heels with pillows when in bed. Every shift, everyday. The LN initialed every shift through 1/23, and night shift initialed on 1/24. On 1/24 the Day and Evening shift column was blank. The column recorded "D/C'd (discontinued) 1/24/14," for the remainder of January. *Turn Q 2 H while in bed -night hours. Night shift, everyday. The LN initialed night shift, everyday of the month through January 29th. *Weekly skin check by license nurse; Y=Skin Intact, N= Skin not intact. Day shift, every Thu (rsday.) The LN recorded on 1/2 "Y," 1/9 "I," 1/16 was initialed, but had not recorded if the skin was Intact or not intact, and 1/23 "I." (NOTE: On 1/2, 1/9, 1/16, and 1/23 the LN's did not identify a concern with the resident's skin, during the skin checks.) The resident's Care Plan recorded: *Focus: Potential for skin breakdown related to: long history of gluteal/coccyx breakdown over the past year. Skin very fragile. *Revision on: 1/6/14. *Interventions: -"Apply moisture barrier cream after each incontinence episode." -"Complete Braden skin assessment on admission/readmission weekly x 4, quarterly and with unanticipated decline." -"Elevate heels off of bed with pillow(s)/other floatation devices." -"Assist to turn and reposition as every___(sic) hours as needed." -"Pressure reducing/relieving devices as ordered." -"Weekly skin assessment." *Focus: Decreased mobility related to : inability to move independently, Loss of muscle strength r/t (related to) neuropatic (sic) pain in lower extremities. *Revision on: 10/2/13 *Interventions: -"Mobility- Independent with electric wheelchair." Revision on: 10/30/13 -"Encourage resident to position self when in bed with use of bilateral assist bars." -"Observe resident for signs of fatigue when sitting in chair." -"Provide and encourage use of pressure redistribution devices." -"Scheduled turning and repositioning. Turn and reposition every 2 hours when in bed laying from r (right) ide(sic) to almost on back, then back to L (left) side. Pressure reducing boots on when in bed, pillows and bedding adjusted for comfort." *Focus: self care deficit change in mobility, loss of muscle strength, physical limitations r/t chair bound, decreased vision, [MEDICAL CONDITION], cardiac problems. *Revision on: 10/30/13 *Interventions: -"Baths and showers per schedule and PRN (as needed.) Skin check, shower, shampoo hair, nail cares, and lotion PRN." Date Initiated: 8/5/13 *Focus: Requires anticoagulant therapy Related to: [MEDICAL CONDITION] Fib *Date initiated: 8/16/13 *Interventions: -"Inspect skin with daily care and observe for bruising." *The resident's Skin Integrity Report for "Sacral area" for initial date 8/5/13, documented: *Anatomical Location: "Sacral Area." *Type of wound: "Pressure," with a note that stated "HX (history) open area x 1 yr (with) wound vac." Not incontinence related, was checked. *The Weekly Data Collection documented: -8/5/13 - Pressure Ulcer Stage: "2." - Appearance: "pink- nonblanching fragile granulation." -Length: "2.0" Width: "2.5" Depth "(less than) 0.1 cm." -9/4/13 -Pressure Ulcer Stage: "2." -Appearance: In the column was a drawing of a buttocks with a circle on the right cheek. -Length: "2.6" Width: "3.0" Depth: "(less than) 0.1." - 9/15, the day the resident was readmitted to the facility, and documented on the original 8/5 report: -Pressure Ulcer Stage: "3." -Appearance: No assessment was provided. -Length: "1.7" Width: "2.4" Depth: "(approximately) 0.1 cm." *(NOTE: Prior to being discharged to the hospital on [DATE] the Stage 2 Pressure Ulcer to the resident's sacral area had increased in length and width, from 8/5 to 9/4.) *A second resident's Skin Integrity Report for "Sacral area" with initial date of 8/15/13, documented: *Type of Wound: "Pressure" *Weekly Data Collection documented: -8/15/13 -Pressure Ulcer Stage: Stage "3." -Appearance: "50% G (granulation), 50% N (necrotic)." -Length: "1.7" Width: "2.4" Depth: "(approximately) 0.1 cm (centimeter)." The column included a picture of a round circle with 3 smaller circles inside it. *(NOTE: No further documentation was found on this wound. On the top of the form was written, "see New form for Re-admit.") *The resident's Skin Integrity Report for "Coccyx" with initial date of 9/15/13, documented: *Anatomical Location: "Coccyx" *The Weekly Data Collection documented: - 9/23/13 -Pressure Ulcer Stage: Stage "3." -Appearance: "(greater than) 75% g." -Length: "0.6" Width: "0.4" Depth: "(approximately) 0.1 cm." - 9/30/13 -Appearance: "E ([MEDICATION NAME]) Surround area excoriated." -Length: "5 cm" Width: "3 cm" Depth: "0.1 cm." -11/4 -Appearance: "E/G" -Length: "0.7" Width: "0.5" Depth: "(less than)0.1." -11/11 and 11/19 -Appearance: "H." -Length: "0.0" Width: "0.0" Depth: "0.0." *(NOTE: The first assessment on this form, which was dated as initiated on 9/15, was completed on 9/23. This was 8 days after the resident had been readmitted . The assessment from 9/23 to 9/30 recorded an increase in the length, width and depth of the wound. The wound had an overall increase in length, width and depth from 9/23 to 11/4, prior to the wound being assessed as healed on 11/11.) *The resident's Skin Integrity Report for "Heel" with initial date of 9/15/13, documented: *Type of Wound: Pressure (right) heel. *The Weekly Data Collection documented: - 9/23/13 -Pressure Ulcer Stage: Stage "1." -Appearance: "(greater than) 75 I (intact)." -Length: "3.5" width: "2.3" Depth: "0." -10/28/13 -Appearance: "I." -Length: "0" Width: "0" Depth: "0" The Report recorded, "Resolved," after the 10/28 assessment. *(NOTE: On 9/23 was the first documentation of the pressure ulcer on the right heel. This was 8 days after the resident was readmitted to the facility.) *The resident's Change of Condition Documentation dated 1/13/14, recorded: -"Res. had her left foot pinned underneath the big left wheel of her electric wheelchair. Res. called out help. I saw the situation & rolled her w/c slightly forward. I freed her left leg and she went about her way. 2 min later, she C/O soreness of her right shin. skin tear measures 1.5 cm x 1.5 cm. Will monitor for s/sx of infection per facility policy. Family has been notified." The resident's IDT (Interdisciplinary Progress Notes) documented: -10/25 "Assessed & redressed buttock area. Area now measuring 0.7 x 6 (crossed out) 0.7 x 0.2, edges pink healthy, (increase) depth is a concern, will continue to assess. -11/11 "Wound review: Coccyx wound is healed. Will cont.(continue) to moniotr x 4 weeks." -12/18 "Skin is closely monitored due to hx pressure ulcers prior to admit, et present upon admit." -12/20 "res. skin is intact. Coccyx & heels are healed. Blanch to touch. No C/O (complaint of) of skin pain. Will CTM (continue to monitor.) -12/29 "She is frequently incontinent of bowel and does use the toilet at her request, but does not always feel when she needs to defacate due to [MEDICAL CONDITION]." "Skin is intact, and pressure relieving devices are used to protect skin. She is on a turning and repositioning program." The following observations were made by the surveyor: *On 1/27 at 1:42 and 2:22 pm, the resident was asleep in bed, lying flat on her back with bilateral feet on the bed. Protective boots were not in place. *On 1/28 at 1:25 pm, the resident was awake in bed lying slightly on the right side, bilateral feet directly on the bed. Protective boots were not in place. When asked about the sores on her back, she stated, "it's a bed sore." When asked if it was getting better the resident stated, "One healed up, and the other one opened up at the hospital." She was asked about her feet being directly on the bed and does the facility use any protection for her. The resident replied,"I have these rubber boots at night." When asked about her mattress, she stated "Yeh it does all kinds of stuff." The resident was observed to have a memory foam overlay on top of the facility mattress along with a Chenille bedspread. The resident was laying on top of the Chenille bedspread. When asked about the memory foam, she stated "I brought it with me. I love it. I have had seven back surgeries." *On 1/28 at 3:07 pm, the resident was asleep in bed slightly on the right side, feet directly on the bed. Protective boots were not in place. *On 1/28 at 4:05 pm, the resident was up in her electric wheelchair propelling down the hall to her room. *On 1/28 at 5:08 pm, 5:15 pm, and 6:07 pm, the resident was in her electric wheelchair at her table in the dining room. *On 1/28 at 6:24 pm, the resident was in her electric wheelchair in her room. The resident was asked what time she liked to go to bed, she stated "I like to go to bed about 7:00 pm. I went to bed early last night. I have to stay up for 30 minutes after eating." When asked if she had problems with getting help, the resident stated "No, I think they do pretty well. They are under handed. They wake me up at 6 for a shower. I have a shower on Monday and Thursday, that girl gives the nicest shower." *On 1/28 at 7:02 pm, the resident was up in her electric wheelchair in her room. *On 1/28 at 7:33 pm, the resident was up in her electric wheelchair in her room. When she was asked if they put the boots on her feet when she was in bed, she stated "Yes they put them on at night." When asked if they ever put them on during the day, she stated "No because I am up and down so much." The resident stated the boots were in the closet and went to the closet to show them to the surveyor. The resident was not able to find the boots in the closet. *On 1/28 at 7:52 pm, the resident was propelling herself down the hall to the medication cart. The resident stated, "I am going to get my pills." A staff member standing nearby stated, "It will probably be at 8:00 pm, (LN name) is getting a bite to eat." The resident was asked by the surveyor if she was ready to go to bed, she replied "I am always ready for bed. I get up at 6." The resident propelled herself towards her room and stated, "I'll turn my light on." At 7:57 pm, the resident went into her room. CNA #1 passed by the resident's room, looked in and kept going. (NOTE: The resident had been up in her electric wheelchair for 3 hours and 52 minutes.) *On 1/29 at 9:40 and 10:51 am, the resident was in her bed asleep, bilateral feet were directly on the bed. Protective boots were not in place. *On 1/29 at 10:58 am, CNA #2 and CNA #3 were getting the resident up from bed to her electric wheel chair. A pillow was taken from under her lower extremities, the resident stated "take off them beautiful boots." CNA #2 stated, "oh no you don't need those til tonight." While moving the resident from side-to-side to place the Hoyer lift pad the resident stated, "it hurts so bad." The resident was asked what hurt, and she stated "it's a bed sore, the right one, trying to get it healed up for a year, comes back for no reason. Today it's really hurting." When CNA #2 was asked about the use of the boots and where they were, she stated "In the top of her closet. They put them on at night. Evening shift puts them on at night. I usually put a pillow under them to elevate them." *On 1/29 at 1:00 pm, SCLN was interviewed concerning the resident's pressure ulcers, he stated "it is resolved right now. It was on her coccyx and her feet." The SCLN stated he uses a Skin Integrity Report to document skin issues. When asked what preventive measures were currently in place he stated, "turn every 2 hours, gets up, has a pressure relieving pad in bed and chair. The shower aide comes to me whenever they spot anything new." When asked about prevention for the resident's feet, he stated "she does have boots, it's up to her whether she wants them on or off. We try to float her heels." When asked if the boots were to be used during the day, he replied "whenever she is in bed." When asked about her previous pressure sores, he stated "I believe she got them when she got here. I took over in September, July, not sure if she came here with them. "The MDS Coordinator was standing nearby, she stated "she came in with them from (Facility name.)" On 1/29 at 1:25 pm, the surveyor went with the SCLN to observe the resident's skin. The residents bilateral feet were directly on the bed, blue boots were not in place. While the SCLN was removing the resident's socks he asked her about the boots, she stated "sometimes they do, sometimes they don't." Upon moving the socks the right heel was clear. The left inner heel, into the back of the heel, was observed to have an area the skin was peeling from and was surrounded by a darker area. The SCLN started to pull the raised skin and stated, "is that tape." When asked what he would call the area, he stated, "I'd call it a stage 2." The SCLN left the room to get a tape measure. The resident was asked by the surveyor if she minded having the boots on, and she stated "No." At 1:30 pm the SCLN returned to the room and measured the area. The length was 4 cm, the width was 5.3 cm and depth was 0. The SCLN then placed a pillow under the resident's lower legs. The surveyor suggested the protective boots be placed on her feet. The resident agreed to the placement of the boots and they were placed on the resident's feet. The surveyor asked to observe the coccyx area. The SCLN rolled the resident up onto her left side, toward himself, and pulled down her brief. The resident was incontinent of stool. The SCLN got CNA #2 in to assist in cares. When the resident was cleaned the coccyx area was assessed to have a red, round, open area to the scar tissue of the coccyx. CNA #2 stated, "It use to be worse, it is getting smaller. When she goes on the commode and we spread the area, it comes open. When we use the bedpan it gets better." CNA #2 was asked when she had noticed the area now presently open and she stated, "Yesterday morning. They know the bathroom situation with her. Throughout the whole 2 weeks I have told the DON, SCLN and (named several other staff)." When asked if she had told anyone about the current open area to the coccyx, she stated, "That one, no." The SCLN was asked if he was going to measure the open area, and he stated "I can't even see it from this side." With the assistance of CNA #2, the SCLN assessed the wound, and stated, "tiny, tiny red spot, .3 x .3 is what I am getting, over old scar tissue." The SCLN was asked whether the mattress the resident had on her bed was pressure reducing or pressure relieving, and he stated "pressure reducing mattress." When asked about the top overlay on the bed, he stated "that's just memory foam." (NOTE: -This is the first the SCLN was aware of the Stage 2 Pressure Ulcer to the coccyx, and the undetermined area to the left heel. -The previous night, 1/28, the resident was observed sitting up in her electric wheelchair for 3 hours and 52 minutes. -The CNA #2 had observed the open area to the coccyx on 1/28, and had not reported the concern to staff.) The Skin Integrity Report with an initial date of 1/28/14, documented: *IHA: In House Acquired. *Anatomical Location: The figure recorded a circle to the coccyx area. *Type of Wound: "Skin Tear." *The Weekly Data Collection documented: -1/29/14 -Pressure Ulcer Stage: "0." -Appearance: Column was left blank. -Length: "0.3 cm" Width: "0.3 cm" Depth: Column was left blank. -Drainage: "NA." -Surrounding Tissue: "H." -Wound Edges: "H." -Odor: "no." (NOTE: The Skin Champion LN #4 (SCLN), identified by the facility as the skin nurse, did not identify the round, open area to the scarred tissue of the resident's coccyx as a Stage 2 pressure ulcer. Refer to the CMS description of a Stage 2 Pressure Ulcer.) A second Skin Integrity Report for the resident with an initial date of 1/28/14, documented: *IHA (In House Acquired) *Anatomical Location: The figure recorded a circle to the area of the back of the left heel. *Type of wound: "Other: Bruise." *The Weekly Data documented: -1/29/14: -Pressure Ulcer Stage: "SDTI (Suspected Deep Tissue Injury)." -Appearance: "IP/ 25% (Intact deep purple), I/ 75%" -Length: "4 cm" Width: "5.3 cm" depth: "0." -Drainage: "NA." -Surrounding Tissue: "H." -Wound Edges: "H." -Odor: "no." (NOTE: -The resident had an incident on 1/13 with the left heel pinned under her electric wheelchair wheel. This was documentd on the resident's "Change of Condition" report dated, 1/13/14. -This was the first documentation of a bruise to the resident's left heel. When the area was identified on 1/29, with the surveyor in attendance, the SCLN described it as a "Stage 2".) On 1/29 at 2:20 pm the DON and CNC was interviewed about the concerns of the resident's skin. When asked about the memory foam on the bed and it's pressure relieving properties, the DON stated "she had it on admission, it was her choice." The DON asked if the resident had been observed on her side very much, and stated "because that was our agreement." The CNC stated the Resident had been to the emergency roiagnom on 1//24 and had a skin assessment on Monday 1/27 and her "skin was fine." The CNC was asked about documentation for the pressure relieving properties of the memory foam overlay, she stated she did not have any to provide but would work on getting it. On 1/29 at 4:00 pm, while discussing the skin concerns with the DON, CNC and LN #5, LN #5 stated "a week ago there was a faint little area that went away, to the left inner heel. My CNA's told me she didn't want to wear the boots. I told them no, she has to, and she has been wearing them on my shift." On 1/30 at 10:00 am, the facility's MD (Medical Director) came to talk to the surveyors about the concerns with the resident's left heel. The MD confirmed the resident was high risk for skin issues related to vascular and arterial problems. He stated that when he is in the building the resident is always up in her chair. He stated he would have more concerns for the resident when she was in her wheelchair than in bed. The surveyor explained to the MD the observations of the resident being in bed between meals, without the preventive boots in place, and her feet directly on the bed. The MD stated, "hum ok." The surveyor then stated the resident is also on antibiotics and not feeling well, maybe she is in bed more than usual and the preventive measures would be important, he stated "that is true." The resident's physician progress notes [REDACTED]. "Patient has several issues I was asked to address today. She has skin changes to a localized area on the inner post aspect of her (left) heel. She is at risk from multiple factor [MEDICAL CONDITION] (hx spinal stenosis / foot drop, she has mild/mod chronic [MEDICAL CONDITION] & has risk for [MEDICAL CONDITIONS] ([AGE] year smoker hx). She has aprox. 4 cm area (with) surrounding resolving callous (with) some deep [DIAGNOSES REDACTED]/ ecchymosis. This looks to me to be traumatic and likely achieved when she got tangled up in her w/c." The resident was harmed when the facility failed to implement interventions to prevent the reoccurrence of a pressure ulcer to the resident's coccyx area. - The resident's memory foam overlay, on top of her pressure reducing mattress, was not assessed for pressure relieving properties. -The resident was observed to be up in her electric wheelchair for longer periods of time than the MD had ordered. -The resident had MD orders and a care plan for protective boots to be in place while in bed. On 1/27, 1/28 and 1/29 observations were made with the resident in bed without the protective boots on. -On 1/29 at 1:35 pm, the surveyor requested the SCLN to perform an assessment of the resident's skin, with the surveyor in attendance. The resident had a new, previously-unidentified Stage 2 pressure ulcer to the coccyx area, where she had a previous Stage 3 pressure ulcer. -The resident's left heel had a new, previously-unidentified area that the SCLN identified as a Stage 2 pressure ulcer, during the observation. On 1/30/14 at 4:00 pm, the Administrator, DON, and CNC were informed of the findings. No additional information was provided at this time. On 1/31/14 at 12:00 pm, after the Exit conference, the DON was asked to provide the pressure relieving information on the electric wheelchair. She stated she would fax it to the office. On 2/3 at 5:00 pm, a fax was received from the DON and documented: "She agreed to continue to remain in bed for pressure relief after breakfast and lunch. On the morning of 1/28/14 with the surveyor in attendance, she presented with a 3 mm open area in the crease of her coccyx which we immediately requested orders for treatment." (NOTE: The CNA #2 stated the open area was observed by her the day before. -The time of the observation was on 1/29 at 1:35 in the afternoon.) "Resident #5 had come to us with a 2" foam overlay with a washable cover that she requested to keep on her bed. It was clean and in good repair. I am continuing to investigate the quality of the pad. The surveyors also had questions about the quality of her w/c cushion. The cushion is custom made for her electric chair from the (name of the store), made by (name of Company.) When the cushion cover is being washed we use one of our (name of company) cushions in her w/c." (NOTE: -The resident had been in the facility approximately 5 months and the facility had not verified the pressure relieving properties of the memory foam overlay. -The facility failed to provide the pressure relieving properties of the resident's electric wheel chair.") "And regretfully she presented to the survey team without her foam boots in place on the first mornings of the visit. There had been some miscommunication concerning the boots with the nursing staff responsible for her care. However, we feel the absence of her boots did not contribute to the worsening of her heel bruise." (NOTE: -The resident was observed in bed without the preventive boots in place on 1/27, 1/28, and 1/29 at varying times both in the morning and afternoon. -The "heel bruise" was not identified by the facility until the 3rd day of the survey when the boots had not been implemented and the surveyor had concerns of the condition of resident's heels. At that time the SCLN was asked to assess the resident's skin, with the surveyor present.) The additional information did not resolve the issues with the resident's skin.