Every finding on record at Tioga Community Care Center

Based on interview, observation, and record review, the facility failed to ensure a resident was treated with respect and dignity and cared for in a manner that promoted maintenance or enhancement of his or her own quality of life by failing to honor a resident's right to be shaved prior to going to his medical appointment for 1 (Resident #71) of 2 residents reviewed for dignity. Findings: Review of the facility's policy titled, Resident Rights with a revised date of 12/2016, read in part.Policy Statement: Employees shall treat all residents with kindness, respect, and dignity. Review of Resident #71's medical record revealed an admission date of 06/01/2026 with diagnoses which included, in part.Spinal Stenosis, Cervical Region; Multiple Sclerosis; Muscle Weakness; and Other Lack of Coordination.Review of Resident #71's admission MDS with an ARD of 06/07/2026 revealed a BIMS score of 13, which indicated intact cognition. Resident #71 used a wheelchair for mobility and required partial/moderate assistance for personal hygiene.Review of Resident #71's care plan with an initiated date of 06/09/2026 revealed in part.Problem: I have an ADL self-care performance deficit related to activity intolerance, C-collar, impaired balance, and pain. Interventions: Personal Hygiene: I require limited assistance by (1) staff with personal hygiene.Interview and observation on 06/23/2026 at 9:41 a.m. revealed Resident #71 sitting up in a wheelchair in his bedroom unshaved with an untrimmed thick beard. Resident #71 stated he would like to be shaved and since being admitted to the facility, no one has ever offered to give him a shave. Resident #71 stated he has a medical appointment tomorrow and doesn't want to go looking like this. Resident #71 stated the facility always sent him to his appointments looking a mess and it made him feel embarrassed. Interview and observation on 06/24/2026 at 9:50 a.m., Resident #71 stated he just received his whirlpool shower and S4 CNA didn't shave him. Resident #71 stated he was getting ready to go to his medical appointment and stated, Now, I have to go to my appointment looking like a bum. Resident #71 stated he wanted to be shaved prior to his appointment this morning. Observed Resident #71 with an unshaved and untrimmed, thick beard. Interview on 06/24/2026 at 9:51 a.m., S4 CNA revealed she assisted Resident #71 with his whirlpool shower this morning. S4 CNA stated she didn't have time to shave Resident #71 prior to his appointment.Interview on 06/24/2026 at 10:24 a.m., S2 CNA Supervisor stated residents received a shave during their showers or when a barber came to the facility. S2 CNA Supervisor confirmed Resident #71 should have been shaved during his whirlpool shower prior to his appointment this morning, but did not.

Based on interview and record review, the facility failed to promptly notify the physician and responsible party after a change in resident's condition for 1 (Resident #9) of 2 residents investigated for accidents. The facility failed to notify the physician and responsible party in a timely manner after a witnessed fall, which resulted in an injury.Findings:Review of a facility policy on 06/24/2026 at 3:00 p.m. titled, Change in Resident's Condition or Status with a revision date of 03/2024 revealed the following in part.Our facility notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (example: changes in level of care) in a timely manner. 1. The nurse will notify the resident's attending physician or physician on call when there has been a. accident or incident involving the resident; d. significant change in the resident's physical/emotional/mental condition; g. need to transfer the resident to a hospital/treatment center. 3. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: a. The resident is involved in any accident or incident that results in any injury including injuries of an unknown source. 6. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. Review of a facility policy on 06/24/2026 at 3:00 p.m. titled, Falls and Fall Risk, Managing with a revision date of 03/2018 revealed the following in part.According to the MDS (Minimum Data Set), a fall is defined as: Unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force (example: resident pushes another resident). An episode where a resident lost his/her balance and would have fallen, if not another person if he or she had not caught him/herself is considered a fall. A fall without injury is still a fall. Review of Resident #9's medical record revealed an admission date of 05/02/2025 with diagnoses which included in part.Acquired Absence of the Left Leg Above the Knee (onset date: 11/26/2023), Acquired Absence of Right Leg Below the Knee (onset date: 08/04/2023), and Unspecified Fracture of the Lower End of Right Femur, Initial Encounter For Closed Fracture (onset date: of 05/20/2026). Review of Resident #9's Quarterly MDS with an ARD of 05/25/2026 revealed a BIMS score of 10, which indicated moderate cognitive impairment. Resident #9 required partial/moderate assistance with chair to bed transfers and used a wheelchair for mobility. Review of Resident #9's Fall Risk Evaluation dated 05/18/2026 revealed a score of 20, which indicated At Risk for Falls.Review of Resident #9's care plan with an initial date of 08/05/2023 revealed the following in part.Problem: I am high risk for falls related to history of falls, below the knee and above the knee amputations; 05/19/2026 fall. Review of a facility witnessed fall report on 06/23/2026 at 2:45 p.m. revealed the following in part.Resident #9 had a witnessed fall on 05/19/2026 at 4:47 p.m., which occurred in the resident's room. -Nursing Description: CNA came into the hallway from the resident's room and stated that the resident was eased to the floor during transfer. -Resident Description: Resident stated, I fell, it was an accident. Level of Pain: 4/10 on pain scale. -Physician Notification: 05/20/2026 at 7:43 a.m. -Family Member Notification: 05/20/2026 at 7:35 a.m. -Notes: 05/20/2026 written by S2 DON- Resident seen by Nurse Practitioner on rounds and continued to complain of pain of the right knee/leg area. An X-Ray was ordered. 05/20/2026: X-Ray showed acute impacted fracture of the distal femur. Resident was sent to the emergency room for evaluation and treatment. Returned to the facility with a knee mobilizer in place. In a telephone interview on 06/19/2026 at 11:06 a.m., S3 CNA revealed she transferred Resident #9 from wheelchair to bed on 05/19/2026 in the afternoon and had to ease him down to the floor. S3 CNA stated Resident #9 complained of his leg hurting and S3 CNA notified S6 LPN immediately. In an interview on 06/23/2026 at 9:29 a.m., Resident #9 revealed he had a fall recently. Observed right lower extremity with an external immobilizer in place. In an interview on 06/23/2026 at 9:34 a.m., S5 LPN revealed she worked 6:00 a.m.-2:00 p.m. on 05/20/2026, during nursing report she was not notified of Resident #9 having a fall from the previous evening. S5 LPN revealed Resident #9 requested pain medication around breakfast-time and stated to S5 LPN he fell the night before (05/19/2026). S5 LPN then assessed the resident, Resident #9 stated to S5 LPN that he told S6 LPN about his fall on 05/19/2026. S5 LPN then notified the Nurse Practitioner on 05/20/2026 at 7:43 a.m. of Resident #9's fall which occurred on 05/19/2026 in the afternoon. S5 LPN revealed when a resident falls the nurse on duty is to complete an assessment on the resident and notify the MD/NP/RP (Medical Director/Nurse Practitioner and the Responsible Party) immediately. In an interview on 06/23/2026 at 4:10 p.m., S6 LPN revealed she worked on 05/19/2026 from 2:00 p.m.-10:00 p.m. and at the time of Resident #9's fall. S6 LPN stated S3 CNA called her to Resident #9's room to inform her that S3 CNA had to lower Resident #9 to the floor during a transfer. S6 LPN stated Resident #9 reported he just fell, pointed to his right knee and complained of pain. S6 LPN confirmed she forgot to call the MD/NP/RP and document the incident in the medial record. S6 LPN confirmed Resident #9's fall that occurred on her shift was a change in condition and S6 LPN should have contacted the MD/NP/RP, and document the incident in the medial record immediately, but did not.In an interview on 06/23/2026 at 4:11 p.m., S2 DON revealed when she arrived to the facility on [DATE], staff reported to her Resident #9 fell on [DATE]. S2 DON became aware S6 LPN did not complete the incident report or notify the MD/NP/RP at the time of the fall. S2 DON revealed she expected the nurses to complete a head-to-assessment with vital signs, complete a fall/incident report, and contact the MD/NP/RP as soon as possible after a resident falls. S2 DON confirmed S6 LPN failed to document and notify the MD/NP/RP timely of Resident #9's fall (change in condition) immediately, which resulted in a fracture. In a telephone interview on 06/23/2026 at 6:38 p.m., S7 LPN revealed she relieved S6 LPN on 05/19/2026 and S7 LPN worked 10:00 p.m. - 6:00 a.m. S7 LPN stated she was not told in report given by S6 LPN of Resident #9's fall, which occurred earlier that afternoon. S7 LPN stated Resident #9 slept for the 10:00 p.m. - 6:00 a.m. shift. S7 LPN revealed if she was aware of Resident #9's fall, she would have assessed him and notified the proper personnel of the fall, but was not.

Based on record review, observation, and interviews, the facility failed to implement a comprehensive person-centered care plan for each resident as evidenced by failing to provide the required two-person assistance with transferring for 1 (Resident #71) and failing to provide supervised smoking for 1 (Resident #26) out of a sample of 36 residents.Findings: Review of the facility's policy titled Care Plans, Comprehensive Person-Centered with a revision date of March 2022 revealed in part.Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation: (8) Services provided for or arranged by the facility and outlined in the comprehensive care plan are: a. provided by qualified persons; b. culturally competent; and c. trauma informed. #71Review of Resident #71's medical record revealed an admission date of 06/01/2026 with diagnoses which included, in part.Spinal Stenosis, Cervical Region, Multiple Sclerosis, Muscle Weakness, and Other Lack of Coordination.Review of Resident #71's admission MDS with an ARD of 06/07/2026 revealed a BIMS score of 13, which indicated intact cognition. Resident #71 used a wheelchair for mobility, required partial/moderate assistance for chair/bed-to-chair transfer, and substantial/maximal assistance for tub/shower transfer.Review of Resident #71's care plan with an initiated date of 06/09/2026 revealed in part.Problem: I have an ADL self-care performance deficit related to activity intolerance, C-collar, impaired balance, and pain. Interventions: Transfer-I require extensive assistance by (2) staff to move between surfaces. Problem: I have limited physical mobility related to spinal stenosis, status-post cervical fusion, neuralgia, I wear a C-collar. Interventions: Locomotion-I use a manual wheelchair.Review of Resident #71's side rail/bed mobility/lift assessment dated [DATE] revealed in part.Level of Assistance: 34. What is the resident's level of assistance, 2-person assist=yellow dot #2. Approach: Transfer-(2) staff assistance support for my transfer.Observation and interview on 06/23/2026 at 9:41 a.m. with Resident #71 revealed a yellow circle with the #2 above his bed. Resident #71 stated he required 2 people to assist him with getting out of bed onto his wheelchair.Interview on 06/23/2026 at 12:44 p.m., S9 LPN stated Resident #71's biggest issue was transferring himself since his surgery prior to his admission to the facility. S9 LPN stated Resident #71 required 2-person assistance with all transfers.Observation on 06/24/2026 at 8:55 a.m., while standing on Hall W across from Resident #71's bedroom, revealed S4 CNA entering Resident #71's bedroom alone. At 9:11 a.m., S4 CNA was observed exiting Resident #71's room and wheeling Resident #71 to Hall W's shower room. An observation of Resident #71's bedroom at that time revealed a yellow circle above the head of his bed with the #2 listed on it.Interview on 06/24/2026 at 9:50 a.m., Resident #71 stated prior to S4 CNA entering his bedroom he was lying in bed. Resident #71 stated S4 CNA transferred him from his bed onto his wheelchair all by herself. Resident #71 stated he required 2 people to assist him for transfers from his bed to his wheelchair.Interview on 06/24/2026 at 9:51 a.m., S4 CNA stated she's been working here at the facility for 3 weeks. S4 CNA stated Resident #71 required 2-person assistance with transfers. S4 CNA stated she would review the signage above a resident's bed to see what type of transfer assistance was required. S4 CNA confirmed she didn't look at the signage above Resident #71's bed but knew he was a 2 person assist with all transfers. S4 CNA stated prior to bringing Resident #71 to the shower room on Hall W, he was lying in bed and she transferred him from his bed to his wheelchair by herself. When asked by surveyor why she got Resident #71 up by herself, S4 CNA shrugged her shoulders and stated, I don't know.Interview on 06/24/2026 at 2:04 p.m., S2 CNA Supervisor revealed Resident #71 required 2-person assistance with all transfers and all the CNAs working with him were aware of his transfer status. S2 CNA Supervisor stated that if S4 CNA was not sure of Resident #71's transfer status, she should have looked at his OBS, which was a yellow circle with a 2, which indicated 2-person assistance. S2 CNA stated she educated all CNAs daily in huddles about using the correct staff assist for all residents in the facility. Interview on 06/24/2026 at 9:30 a.m., S8 LPN stated Resident #71 required assistance with ADLs and was a 2-person transfer.Interview on 06/24/2026 at 2:10 p.m., S1 DON revealed that Resident #71's OBS and care plan both reflected he required 2-person assistance with transfers. S1 DON confirmed S4 CNA failed to follow Resident #71's care plan regarding requiring two person assist for transfers. #26Review of Resident #26's medical record revealed an admit date of 12/30/2025, with diagnoses that included, in part.Hemiplegia and Hemiparesis following Cerebral Infarction, Dementia, other Psychotic Disorder, Major Depressive Disorder, and Nicotine Dependence. Review of Resident #26's Quarterly MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 04/01/2026 revealed in part.Resident #26 had a BIMS (Brief Interview for Mental Status) score of 7, which indicated severe cognitive impairment. Review of Resident #26's Comprehensive Care Plan, with an initiation date of 12/30/2025 with a next review date of 06/30/2026 revealed in part.Resident #26 required supervision while smoking initiated on 01/30/2026.Observation on 06/23/2026 at 9:53 a.m. revealed Resident #26 was sitting in her wheelchair in the dining room. A small, circular hole which appeared to be a cigarette burn hole was observed in the cushion of Resident #26's wheelchair.Interview on 06/23/2026 at 11:40 a.m. with S2 CNA Supervisor revealed Resident #26 holds her own cigarettes, but she cannot have her lighter. S2 CNA Supervisor responded yes when asked if Resident #26 could smoke alone.Observation on 06/23/2026 at 11:41 a.m. with Resident #26 revealed while Resident #26 was smoking unsupervised, Resident #26 would close her eyes for approximately 15 seconds without smoking. During this time, the cigarette in her hand continued burning and developed a moderate amount of ash before Resident #26 reopened her eyes and resumed smoking. Resident #26 repeated the same behavior a second time. Additional cigarette ashes were observed on Resident #26's clothing.During an interview on 06/23/2026 at 12:32 p.m., with S1 DON and S12 ADON both confirmed Resident #26 had a cigarette hole in her wheelchair cushion. S1 DON and S12 ADON confirmed Resident #26's had been smoking unsupervised but should not have been, according to her care plan.

Based on record review and interview, the facility failed to promote and facilitate resident self-determination through support of resident choice about aspects of his or her life in the facility that were significant to the resident for 1 (#3) of 3 sampled residents. The facility failed to ensure Resident #3 had a choice of when to get out of bed. Findings: Review of the Facility's 12/2016 policy titled Resident Rights read in part. Employees shall treat all residents with kindness, respect, and dignity. 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident rights to: C. be free from abuse, neglect, misappropriation of property, and exploitation. D. be free from corporal punishment or involuntary seclusion, and physical or chemical restraints not required to treat the resident's symptoms. E. self-determination. G. exercise his or her rights as a resident of the facility and as a resident or citizen of the United States. Review of Resident #3's medical record revealed an admission to the facility on [DATE] with the following diagnoses in part.Unspecified Atrial Flutter, Type 2 Diabetes Mellitus, Morbid Obesity, Hypertensive Heart Disease, Vascular Dementia, and Acquired Absence of Left Leg above the Knee. Review of Resident #3's Quarterly MDS with ARD of 11/26/2025 revealed a BIMS score of 15 indicating intact cognition. Resident #1 was dependent on staff for transfers. Review of Resident #3's Care Plan with a review date of 02/20/2026 read in part.I have an ADL self-care performance deficit related to weakness due to morbid obesity and require the use of the lift system and a brown sling with 2 staff member assistance support for my transfer. In an interview on 01/27/2026 at 10:50 a.m., Resident #3 stated the weekend of 1/23/2026-01/25/2026 he was left in bed after repeatedly asking to get up and was told that there was no lift pads available or that the lift wasn't working. In an interview on 01/27/2026 at 11:45 a.m. S2CNA stated that she worked on 01/24/2025 from 6:00 a.m. to 10:00 p.m. and revealed the lifts on X hall were not working therefore Resident #3 was not gotten up out of the bed. S2CNA stated that Resident #3 had asked to get up on this shift but he was notified that the lifts were not working so he was not able to get up. S2CNA stated she made an attempt to get a lift from the other halls, but they were also not working. In an interview on 01/27/2026 at 12:45 p.m. S1Admin stated that he was made aware of lift issues the week of 01/18/2026 and had maintenance check all lifts, batteries and charging ports and all were working fine. S1Admin stated he was not aware that the X hall lift was not working over the weekend of 01/24/2026-01/25/2026 but was made aware of an issue with X Hall lift today (01/27/2026) but stated that the lift was working yesterday (01/26/2026). In an interview on 01/27/2026 at 1:50 p.m. S3CNA stated she worked the weekend of 01/23/2026 thought 01/25/2026 from 6:00 a.m. to 6:00 p.m. and stated the lifts were not working. S3CNA denied seeing Resident #3 out of bed during that weekend. In an interview on 01/27/2026 at 1:56 p.m., S4CNA stated she worked from 01/23/2026 thought 01/25/2026 and stated the residents that needed to be gotten up with a lifts were not, because of lift issues. S4CNA stated there had been frequent issues over the last 3 weeks and that staff could use the lifts from other halls but the batteries aren't being charged. S4CNA stated at times there was only 1 lift in the building working. S4CNA stated she cannot recall if Resident #3 got out of bed over the weekend of 01/23/2026 through 01/25/2026 but stated the only time he does not get out of bed is if we are having problems with the lifts, which has been often lately. In an interview on 01/28/2026 at 10:51 a.m., S5LPN stated that she knew Resident #3 did not get up out of bed over the weekend and did hear Resident #3 state I better get up on Monday. S5LPN stated she was unsure of how long the lift issues had been going on but knew there were an issues with keeping the batteries charged over the weekend of 01/24/2026 through 01/25/2026. In an interview on 01/28/2026 at 11:00 a.m., Resident #3's responsible party stated that over the last few weeks Resident #3 had called and notified him that there were issues with getting out of bed due to lift problems. Resident #3's Responsible Party stated that he spoke with nursing home administration today (01/28/2026) and was notified that there had been some lift issues In an interview on 01/28/2026 at 9:25 a.m., S1Admin confirmed no one reported issues with the lifts to him over the weekend of 01/23/2026-01/25/2026. S1Admin confirmed that if Resident #3 had requested to get out of bed over the weekend, staff should have utilized a working lift to assist the resident out of bed.

Based on observation and interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety by failing to:Ensure food, dish washer, refrigerator, and freezer temperatures were performed and recorded appropriately; and Ensure food was properly stored in the kitchen. This deficient practice had the potential to affect the 93 residents that received meals prepared in the kitchen. Findings:Review of the facility's undated policy titled, Prevention of Food Borne Illness read in part.Holding: Assure holding temperatures are maintained as needed for hot/cold foods. Measures temperatures using a calibrated thermometer and check temperatures at 2 hours intervals. Review of the facility's 10/2017 policy titled, Food Receiving and Storage read in part.Policy statement: Foods shall be received and stored in a manner that complies with safe food handling practices. Policy interpretation: 8. All foods stored in the refrigerator or freezer will be covered, labeled and dated ( received and/or open date). Review of the facility's 12/2014 policy titled, Refrigerators and Freezers read in part.Policy statement: This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitations, and will observe food expiration guidelines. Policy Interpretations: 3. Food service supervisors or designated employees will check and record refrigerator and freezer temperature daily with first opening and at closing in the evening. Review of the facility's 04/10/2014 policy titled, Dishwasher Use and Maintenance Household and Neighborhood and Log read in part.Dishwasher Log: 1. Run/record at least (1) dishwasher check before using machine at each mealtime. 4. Do not use dish washer until the temperature and chemical checks are within the required range. In an observation on 07/21/2025 at 6:15 a.m. of the walk-in freezer revealed 2 opened boxes of home style yeast roll dough open to air. Interview on 07/21/2025 at 10:15 a.m. S12 [NAME] confirmed all the above findings. Review of the facility's Daily Temperature Log revealed the following:No refrigerators x 2, freezer, or dishwasher temperatures were completed for 07/03/2025 07/04/2025, 07/05/2025, 07/06/2025, 07/08/2025, 07/09/2025, 07/10/2025, 07/11/2025, 07/12/2025, 07/13/2025, and 07/14/2025. No food temperatures were completed for dinner meal services on 07/11/2025 and 07/15/2025. Interview on 07/22/2025 at 10:50 a.m. with S12 [NAME] confirmed the all the above findings and stated the temperature checks were not completed appropriately, but should have been. S12 [NAME] stated she had not been monitoring the temperature logs to ensure they were completed appropriately by the dietary staff, but should have.

Based on observation, record review, and interview the facility failed to provide care and services that met professional standards of quality. The sampled residents were 31. The facility failed to: 1. Ensure proper physician orders were obtained for Resident #13's oxygen requirements.2. Ensure proper physician orders were obtained for Resident #36's rescue inhaler.3. Ensure Resident #36's rescue inhaler was stored in a safe and secure manner. Findings: Review of an undated facility policy on 07/23/2025 at 9:34 a.m. titled, Oxygen Administration revealed the following in part.The purpose of this procedure is to provide guidelines for safe oxygen administration. Verify that there is a physician's order for this procedure. Review the physician's orders or the facility protocol for oxygen administration. Review of a facility policy on 07/23/2025 at 9:34 a.m. titled, Storage of Medications with a revision date of 11/2020 revealed the following in part.The facility stores all drugs and biologicals in a safe, secure, and orderly manner. 1. Drugs and biologicals used in the facility are stored in locked compartments. Only persons authorized to prepare and administer medications have access to locked medications. Resident #13Review of Resident #13's medical record revealed an admission date of 07/09/2024, with diagnoses that included in part.Parkinson's Disease, Type II Diabetes Mellitus with other Specified Complication, Emphysema, and Schizophrenia. Review of Resident #13's admission MDS with an ARD of 07/14/2025 revealed a BIMS of 7, which indicated severe cognitive impairment. Resident #13 required total dependence with showering, bathing, and dressing and required partial/moderate assistance with personal hygiene.Review of Resident #13's current physician orders revealed orders for the following in part. -Oxygen at 2 liters per nasal cannula PRN O2 saturation less than 92% as needed for shortness of breath with a start date of 07/21/2025. -Resident #13 had no other current physician orders for oxygen therapy. Review of Resident #13's nursing progress notes revealed in part.Resident #13 received oxygen therapies on 07/20/2025: 4 liters nasal cannula; and 07/21/2025: 4 Liters nasal cannula. Observation on 07/21/2025 at 7:15 a.m. revealed Resident #13 with continuous oxygen therapy in progress. Observed oxygen settings at 4 liters via oxygen concentrator. Observation on 07/22/2025 at 1:45 p.m. revealed Resident #13 with continuous oxygen therapy in progress. Observed oxygen setting at 4 liters via oxygen concentrator. In an interview on 07/22/2025 at 2:15 p.m., S17 LPN revealed Resident #13 had continuous oxygen therapy in progress. S17 LPN confirmed Resident #13's oxygen settings were set at 4 liters via oxygen concentrator. In an interview and record review on 07/22/2025 at 3:16 p.m., S7 ADON revealed Resident #13's current physician's orders reflected an order for oxygen at 2 liters per nasal cannula as needed for shortness of breath or oxygen saturation less than 92%. S7 ADON confirmed there were no current physician orders for Resident #13 to have a continuous flow of 4 liters of oxygen via concentrator. S7 ADON confirmed the nurse should have obtained the required oxygen orders prior to applying a continuous flow of 4 liters of oxygen for Resident #13, but did not. Resident #36Review of Resident #36's medical record revealed an admission date of 07/08/2024, with diagnoses that included in part. Systolic (Congestive) Heart Failure, Non-St Elevation (Nstemi) Myocardial Infarction, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, Cerebral Infarction, And Chronic Obstructive Pulmonary Disease. Review of Resident #36's admission MDS with an ARD of 07/15/2025 revealed a BIMS of 15, which indicated intact cognition. Review of Resident #36's current physician orders (as of 07/21/2025) revealed no orders for any inhalers. Review of Resident #36's care plan with an initiated date of 07/10/2025 revealed in part.Problem: I have COPD. Approaches: I will receive aerosol or bronchodilators as ordered. Monitor/document any side effects and effectiveness. In an interview on 07/21/2025 at 8:14 a.m., with Resident #36 revealed that she uses her rescue inhaler daily every day since she admitted to the facility on [DATE]. Resident #36 stated the nurses know and do not help her with administering her inhaler. An inhaler was observed on the resident's bedside dresser at the time of interview. In an interview on 07/22/2025 at 3:02 p.m., with Resident #36 revealed she gave herself the rescue inhaler today. Resident #36 stated the doctor gave her orders to take the inhaler every day and she kept it at her bedside. Observation revealed an inhaler on the resident's bedside dresser. In an interview and record review on 07/22/2025 at 3:06 p.m., S17 LPN revealed she did see an inhaler on Resident #36's bedside dresser today. S17 LPN confirmed Resident #36 did not have current physician orders for a rescue inhaler. S17 LPN confirmed that there should had been physician orders obtained for Resident #36's rescue inhaler and the inhaler should had been stored/locked in the medication box, but was not. In an interview and record review on 07/22/2025 at 3:16 p.m., S7 ADON revealed the facility does not allow any residents to self-administer medications during their stay. S7 ADON confirmed Resident #36 did not have current physician orders for a rescue inhaler. S7 ADON confirmed that the inhaler should had been reconciled upon admission to the facility and correct doctor orders obtained for the inhaler, but was not. S7 ADON confirmed Resident #36's inhaler should not be stored at the bedside when not in use.

Based on observation, interview, and record review the facility failed to provide respiratory care consistent with professional standards for 2 (#55, and #87) of 5 (#13, #22, #38 #55, and #87) residents reviewed for respiratory care. The facility failed to:1.Store nebulizer mask appropriately for Resident #55; and2. Ensure oxygen was given or set at prescribed rate for Resident #87.Findings:Resident #87 Review of the facility’s undated policy entitled “Oxygen Administration” revealed, in part…staff is to verify there is a physician’s order for oxygen administration and provide oxygen at the prescribed flow rate. Review of Resident #87’s medical record revealed an admission date of 04/03/2023 with diagnoses including Chronic Obstructive Pulmonary Disease and Shortness of Breath. Review of Resident #87’s Quarterly MDS with an ARD of 04/30/2025 revealed a BIMS Score of 15, indicating intact cognition. Review of Resident #87’s physician’s orders revealed oxygen at 2 LPM per NC was ordered on 03/28/2025. Observation of Resident #87 on 07/21/2025 at 11:00 a.m. revealed the resident’s oxygen flowmeter was set between 2.5 and 3 LPM. Observation of Resident #87 on 07/22/2025 at 9:32 a.m. revealed the resident’s oxygen flowmeter was set between 2.5 and 3 LPM. Observation of Resident #87 on 07/22/2025 at 11:10 a.m. accompanied by S1LPN revealed the resident’s oxygen flowmeter was set between 2.5 and 3 LPM. S1LPN confirmed Resident #87’s oxygen flowmeter should have been set at 2 LPM, but was not. Review of the Facility undated policy titled “Administering Medications Through a Small Volume Nebulizer” read in part….Steps in procedure: When equipment is completely dry, store in a plastic bag with the residents name and the date on it. Resident #55 Review of Resident #55's medical record revealed an admit date of 09/03/2021 with diagnoses that included: Unspecified Sequelae of Unspecified Cerebrovascular Disease, Atherosclerotic Heart Disease, Schizoaffective Disorder, Bipolar Type, Dysphagia, Epilepsy, Unspecified Dementia, and Heart Failure. Review of Resident #55’s 07/2025 Physician Orders read in part….06/23/2025 Albuterol Solution 2.5 mg/3ml inhale orally via nebulizer every 6 hours as needed for shortness of breath. Review of Resident #55’s Care plan with a review date of 10/14/2025 read in part… I have potential for altered respiratory status related to allergic rhinitis and potential for shortness of breath. Interventions: Nebulizer as ordered, change nebulizer mask and tubing as ordered, and monitor oxygen saturation as ordered. In an observation on 07/21/2025 at 1:09 p.m., Resident #55’s Nebulizer mask was observed sitting on the dresser, on top of nebulizer machine, not bagged and open to air. In an observation on 07/22/2025 at 9:24 a.m., Resident #55’s Nebulizer mask was observed sitting on the dresser, on top of nebulizer machine, not bagged and open to air. Interview on 07/22/2025 at 1:14 p.m. with S11 LPN confirmed that the nebulizer mask was left open to air, but should not have been.

Based on observation, interview, and record review, the facility failed to ensure residents who are unable to carry out ADLS (Activities of Daily Living) received the necessary services to maintain good personal hygiene for 2 (#61 and #77) of 3 (#11, #61, and #77) residents reviewed for ADL care. The facility failed to ensure oral care was provided for Resident #61; and Bath/Shower was provided for Resident #77. Findings:Review of the facility's policy dated 03/2018 titled Activities of Daily Living, Supporting read in part Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADL's). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal/oral health. Resident #61 Review of Resident #61's medical record revealed an admission date of 01/31/2020 with diagnoses that included: Hemiplegia and Hemiparesis following Cerebral Infarction affecting left non-dominant side, Spinal Stenosis, Dysphagia, and Disturbance of Salivary Secretions Review of Resident #61’s Quarterly MDS with ARD of 06/18/2025 revealed a BIMS of 03, indicating severely impaired cognition. Resident #61 required substantial/max assistance with oral hygiene and dependent on staff for personal hygiene. Review of Resident #61's care plan with a review date of 10/01/2025 read in part Problem: have an ADL self-care performance deficit. Approach: I require extensive assistance by (1) staff with personal hygiene and oral care. Problem: I have potential for oral/dental health problems related to poor hygiene/condition. Approach: I will be provided mouth care as per ADL personal hygiene. Observation on 07/21/2025 at 8:01 a.m. revealed Resident #61’s was observed lying in bed awake but unable to answer questions when asked. Resident #61 was observed with a large amount of brown and yellow build up to teeth, lips, and gums. Interview on 07/21/2025 at 1:08 p.m. with S13 CNA revealed that she provided oral care this morning but resident has a lot of buildup in his mouth. S13 CNA stated that Resident #61 does not refuse oral care. Observation on 07/22/2025 at 9:40 a.m. revealed Resident #61 continued with a large amount of dried, stuck on brown and yellow build up on teeth. Observation on 07/22/2025 at 1:30 p.m. revealed Resident #61 continued with large amount of dried, yellow and brown build up on teeth. Observation on 07/22/2025 at 1:35 p.m. of S14 CNA providing oral care with S2 DON present. S14 CNA removed a significant amount of yellow/brown buildup from teeth with mouth swabs and water, while some buildup still remained. S14 CNA stated it was dried and she didn't want to rub too hard and make Resident #61’s gums bleed. S14 CNA stated she will attempt with a wash cloth. In an interview on 07/22/2025 at 1:45 p.m., S2 DON confirmed that oral care for Resident #61 did not appear to have been provided after observation of oral care, but should had been done. S2 DON stated that she will be initiating an in service on oral care. Resident #77 Review of Resident #77’s medical record revealed an admit date of 11/12/2024 ….with diagnoses that included in part…Type 2 Diabetes Mellitus without complications, Alzheimer’s Disease, UTI, Dysphagia, Unspecified dementia-mild with mood disturbance, Major depressive disorder, Essential hypertension, Hyperlipidemia, Constipation, Vitamin D deficiency, Other seizures. Review of Resident #77’s Quarterly MDS with an ARD of 05/07/2025 revealed a BIMS of 14, which indicated intact cognition. Further review of MDS revealed Resident #77 required partial/moderate assistance with bathing, supervision or touching assistance with toileting, set-up or clean-up assistance with transfers and bed mobility, and resident was independent with eating. Review of Resident #77’s care plan with a start date of 11/12/2024 revealed she was care planned for assistance with adls and required limited assist of 1 person with bathing. Review of the CNA tasks revealed no documentation of bathing Resident #77 since 07/15/2025. In an interview with Resident #77 on 07/22/2025 at 9:10 a.m., she stated she had not received a bath or bed bath in 7 days. She stated she had not been offered a bath. Observed there were no toiletries in resident’s room. In an interview on 07/22/2025 at 9:45 a.m., S15 CNA stated Resident #77 cannot go to whirlpool because she was on isolation and stated she was independent and can do everything herself. In an interview on 07/22/2025 at 9:45 a.m., S16 CNA stated non skilled residents get bed baths every other day and Resident #77 was independent. In an interview on 07/22/2025 at 3:15 p.m., S7 ADON acknowledged there wasn’t any documentation of Resident #77 getting a bath in over a week. S7 ADON stated when she asked CNA about bathing Resident #77, the CNA stated, “She’s in isolation.” S7 ADON stated she had to explain to CNAs that residents in isolation still require baths, just like COVID patients did. S7 ADON acknowledged that Resident #77 had not been bathed in a week.

Based on observations, record review, and interviews, the facility failed to implement the care plan for 2 (#5 and #13) of 31 sampled residents. The facility failed to: 1. Place an assist rail to the left side of Resident #5's bed, ensuring the resident could reposition himself as needed to maintain bed mobility as indicated on the patient-centered care plan; and2. Use ear protectors on Resident #13's nasal cannula as indicated in the resident's care plan. Findings: Review of a facility policy on 07/23/2025 at 9:34 a.m. titled, “Care Plans, Comprehensive Person-Centered” with a revision date of 03/2022 revealed the following part…A comprehensive, person-centered care plan that includes measurable objective and timetables to meet the resident’s physical, psychosocial and functional needs is developed and implemented for each resident. G. Receive the services and/or items included in the plan of care. Resident #13 Review of Resident #13’s medical record revealed an admission date of 07/09/2024, with diagnoses that included in part…Parkinson’s Disease, Type II Diabetes Mellitus with other Specified Complication, Emphysema, and Schizophrenia. Review of Resident #13’s admission MDS with an ARD of 07/14/2025 revealed a BIMS of 7, which indicated severe cognitive impairment. Resident #13 required total dependence with showering, bathing, and dressing and required partial/moderate assistance with personal hygiene. Review of Resident #13’s current physician orders revealed orders for the following in part… -Oxygen at 2 liters per nasal cannula PRN O2 saturation less than 92% as needed for shortness of breath with a start date of 07/21/2025. -Treatment #13: Pressure, medical device related, stage 1, front right ear-cleanse with wound cleanser and 4X4 gauze, pat dry, apply Betadine, leave open to air (OTA) with an order date of 07/21/2025. Review of Resident #13’s care plan with an initiated date of 07/09/2025 revealed the following part…Problem: (date initiated 07/21/2025) I have a pressure ulcer related to oxygen tubing- Treatment #13: 07/21/2025 pressure, medical device related injury (MDRI), stage 1, front right ear. Approaches: (date initiated 07/21/2025) Nasal cannula ear cushions. Review of Resident #13’s nursing progress notes revealed in part…Resident #13 received oxygen therapies via nasal cannula on 07/19/2025, 07/20/2025, 07/21/2025, and 07/22/2025. Observation on 07/21/2025 at 7:15 a.m. revealed Resident #13 with oxygen therapy in progress. Resident #13 was observed with redness behind bilateral ears and no ear protectors/cushions were observed to the nasal cannula. Observation on 07/22/2025 at 1:45 p.m. revealed Resident #13 with oxygen therapy in progress. Resident #13 was observed with redness behind bilateral ears and no ear protectors/cushions were observed to the nasal cannula. In an interview on 07/22/2025 at 2:15 p.m., S17 LPN revealed Resident #13 had oxygen therapy in progress. S17 LPN confirmed Resident #13 had no ear cushions applied to his nasal cannula and he had redness behind bilateral ears. S17 LPN confirmed Resident #13 should have had bilateral ear cushions applied to his oxygen tubing, but did not. In an interview on 07/22/2025 at 2:45 p.m., S4 RN Wound Care revealed she was aware of the redness behind Resident #13’s bilateral ears and verified that the right ear had a medical device acquired injury (stage 1 pressure injury). S4 RN Wound Care confirmed that she care-planned for Resident #13 to have ear cushions applied to his oxygen tubing, but the ear cushions were not in place. Findings: Resident #5 Review of Resident #5’s medical record revealed an admit date of 05/20/2025 with diagnoses including Intraspinal Abscess and Granuloma, Cutaneous Abscess of Back, PVD, COPD, A-Fib, Pressure Ulcers, and Edema. On 07/21/2025 at 6:35 a.m., Resident #5 was observed lying on his back with the head of the bed elevated with an assist rail on the right side of the bed and a trapeze bar above the bed. The resident stated he can reposition himself. He also stated that the staff does not come routinely or every two hours to help reposition him. The resident stated that he can use the assist rail on the right side and the trapeze above the bed and had requested an assist rail for the left side of the bed. The resident demonstrated that the trapeze is loose, and he states that he has been told the left assist rail had been ordered. Review of Resident #5’s current care plan revealed a problem section for “ADL self-care performance deficit” initiated on 08/1/2022 and revised on 6/24/2025. Interventions revealed: “Bed Mobility: I require total dependent x 2, trapeze to assist with bed mobility and bilateral side rails.” This task has an initiated date of 08/01/2022 and a revision date of 05/08/2025. In an interview on 07/22/2025 at 10:34 a.m., S2 MDS confirmed Resident #5’s bed should have two assist rails. S2 MDS stated that the request was sent to maintenance on 07/09/2025. S2 MDS stated S8 MDS, texted the maintenance supervisor, S9 Maintenance, to install an additional assist rail on the left side of Resident #5’s bed. On 07/22/2025 at 11:02 a.m., S9 Maintenance was asked if he knew about Resident #5’s bed needing a left side rail. S9 Maintenance stated he was told about the assist rail need “a couple of days ago.” S9 Maintenance was asked if he could produce the order for a new left side rail for the resident’s bed. S9 Maintenance stated that there would not be an order because he would just take the assist rail from another bed frame that was not in use currently. S9 Maintenance was asked why he hadn’t done this yet, he stated that he “forgot about it.” In an interview on 07/22/2025 at 3:50 p.m., S6 DON and S7 ADON both confirmed that Resident #5’s care plan had two assist rails specified and the resident should have had two assist rails on each side of bed and did not.

Based on record review and interview, the facility failed to ensure the physician documented a clinical rationale for a denial of a gradual dose reduction for 2 (#30 and #77) of 5 (#6, #30, #55, #77, and #79) sampled residents reviewed for unnecessary medications. The facility failed to ensure the physician documented on the Pharmaceutical Consultant Report a clinical rationale for not reducing psychoactive medications recommended for gradual dose reduction (GDR). Findings: Review of a facility policy on 07/23/2025 at 9:34 a.m. titled, “Psychotropic and Antipsychotic Medications and Non-Pharmacological Intervention” with an effective date of 01/2025 revealed in part…Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. Residents should only receive psychotropic medications when other non-pharmacological interventions have been attempted and/or have been documented as being clinically contraindicated. Gradual Dose Reductions: Residents must only remain on psychotropic medications when gradual dose reduction and behavioral interventions (non-pharmacological interventions) have been attempted and/or deemed clinically contraindicated. Resident #30 Review of Resident #30’s medical record revealed an admission date of 03/06/2024 with diagnoses that included in part… Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris, Chronic Diastolic (Congestive) Heart Failure, Atrial Fibrillation, and Depression. Review of Resident #30’s current physician orders revealed an order for Trazodone HCl Tablet 50 mg by mouth at bedtime related to depression with a start date of 05/19/2025. Review of Resident #30’s Quarterly MDS with an ARD of 06/11/2025 revealed the resident received antidepressants and had a BIMS of 13, which indicated intact cognition. Review of Resident #30’s “Pharmaceutical Consultant Report Psychoactive Gradual Dose Reduction” form completed on 03/28/2025 revealed the pharmacy consultant requested a gradual dose reduction for Trazodone HCL 50mg tablet. The report read in part…Note to Physician: According to CMS Interpretive Guidelines for Long Term Care Facilities, justification for not reducing a psychoactive must be documented. Further review of the document revealed, the physician did not document if a dose reduction was appropriate or a clinical rationale for the psychotropic medication. In an interview and record review on 07/22/2025 at 3:16 p.m., S7 ADON revealed Resident #30 currently received Trazodone HCL 50mg tablet at bedtime related to depression. S7 ADON confirmed the GDR written on 03/28/2025 for Resident #30 did not have documentation regarding if the dose reduction was appropriate or a documented clinical rationale, but should have. Resident #77 Review of Resident #77’s medical record revealed an admit date of 11/12/2024 with diagnoses that included in part…Type 2 Diabetes Mellitus without complications, Alzheimer’s Disease, UTI, Dysphagia, Unspecified Dementia-mild with mood disturbance, Major Depressive Disorder, Essential Hypertension, Hyperlipidemia, Constipation, Vitamin D deficiency, and other Seizures. Review of Resident #77’s Quarterly MDS with an ARD of 02/01/2024 revealed a BIMS of 14, which indicated intact cognition. Further review of MDS revealed Resident #77 had no behaviors. Resident #77 received an antipsychotic and an antidepressant medication. Review of Resident #77’s care plan with a start date of 11/12/2024 revealed in part she was care planned for impaired cognitive function/dementia or impaired thought processes r/t Alzheimer's Dementia and Potential for behavior problem related to dementia, mild with mood disturbances, attention seeking behaviors, gets upset when unable to complete sentences… Review of Resident #77’s Physician’s orders revealed the following: Aripiprazole tablet 2 mg by mouth one time a day Sertraline HCL Oral tablet 100 mg by mouth one time a day Review of the Pharmaceutical Consultant Report that was sent to NP on 05/26/2025 revealed the following: The Pharmacy Consultant Note to Physician read: According to CMS Interpretive Guidelines for Long Term Care Facilities, justification for not reducing a psychoactive must be documented either on this form or within the clinical record in order to be considered “clinically contraindicated” as to why the reduction is not desired at this time. Review of the 05/26/2025 GDR revealed no documentation was noted for the questions of: Is a dose reduction appropriate, and is the dose a minimal effective dose. Further review revealed the NP failed to provide a handwritten clinical rationale explaining why a dose reduction would be clinically contraindicated. The facility NP documented “continue current plan of care.” Review of the Pharmaceutical Consultant Report that was sent to NP on 11/24/2024 revealed the following: The pharmacy consultant Note to Physician read: According to CMS Interpretive Guidelines for Long Term Care Facilities, justification for not reducing a psychoactive must be documented either on this form or within the clinical record in order to be considered “clinically contraindicated” as to why the reduction is not desired at this time. Upon reviewing the 11/24/2024 GDR, it was checked “no” for question of was a dose reduction appropriate and checked “yes” to Minimal Effective Dose. Facility NP failed to provide a handwritten clinical rationale explaining why a dose reduction would be clinically contraindicated. Review of the Pharmaceutical Consultant Report that was sent to NP on 11/12/2024 revealed the following: The pharmacy consultant Note to Physician read: According to CMS Interpretive Guidelines for Long Term Care Facilities, justification for not reducing a psychoactive must be documented either on this form or within the clinical record in order to be considered “clinically contraindicated” as to why the reduction is not desired at this time. Upon reviewing the 11/12/2024 GDR, no documentation was noted for the questions of is a dose reduction appropriate and is the dose a Minimal Effective Dose. NP failed to provide a handwritten clinical rationale explaining why a dose reduction would be clinically contraindicated. The facility NP documented “no changes.” Review of Resident #77’s 05/30/2025 Psychiatric NP progress notes revealed in part…No changes. Diagnoses were Dementia, mild without behaviors and Major Depression. No clinical rationale was provided for not attempting a GDR. Review of Resident #77’s MD progress notes from 06/02/2025 and 07/02/2025 revealed no rationales for continued medication therapy of Aripiprazole and Sertraline HCL. Review of Resident #77’s NP progress notes from 05/14/2025 and 07/14/2025 revealed no rationales for continued medication therapy of Aripiprazole and Sertraline HCL. Interview with S6 DON on 07/23/2025 at approximately 3:00 p.m., acknowledged Resident #77 had no GDR attempted and no physician rationale listed on GDR requests or medical record as required. S6 DON stated Resident #77 had been on both of these medications since she was admitted to the facility.

Based on interview and record review, the facility failed to ensure a resident was free from staff to resident verbal abuse for 1 (Resident #4) of 9 (#1, #2, #3, #4, R1, R2, R3, R4, and R5) sampled residents investigated for abuse. Resident #4, a cognitive residents, experienced mental anguish and psyshosocial harm as a result of the verbal abuse by staff. This deficient practice resulted in an actual harm on 02/11/2025 at 10:00 a.m., when S3 CNA told Resident #4, Shut the F*** up and F*** this Sh**! during ADL care (showering). Resident #4 stated this caused him mental anguish and psychosocial harm/emotional distress, as he felt disrespected, insulted, and pissed off that S3 CNA cursed and spoke to him in that way. Resident #4 reported the incident to staff and told them he did not want S3 CNA in his room again. Findings: Review of the facility's policy on 02/26/2025 at 4:03 p.m. titled, Abuse Components Plan, Elder Justice Act and Affordable Care Act, with an effective date of 10/24/2022, read in part .Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish .It includes verbal abuse, sexual abuse, physical abuse, and mental abuse. Review of the facility's employee Relias Training course on 02/26/2025 at 4:03 p.m. titled, Abuse, Neglect, and Exploitation dated 00/00/2022 read in part .Mental Abuse can be verbal or non-verbal .Mental Abuse includes: Humiliating .Verbal Abuse is a type of Mental Abuse. It includes: Mocking or ridiculing, yelling, threatening to withhold contact from others, and scolding .these actions are Verbal Abuse even if the resident does not understand what the person says. Review of Resident #4's medical record revealed an admitted [DATE], with diagnoses that included in part .Myotonic Muscular Dystrophy, Abdominal, Anxiety Disorder, Chronic Inflammatory Demyelinating Polyneuritis, Muscular Dystrophy, Major Depressive Disorder, Recurrent, Severe with Psychotic Symptoms, and Anxiety Disorder. Review of Resident #4's Quarterly and State Optional MDS with an ARD of 01/01/2025, revealed a BIMS score of 14, which indicated cognition was intact. Resident #4 required total dependence with two person physical assistance with bed mobility, toilet use, and transfers. Review of Resident #4's care plan with a start date of 01/24/2025, revealed the following the part . -Problem: I have an ADL-self-care performance deficit, wheelchair bound with diagnosis of Muscular Dystrophy. Interventions included bathing/showering - I am totally dependent on one staff to provide bath/shower, with a start date of 11/01/2018. -Problem: Potential for Depression. Interventions included - may see LCSW of choice with a start date of 11/03/2023, and psych visits as needed/scheduled with a start date of 08/31/2021. Review of a Visitation/Progress Note completed by S9 Social Worker on 02/20/2025, revealed the following in part .Resident #4 mentioned that he had not been feeling good recently. He expressed that he's been having rough days and did not feel good after recent events .reports an incident with a staff member who said ugly things and she got fired .I didn't want her to get fired but she did it to herself. Review of a facility report completed by S1 Administrator titled, Grievance: Other dated 02/11/2025 at 10:15 a.m., revealed the following in part .Grievance dated 02/11/2025 for Resident #4: Resident Description: Nurse Aide Supervisor reported to DON and Administrator that resident just complained that a particular nurse aide did not know how to do her job, and that he wanted her wrote up for telling him to Shut the F*** up. Notes: 02/11/2025: Resident has a BIMS of 14, cognitively intact. Administrator and DON met with resident to discuss incident. Resident verified identity of aide and witnesses. Resident stated that aide did not cover the bed sheets and they were getting wet after his shower. Resident stated that he wanted her written up because she told him to shut the F*** up when he said she did not know how to do her job. Review of a written statement completed by S6 CNA on 02/11/2025, revealed the following in part .I, S6 CNA, was helping S3 CNA do Resident #4, getting him out of the shower, and Resident #4 said that you don't know your job. S3 CNA said Shut the F*** up, I know my job. Review of a written statement completed by S8 Treatment Nurse on 02/11/2025, revealed the following in part .While I was doing treatments down Hall X, S3 CNA requested my assistance in Resident #4's room. Verbal conflict with resident to aide continued the entire time of patient care, resident repeatedly called out S4 CNA Supervisor's name. Review of a written statement completed by S3 CNA on 02/11/2025, revealed the following in part .I was showering Resident #4. Once he was done he told me I needed to cover the sheets because they was going to get wet. I already did that, and I explained that to him. He proceeded to say I didn't. I told him once again I did and this is not my first time taking care of him. I know how to do my job. He then told me I don't. I'm retarded, I'm dumb and slow. I told him I wasn't and that was not nice. I stepped out and asked S8 Treatment Nurse to assist for a witness because he (Resident #4) asked for S4 CNA Supervisor. In an interview on 02/26/2025 at 10:12 a.m., S4 CNA Supervisor revealed in part .recently (about 2 weeks ago-could not remember the exact date) there was a situation where a CNA was terminated for verbal abuse. The verbal abuse was from the CNA to a resident. S4 CNA Supervisor could not remember the details of the verbal abuse incident or the CNA and Resident involved because she was out of the facility at that time. S4 CNA Supervisor stated that S2 DON and S5 ADON investigated the verbal abuse incident. In an interview on 02/26/2025 at 10:35 a.m., S2 DON revealed she was not aware of any verbal abuse situations, or SIMS reports in the last two weeks - four weeks. S2 DON stated there were no verbal abuse allegations reported or investigated. S2 DON stated that she was alerted by S4 CNA Supervisor via telephone and was told of a situation. S2 DON stated she and S1 Administrator interviewed S3 CNA in the administrative office. S3 CNA stated Resident #4 was having an episode and S3 CNA fussed at him because he wanted the bedding changed. S2 DON stated S1 Administrator sent S3 CNA home on suspension pending the investigation. S2 DON said she and S1 Administrator then interviewed Resident #4, and he stated that S3 CNA said F*** you, during his shower. S2 DON stated she and S1 Administrator terminated S3 CNA via telephone for unprofessional interaction with a resident. S2 DON stated they did not classify this as verbal abuse, and did not report the incident. S2 DON stated they filed it as a facility Other Grievance. S2 DON stated she could not remember the actual date and time of the event because there was no abuse incident report. In an interview on 02/26/2025 at 11:20 a.m., Resident #4 revealed he remembered the incident with S3 CNA very well. Resident #4 stated it happened on 02/11/2025 before 10:00 a.m., when S3 CNA told him, F*** you and F*** this S***! during his shower on that day. Resident #4 revealed that S3 CNA had an attitude and was mad the entire time of the shower because she did not want to shower him. Resident #4 revealed that he felt disrespected, insulted, and pissed off that S3 CNA cursed and spoke to him in that way. Resident #4 stated that he hollered out for S4 CNA supervisor during that time, but S4 CNA Supervisor did not come. Resident #4 stated that he did not know S3 CNA very well and she should have never spoken to him like that. Resident #4 stated that S6 CNA and S8 Treatment Nurse were in the room assisting S3 CNA during the incident. Resident #4 stated that this had never happened to him from any other staff members, and was the first time. Resident #4 revealed that he was upset that it even happened to him. He stated that S3 CNA left his room after he was put back to bed and the situation was over. Resident #4 stated that S5 ADON, S2 DON, and S1 Administrator came to his room to talk to him later that day. Resident #4 stated that he was told by S1 Administrator that S3 CNA was sent home on suspension. In a telephone interview on 02/26/2025 at 12:37 p.m., S6 CNA revealed that she witnessed the situation with Resident #4 on 02/11/2025 at about 10:00 a.m. S6 CNA stated S3 CNA asked her on Hall X to assist with showering Resident #4. S6 CNA stated she went into the resident's shower stall and Resident #4 was upset about his neck placement, and he told S3 CNA to adjust his neck. S6 CNA confirmed that at this time, S3 CNA stated to the resident, Shut the F*** up, F*** this shit, and I know how to do my job! S6 CNA stated she immediately left the resident's room and told the closest CNA on the hall, which was S7 CNA. S6 CNA stated that S7 CNA then phoned S4 CNA Supervisor and reported what S3 CNA said to Resident #4. In an interview on 02/26/2025 at 12:40 p.m., S7 CNA revealed that on 02/11/2025 at about 10:00 a.m., she was alerted by S6 CNA that S3 CNA cursed out Resident #4 during his shower. S7 CNA immediately called S4 CNA Supervisor and reported the situation. S7 CNA revealed that she cared for Resident #4 the rest of the day, and he was still upset about the situation that occurred earlier in the day. S4 CNA stated that Resident #4 kept telling her to not let S3 CNA back in his room. In a telephone interview on 02/26/2025 at 1:30 p.m., S8 Treatment Nurse revealed that she was present on 02/11/2025 at about 10:00 a.m. when the situation happened with Resident #4. S8 Treatment Nurse stated that she did assist S3 CNA briefly with supervising Resident #4 in the shower and then dressing. S8 Treatment Nurse stated she remembered Resident #4 hollering out for S4 CNA Supervisor. S8 Treatment Nurse stated that Resident #4 was very upset at this point. S8 Treatment Nurse stated she did not hear any cursing from S3 CNA during her interactions; however, S8 Treatment Nurse was not present in the shower and bedroom the entire time. In a telephone interview on 02/26/2025 at 1:45 p.m., S9 Social Worker revealed in part .she visited with Resident #4 on 02/20/2025, during her routine rounds, and he brought to her attention a recent incident that occurred with a CNA who cursed at him and that she was fired. In an interview on 02/26/2025 at 2:00 p.m., S2 DON revealed in part .she was alerted by S4 CNA Supervisor via telephone at about 10:00 a.m. on 02/11/2025 .she revealed that during her investigation of the incident, Resident #4 complained about wet linens, how S3 CNA could not do her job, and how S3 CNA cursed at him. S2 DON stated that Resident #4 had a louder tone and voice during this interview. S2 DON stated she could not remember if she contacted S10 NP, but she must have, because she got the order for psychosocial monitoring every shift for Resident #4. S2 DON stated she did not consider cursing a resident as verbal abuse; however, she considered it as an unprofessional interaction. S2 DON confirmed that she does not expect staff to curse at residents, and the incident with S3 CNA and Resident #4 should not have happened. In an interview on 02/26/2025 at 2:16 p.m., S1 Administrator revealed in part .he was alerted on 02/11/2025 in the morning by S2 DON of the situation with Resident #4. S1 Administrator stated he, S2 DON, and S5 ADON started an investigation. S1 Administrator stated during an interview with Resident #4, he (Resident #4) was mad, and told S1 Administrator that S3 CNA cursed him saying, F*** you, and F*** this S***! during his shower. S1 Administrator stated he, S2 DON, and S5 ADON obtained S3 CNA's statement, and then sent her home on suspension. S1 Administrator stated this was not verbal abuse, and referred to a facility form dated 00/00/2018 and stated, Because the resident did not have psychosocial harm, it was not verbal abuse, and not a reportable event. S1 Administrator stated he telephoned S9 Social Worker on 02/11/2025, who said she was going to visit Resident #4 on her next rounds (02/20/2025). S1 Administrator stated that S9 Social Worker determined there was no psychosocial harm when she saw Resident #4 on 02/20/2025, 9 days after the incident. S1 Administrator revealed that no in-servicing of staff was completed post event and he did not notify S10 NP nor S11 MD. S1 Administrator denied this event being verbal abuse or a reportable event. S1 Administrator confirmed the incident did occur and confirmed S6 CNA witnessed S3 CNA tell Resident #4 to Shut the F*** up.

Based on record review and interview, the facility failed to ensure an incident of abuse was reported immediately, but not later than 2 hours after the allegation was made, to the State Survey Agency in accordance with state law for 1 (#4) of 9 (#1, #2, #3, #4, R1, R2, R3, R4, and R5) residents reviewed for abuse The provider failed to report staff to resident verbal abuse for Resident #4. Findings: On 02/26/2025, a review of the facility's policy titled Abuse Components Plan, Elder Justice Act and Affordable Care Act with an effective date of 10/24/2022 read in part .Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish It includes verbal abuse, sexual abuse, physical abuse, and mental abuse . Reporting: All alleged violations involving abuse, neglect, exploitation, mistreatment .will be reported by the Administrator or designee, to the following persons or agencies as required to provide notification: a. LDH online tracking system, Statewide Incident Tracking System (SIMS). b. An alleged violation involving abuse, neglect, exploitation, mistreatment, injuries of unknown source, misappropriation of property/funds, and/or any other reportable incident will be reported immediately, but no later than: a. Two (2) hours if the alleged violation involves abuse or has resulted in serious bodily injury; or b. Twenty four (24) hours if the alleged violation does not involve abuse . Review of Resident #4's medical record revealed an admitted [DATE] with diagnoses that included in part .Anxiety and Major Depressive Disorder. Review of Resident #4's Quarterly MDS with an ARD of 01/01/2025 revealed a BIMS score of 14, which indicated the resident was cognitively intact. Review of the MDS revealed Resident #4 was dependent with eating, showering/bathing, rolling left or right, sitting to lying, lying to sitting on side of bed, and chair/bed to chair transferring. Review of a grievance dated 02/11/2025 revealed . Resident Description: Nurse Aide Supervisor reported to DON and Administrator that resident just complained that a particular nurse aide (S3 CNA) did not know how to do her job and that he wanted her wrote up for telling him to Shut the f___ up. In an interview on 02/26/2025 at 11:20 a.m., Resident #4 stated S3 CNA cursed at him. Resident #4 reported S3 CNA had an attitude because she had to give him a shower. Resident #4 stated he told her she was getting his sheets wet and she started cursing him. Resident #4 reported S3 CNA told him to Shut the f___ up and F___ this sh__. Resident #4 stated this made him feel mad and disrespected. Resident #4 stated he told administration he didn't want her in his room anymore. In an interview on 02/26/2025 at 2:20 p.m., S1 Administrator confirmed S3 CNA cursed Resident #4 and confirmed it was witnessed by another CNA. S1 Administrator reported he did not report this incident to the State Agency because he did not feel it met the definition of abuse because Resident #4 did not show evidence of psychological harm. S1 Administrator reported the incident was not abuse, but an unprofessional interaction with a resident by staff. S1 Administrator confirmed the incident was never reported to the State Agency and a SIMS was never completed.

Based on interview and record review the facility failed to ensure Resident #1's Responsible Party (RP) was informed of changes in the resident's condition for 1 (Resident #1) of 3 (Resident #1, Resident #2 and Resident #3) sampled residents. Findings: Review of the facility's policy titled Change in a Resident's Condition or Status read in part . Our facility promptly notifies the resident, his or her attending physician and the resident representative of changes in the resident's medical/mental condition and/or status in a timely manner. Review of Resident #1's clinical record revealed an admitted [DATE] with diagnoses that included Alzheimer's disease with late onset, Generalized Anxiety Disorder (GAD), Major Depressive Disorder, Recurrent, Insomnia and Dementia, unspecified severity with other behavioral disturbance. Review of Resident #1's Annual MDS Assessment with an ARD of 07/03/2024 revealed a BIMS score of 3 indicating severe cognitive impairment. Resident #1 received antianxiety and antidepressant medications. Review of Resident #1's Quarterly MDS with an ARD of 05/29/2024 revealed a BIMS score of 3, indicating severe cognitive impairment. Resident #1 received antidepressant medications. Review of Resident #1's Care Plan with a target date of 06/20/2024 revealed a problem initiated on 04/17/2024 when Resident #1 was prescribed anti-anxiety meds related to Anxiety disorder with interventions that included in part . to monitor/record/report prn if exhibited adverse reactions to anti-anxiety therapy. Review of Resident #1's Physician's Orders read in part . 04/17/2024 - Trazodone HCl oral tablet give 12.5mg by mouth 2 times a day for anxiety and depression. Start date 04/17/2024. Discontinued 04/24/2024. 04/24/2024 - Trazodone HCl oral tablet give 25mg by mouth 2 times a day for anxiety and depression. Start date 04/24/2024. Discontinued 05/22/2024. 05/22/2024 - Trazodone HCl oral tablet give 50mg by mouth 2 times a day for anxiety and depression. Start date 05/22/2024. 05/31/2024 - Xanax oral tablet 0.25mg 1 tablet by mouth BID for GAD. Start dated 05/31/2024. 06/13/2024 - Xanax oral tablet 0.25 mg 1 tablet by mouth every p.m. for GAD. Start dated 06/13/2024. Review of Resident #1's Progress or Nurses Notes revealed no documentation of the above medication changes and no documentation that Resident #1's RP was notified of medication changes. Telephone interview on 08/13/2024 at 3:50 p.m. with S3 LPN revealed she had cared for Resident #1. S3 LPN revealed she had spoken with Resident #1's daughter a couple of times when she would visit about some of her care and behaviors but could not recall what and when she had documented. Interview on 08/14/2024 at 10:20 a.m. with S2 ADON verified that the nurses should have informed Resident #1's RP of medication changes but did not. Interview on 08/14/2024 at 10:40 a.m. with S1 DON revealed there was no evidence that Resident #1's RP had been notified of medication changes. S1 DON confirmed Resident #1's RP should have been notified of changes in her medication regimen and had not been.

Based on interview and record review, the facility failed to ensure the Quality Assessment and Assurance (QAA) committee meeting included the required 6 staff members for the facility's last 4 quarterly committee meetings. Findings: Review of the facility's quarterly Quality Assessment and Assurance (QAA) committee sign in sheets conducted on April 11, 2024, January 18, 2024, October 3, 2023, and July 13, 2023 revealed staff in attendance was the facility's Medical Director, Administrator, Director of Nurses, and the Infection Preventionist. During an interview on 5/22/2024 at 12:10 p.m., S3 Administrator indicated that he was not aware of the other members required attendance in the Quarterly QAPI meetings.

Based on record review and interview, the facility failed to implement the person-centered care plan for 1 (#81) of 3 (#76, #81, & #87) residents reviewed for pain management by failing to order and administer Lidocaine patches for pain, as recommended by the resident's orthopedic doctor. Findings: Review of Resident #81's medical record revealed an admitted [DATE] with diagnoses that included in part .Lumbago with Sciatica, Muscle Weakness, and Left Arm Pain. Review of Resident #81's MDS with an ARD of 05/01/2024 revealed a BIMS score of 14, which indicated the resident was cognitively intact. Review of the MDS revealed Resident #81 used a walker to ambulate and her primary medical condition was listed as Lumbago with Sciatica, right side. Review of the MDS revealed the resident received prn pain medications. Review of Resident #81's current physician's orders revealed the following: 05/13/2024: Appointment with Orthopedist 05/23/2024 Right iliolumbar ligament and right sacroiliac joint injections 05/13/2024: Acetaminophen 325 mg -give 2 tablets po q 4 hours as needed for general discomfort 04/23/2024: Norco Oral Tablet 5-325 mg po q 12 hours prn pain 05/06/2024: Tizanidine HCL 2 mg give 1-2 tablets po at hs Review of Resident #81's care plan with a target completion date of 05/16/2024 revealed she was care planned for I am on pain medication related to Scoliosis, Cervicalgia, Osteoporosis, and Lumbago with Sciatica, right side. Interventions included: I will be free of any discomfort or adverse side effects from pain medication through the review date; Administer my analgesic medications as ordered by physician. Monitor/document side effects and effectiveness every shift; Monitor/document/report as needed If I exhibit adverse reactions to analgesic therapy. Review of the nurses' notes for Resident #81 revealed the following: 05/13/2024 at 12:19 p.m.: Resident returned from appointment with (Orthopedist), per wheelchair via facility's transportation. Resident returned in stable condition. Lidocaine patches recommended to affected area 12 hours on 12 hours off. Schedule for right iliolumbar ligament and right sacroiliac joint injections under fluoroscopy on 05/23/2024. By S2 LPN. In an interview on 05/20/2024 at 9:32 a.m., Resident #81 stated her back was hurting and asked if I could find out about her getting some pain medicine for it. Resident #81 stated she only received Tylenol for the pain and stated it doesn't work. In an interview on 05/21/2024 at 8:45 a.m., Resident #81 stated her back hurts this morning. Resident #81 stated she was hoping to get some relief when she goes to the Orthopedist on Thursday to get her injections. In an interview on 05/21/2024 at 9:57 a.m , Resident #81 confirmed at her appointment on 05/13/2024 the Orthopedist did recommend Lidocaine patches but stated the nurses haven't put any patches on her yet. Resident #81 stated she wanted to try the patches. In an interview on 05/21/2024 at 10:39 a.m., S2 LPN stated Resident #81 went to the doctor and returned with a progress note that recommended Lidocaine patches. S2 LPN stated she called the Orthopedist's office to get an order for the patches and left a message, but they never called her back. S2 LPN confirmed she never followed up with the doctor by trying to call them back. Review of the progress note dated 05/13/2024 on 05/21/2024 at 10:42 a.m. with S1 ADON revealed the Orthopedist recommended Lidocaine patches to affected area, 12 hours on and 12 hours off. S1 ADON stated S2 LPN should have called the facility's Medical Director or Resident #81's Nurse Practitioner to see if they wanted to carry out this order, but did not.

Based on interviews, and record review, the facility failed to ensure services were provided by the facility to meet quality professional standards for 1 (Resident #3) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. The facility failed to ensure Resident #3's physician order was transcribed and a urinalysis was collected as ordered by the physician. Findings: Review of the clinical record for Resident #3 revealed an admitted [DATE] with diagnoses that included Fibromyalgia, Cerebral Infarction, Osteoarthritis, Atherosclerotic Heart Disease, Essential Hypertension, Type 2 Diabetes Mellitus, and Unspecified Dementia. Review of Resident #3's Quarterly MDS with an ARD of 02/14/2024 revealed a BIMS of 10, which indicated moderately impaired cognition. Review of Resident #3's Nurses Notes written on 03/04/2024 at 1:07 p.m. by S1 LPN read in part . Resident complains of pain and burning during urination. Nurse practitioner notified with new order to obtain a urinalysis. Review of Resident #3's March 2024 Physician's orders revealed no order for a urinalysis on 03/04/2024. An interview on 03/05/2024 at 12:14 p.m. with Resident #3 revealed the last time a urine sample was collected by a staff member had been a few weeks ago, and she denied that a staff member had attempted to collect a urine sample on her in the last few days. An interview on 03/06/2024 at 9:36 a.m. with S1 LPN revealed on 03/04/2024 Resident #3 had just finished a round of Macrobid (antibiotic) for a urinary tract infection on the day prior, but continued to complain of burning and pain with urination. S1 LPN stated she called the nurse practitioner and received a verbal order for a repeat urinalysis. S1 LPN stated she filled out the lab slip and went to collect urine from Resident #3, but she was in the wheelchair and was not ready to get back in bed. S1 LPN stated she notified the oncoming nurse, S2 LPN, that urine needed to be collected from Resident #3. S1 LPN confirmed she forgot to input the urinalysis order in Resident #3's electronic physician orders to be collected. An interview with S2 LPN on 03/06/2024 at 11:34 a.m. revealed she was notified on 03/04/2024 by S1 LPN that a urinalysis was ordered for Resident #3 and that she was unable to collect the urine. S2 LPN stated on 03/04/2024 the 2:00 p.m. to 10:00 p.m. shift she tried to collect the urinalysis for Resident #3 using a straight catheter, but was unable to collect any urine at the time. S2 LPN stated she did not document that she attempted to collect the urine in a nurse's note, but should have. S2 LPN stated she did not remember notifying the oncoming nurse that a urine sample needed to be collected for Resident #3. S2 LPN stated on 03/05/2024 at 4:30 p.m. she contacted the nurse practitioner notifying her that Resident #3's urinalysis had not been collected and that Resident #3 continued with pain with urination and began with itching to perineal area. S2 LPN revealed the nurse practitioner stated to collect Resident #3's urine today and start Diflucan (antifungal) for 2 days. S2 LPN revealed she collected urine from Resident #3 and it was sent to the lab on 03/06/2024. An interview on 03/06/2024 at 10:42 a.m. with S3 DON confirmed a urinalysis was ordered for Resident #3 on 03/04/2024, but was not transcribed into Resident #3's Physician orders, or collected in a timely manner, and should have been.

Based on observation and interview the facility failed to provide a safe, functional, sanitary and comfortable environment for residents who received showers or whirlpools in a facility spa room. Findings: Observation on 11/14/2023 at 8:29 a.m. of the Spa Room on Hall W revealed 4 dirty, wet towels scattered on the floor around the whirlpool tub. There was a wet, dirty towel noted on the floor in the shower area. There were 2 hangers, trash and used gloves laying on the floor. One of the shower curtains was noted with only the top netted part hanging, the remainder of the curtain was missing or in torn strips hanging from the netted part. The sink was noted to be dirty and the trash cans were full and overflowing with trash. The small cabinet in the room was opened with supplies scattered throughout. Interview on 11/14/2023 at 8:30 a.m. with S3 CNA revealed Spa Room on Hall W was used on a daily basis for resident showers and baths. S3 CNA stated it did not take but a minute to clean the area and she did not understand why it looked like it did. Interview on 11/14/2023 at 8:32 a.m. with S2 LPN confirmed the above information. She stated the spa room should be cleaned after each use. Interview on 11/14/2023 at 10:00 a.m. with S4 Housekeeping Supervisor revealed that she had been hired as the housekeeping supervisor in 11/2023 and was previously the CNA supervisor. S4 Housekeeping Supervisor stated she was made aware of the condition of the Spa Room on Hall W and stated it should not be in that shape.

Based on observation and interview the Facility failed to ensure food was stored in accordance with professional standards for food service safety. Findings: Observation on 05/08/2023 at 8:20 a.m. of the walk in freezer/cooler revealed: 1. 1 box of beef patties open to air and undated. 2. 1 bag of French fries open to air and undated. 3. 1 bag of potatoes open to air and undated. 4. 1 bag of meatballs open to air and undated. Interview at the time of observation with S3 DM revealed the staff who opens a food item should label and date it and store it properly. S3 DM confirmed: The above listed items were not dated and they should have been; the above listed items were open to air and they should not have been.

Based on observation, record review and interview the facility failed to provide pharmaceutical services that assure accurate acquiring, receiving, dispensing and administration of medications to meet the needs of each resident by: 1.Failing to ensure accurate accounting for controlled medications were completed at the time of receiving narcotics on Hall 1 medication cart for Resident #40 and failing to ensure controlled medications were reconciled for the Hall 1 medication cart by the nurse coming on duty. 2. Failing to provide medications to meet the needs of residents for 1 (Resident #251) of 1 sampled resident on Contact Precautions. Findings: #40 Review of the facility's Controlled Substance policy read in part . 3. Controlled substance must be counted upon delivery. The nurse receiving the medication, along with the person delivering the medication must count the controlled substance together. 9. Nursing staff must count the controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing Services. Observation of Hall 1 medication cart on 05/10/2023 at 9:30 a.m. with S8 LPN revealed a medication card for Resident #40 for Tramadol 50 mg tablet with instructions to give 1 tablet by mouth 3 times a day. 57 tablets were observed in the medication card. Review of the Individual Resident Narcotic Record for Tramadol 50 mg, for Resident #40 read as follows: S8 LPN 05/10/2023, 08:12 a.m. amount on hand 57, amount given 1, amount remaining 56. Review of Resident #40's May 2023 Medication Administration Record revealed during the AM medication pass on 05/10/2023, S8 LPN documented that Resident #40 complained of pain 2/10, and S8 LPN administered the scheduled dose of Tramadol 50 mg tablet. Interview on 05/10/2023 at 9:40 a.m. with S8 LPN revealed she administered Tramadol 50 mg tablet to Resident #40 during morning medication pass on 05/10/2023. S8 LPN stated that she did not complete a narcotic count at the beginning of her shift on 05/10/2023 when she received the keys to the medication cart, but should have. Interview on 05/10/2023 at 10:00 a.m. with S2 DON revealed the nurse coming on duty and the nurse going off duty are required to count narcotics at the beginning and end of every shift. S2 DON confirmed Resident #40's Individual Resident Narcotic Record for Tramadol 50 mg tablet was not correct, and was not accurately reconciled according to the locked narcotics within Hall 1 medication cart. 41124 #251 Review of the facility policy titled Medication Therapy revealed in part . Medication use shall be consistent with an individual's condition, prognosis, values, wishes, and response to treatment. All medication orders will be supported by appropriate care processes and practices. Review of Resident #251's clinical record revealed laboratory results dated [DATE] stating Resident #251's stool specimen was positive for Clostridium Difficile. Review of Resident #251's Physician's Orders revealed an order dated 05/08/2023 at 3:59 p.m. for Flagyl (antibiotic) 500mg by mouth every 8 hours every 10 days. Review of Resident #251's Physician's Orders also revealed an order dated 05/09/2023 at 10:25 a.m. for Flagyl 500mg by mouth every 8 hours for 10 days for C-diff (Clostridium Difficile). Review of Resident #251's Medication Administration Record revealed Resident #251 received doses of Flagyl 500mg at 4:00 p.m. on 05/08/2023, 4:00 p.m. on 05/09/2023, and at 12:00 a.m. and 8:00 a.m. on 05/10/2023. Interview on 05/10/2023 at 10:00 a.m. with S4 LPN revealed the duration of the Flagyl ordered had been entered incorrectly on 05/08/2023. S4 LPN stated she realized the error on 05/09/2023 and reentered the order at 10:25 a.m. Interview on 05/10/2023 at 10:32 p.m. with S4 LPN revealed Resident #251 did not receive Flagyl 500mg every 8 hours as ordered for her diagnosis of C-diff. S4 LPN stated she should have entered a one time order to administer Flagyl on 05/09/2023 at 10:25 a.m. when she noticed the error but she did not. S4 LPN confirmed Resident #251 missed doses of Flagyl (antibiotic) on 05/09/2023 at 12:00 a.m. and 05/09/2023 at 8:00 a.m. and should not have. Interview on 05/10/2023 at 10:49 a.m. with S2 DON confirmed Resident #251 did not receive antibiotics as ordered. S2 DON stated Flagyl (antibiotic) doses had been missed and should not have been.

Based on record review and interview, the facility failed to transmit a MDS (Minimum Data Set) Assessment within 14 days of completion for 4 (Resident #22, Resident #33, Resident #70, and Resident #72 ) of 4 sampled residents with MDS record over 120 days old. Findings: Review of the facility's MDS (Minimum Data Set) transmission report revealed Resident #22 and Resident #72's Annual MDS Assessments with ARD's (Assessment Reference Date) of 03/22/2023 had not been transmitted until 04/30/2023. Review of the facility's MDS transmission report revealed Resident #70's Quarterly MDS Assessment with ARD of 03/22/2023 and Resident #33's Quarterly MDS Assessment with ARD of 03/15/2023 had not been transmitted until 04/30/2023. Interview on 05/09/2023 at 3:15 p.m. with S2 DON confirmed the above MDS assessments had not been transmitted timely and should have been.

Based on record review and interview, the facility failed to protect 4 (#4, #6, #8, and #9) of 9 (#1, #2, #3, #4, #5, #6, #7, #8, #9) residents from staff to resident verbal, mental, and physical abuse. This deficient practice resulted in an actual harm situation for Residents #4, #6, #8 and #9 that began on 07/17/2022 at 2:08 p.m. when S2 DON and S3 ADON became aware of a grievance filed by Resident #6, which alleged verbal and physical abuse by S4 CNA. S2 DON and S3 ADON received grievances that alleged verbal and physical abuse by S4 CNA from Resident #4 on 07/17/2022 at 2:22 p.m., and Resident #8 on 07/17/2022 at 2:36 p.m. During an interview, Resident #4 reported S4 CNA was rude to her and rough when changing her which made it painful. Resident #4 reported she was intimidated by S4 CNA and feared nighttime when she would return. Resident #6 reported S4 CNA was rough when changing her and S4 CNA made her feel like a little child because she yelled and hollered at her. Resident #8 reported S4 CNA verbally abused him by saying mean things to him like she hated taking care of him and everyone on the hall hated me. Resident #9 reported that S4 CNA didn't clean her when she had a bowel movement, would tell her she would break her legs due to contractures if she cleaned her, and would just cover her back up. Resident #9 also stated she had vomited, and S4 CNA threw a towel and sheet at her, and would not clean her up. S2 DON and S3 ADON allowed S4 CNA to work in the facility on Hall A on 07/17/2022 and 07/18/2022 from 10:00 p.m. to 6:00 a.m., and have continued access to the residents. Findings: Review of the facility's policy titled Abuse Components Plan Elder Justice Act and Affordable Care Act revealed the following in part . Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish . . Protection: The Administrator or designee will immediately ensure that any further potential abuse, neglect, exploitation or mistreatment is prevented . Interventions are initiated during the investigation period to prevent further potential abuse . Any facility employee accused of resident abuse, neglect, misappropriation of property/funds, retaliation and suspicious death or major injuries of unknown origin may be reassigned to nonresident care duties, or suspended from duty until results of the investigation have been reviewed by the Administrator or their designee. Resident #4 Review of the medical record for Resident #4 revealed an admitted [DATE], and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #4's medical record revealed she resided on Hall A. Review of Resident #4's Quarterly MDS Assessment, with an ARD of 07/06/2022, revealed a BIMS score of 12, which indicated moderately impaired cognition, and revealed the resident required extensive two person physical assistance with bed mobility, transferring, and toilet use. Review of Resident #4's current Care Plan revealed she was care planned for ADL self-care due to [CONDITION(S)] and a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan revealed Resident #4 required the use of a lift by two staff members for safety due to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Approaches included: Resident #4 required extensive assistance by two staff with turning and repositioning in bed, toilet use, and transferring. Review of a grievance filed by Resident #4 dated 07/17/2022 at 2:22 p.m. and prepared by S3 ADON revealed the following: Nursing Description: Informed by Hall A nurse that resident had a complaint about a CNA and she needed to speak to someone in charge. Resident Description: I myself ADON spoke with resident in her room with curtain pulled and door closed. Resident stated the 10-6 CNA that works with me S4 CNA comes in room after I had my call light on for at least 20-30 minutes and stated, What do you want now 'in an angry tone of voice' then she turns my call light off and says I'm doing something and I will be back. But doesn't come back for a long time and she is rough and rude when changing me, hurts me when she turns me. 07/20/2022 Notes: Employee contacted and requested to come in to speak with DON, ADON, and CNA Supervisor. Employee stated that she could not come in that day. Instructed employee to come in the morning of 7/21/22. As of 3 p.m. on 07/21/2022 employee still had not come in facility. Employee contacted and stated that she wasn't going to be able to come in. When attempting to discuss issue with employee, employee became argumentative, rude and disrespectful to supervisor on phone with her. Supervisors attempted to discuss issues with employee she continued to argue stating that supervisors don't know what they are talking about. Then stated take me off the schedule. This serves as employee as voluntary resignation and will no longer return to work at facility. Review of Resident #4's ADL sheets for July 2022 revealed S4 CNA documented performing bed mobility and toileting at 12:27 a.m. and transferring at 12:28 a.m. for Resident #4 on the 10:00 p.m. to 6:00 a.m. shift the night of 07/17/2022. In an interview on 08/10/2022 at 3:05 p.m., Resident #4 reported S4 CNA would turn and push her hard when changing her, and dig her hands into Resident #4's skin which hurt because she (Resident #4) had [CONDITION(S)]. Resident #4 stated she felt intimidated like she didn't know what S4 CNA would say or do next, and feared when night came on, because she knew S4 CNA would be coming back to work. Resident #6 Review of Resident #6's medical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #6's medical record revealed she resided on Hall A. Review of Resident #6's Discharge MDS Assessment, with an ARD date of 06/16/2022, revealed a BIMS score of 5, which indicated severely impaired cognition, and contained no functional status assessment. Review of Resident #6's Significant Change MDS Assessment, with an ARD of 05/29/2022, revealed a BIMS score of 14, which indicated intact cognition, and revealed Resident #6 required extensive assistance by two persons with bed mobility, transferring, and toilet use. Review of Resident #6's current Plan of Care revealed a problem of I have an ADL self-care performance deficit related to limited physical mobility associated with right 2nd toe [CONDITION(S)], Right Sided [CONDITION(S)], and uses a wheelchair as primary mode of transportation. The approaches included: resident was totally dependent on two staff for toilet use, independent for repositioning and turning in bed, and required a mechanical lift with two staff assist to transfer. Review of a grievance filed by Resident #6 on 07/17/2022 at 2:08 p.m. prepared by S3 ADON revealed the following: Nursing Description: Informed by Hall A nurse that she had a resident with complaints and wanted to speak to someone about a CNA that she was having problems with. Resident Description: I myself ADON spoke with Resident in private pulled curtain and closed the door. Resident said, That CNA (S4 CNA) is very mean, disrespectful to me, told me to stop putting on the call light because she doesn't make rounds until 12 midnight and then I have to wait my turn after she starts her rounds. Notes: 07/20/2022: Employee contacted and requested to come in to speak with DON, ADON and CNA Supervisor. Employee stated that she could not come in that day. Instructed employee to come in the morning of 07/21/2022. As of 3 p.m. on 07/21/2022 employee still had not come in facility. Employee contacted and stated that she wasn't going to be able to come in. When attempting to discuss issue with employee, employee became very argumentative, rude and disrespectful to supervisor on phone with her. Supervisors attempted to discuss issues with employee she continued to argue stating that supervisors don't know what they are talking about. Then stated take me off the schedule. This serves as employee as voluntary resignation and will no longer return to work at facility. In an interview at 12:30 p.m. on 08/09/2022, Resident #6 reported she had ongoing problems with S4 CNA. Resident #6 reported on 07/17/2022, she and her roommate told the nurse to get someone in charge for them to talk to about S4 CNA. Resident #6 reported S4 CNA was rough with her when she changed her and would come in and yell Turn over. Resident #6 reported S4 CNA was hateful, and mean to us. In an interview on 08/10/2022 at 9:10 a.m., Resident #6 stated S4 CNA made me mad with the way she knocked me around. Resident #6 stated it hurt when S4 CNA handled her roughly when changing her. Resident #6 reported it made her feel like a little child when she was being hollered at. Resident #6 explained she would roll over to be changed, and S4 CNA would shove her over against the side rail with her hands. Resident #6 explained S4 CNA was verbally abusive and wouldn't answer if I asked her something. Resident #6 further reported S4 CNA told her you better get changed now because I am not running up and down the hall. Resident #6 stated she dreaded the days S4 CNA worked. Resident #8 Review of the medical record for Resident #8 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #8's medical record revealed the resident resided on Hall A. Review of Resident #8's Quarterly MDS Assessment, with an ARD of 06/29/2022, revealed a BIMS score of 9, which indicated the resident had moderately impaired cognition. The MDS revealed Resident #8 required extensive assistance by two persons with bed mobility, transferring, and toilet use, and extensive assistance by one person with eating. Review of Resident #8's current Care Plan revealed Resident #8 was care planned for having an ADL self-care deficit related to being wheelchair bound, and having a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The approaches included: extensive assistance by two staff members to turn and reposition in bed and toilet use, two staff members using a mechanical lift for transfers, and extensive assistance by one staff member with eating. Review of a grievance form filed by Resident #8 on 07/17/2022 at 2:36 p.m. revealed the following: Resident Description: I myself ADON spoke with resident in room with curtain pulled and door closed. Resident stated, I put my call light on to get someone to change me and (S4 CNA) comes in and turns my call light off and states I'm not the one assigned to you and I don't take care of you, and then she states I will tell the CNA on Hall D to come see about you and then no one comes and then its morning shift that shows up and takes care of me. Notes: 07/20/2022: Employee contacted and requested to come in to speak with DON, ADON and CNA Supervisor. Employee stated that she could not come in that day. Instructed employee to come in the morning of 07/21/2022. As of 3 p.m. on 07/21/2022 employee still had not come in facility. Employee contacted and stated that she wasn't going to be able to come in. When attempting to discuss issue with employee, employee became very argumentative, rude and disrespectful to supervisor on phone with her. Supervisors attempted to discuss issues with employee she continued to argue stating that supervisors don't know what they are talking about. Then stated take me off the schedule. This serves as employee as voluntary resignation and will no longer return to work at facility. In an interview on 08/09/2022 at 2:30 p.m., Resident #8 confirmed he filed a grievance about S4 CNA. Resident #8 reported she was a problem so a couple of the residents on our hall got together and complained about her so they would finally do something about it. Resident #8 reported S4 CNA didn't want to change him or wouldn't do it right. Resident #8 explained when S4 CNA would change him, she would not cover him back up, and leave him exposed and cold. Resident #8 further reported S4 CNA always made him wait to be changed, sometimes 2-3 hours. Resident #8 reported she said mean things to him like she hated taking care of me and everyone on the hall hates me. Resident #9 Review of the medical record for Resident #9 revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #9's medical record revealed she resided on Hall A. Review of Resident #9's Significant Change MDS Assessment, with an ARD of 05/28/2022, revealed Resident #9 had a BIMS score of 6, which indicated severely impaired cognition, and required extensive assistance by two persons with bed mobility, transferring, and toilet use. Review of Resident #9's current Care Plan revealed Resident #9 was care planned for having an ADL self-care performance deficit, and required extensive assistance by two staff with bed mobility, and transferring with a mechanical lift. Review of a grievance filed by Resident #9 on 07/20/2022 at 5:07 p.m. revealed the following: Resident Description: Social Services Director spoke with resident in her room. Resident reported that the CNA named (S4 CNA) was very mean and shows her no respect. Resident stated S4 CNA said, I am not going to clean you up because you can't open your legs. I will have to break your legs in order to clean you up. Resident said she was always finding fault in me. She never speaks to me nicely. Resident repeatedly said she always have a problem with me when I need cleaning up. In an interview on 08/09/2022 at 2:45 p.m., Resident #9 confirmed she filed a grievance related to S4 CNA stating because she had nasty ways. Resident #9 reported S4 CNA didn't want to change her if she had a bowel movement and she came to work angry. Resident #9 explained S4 CNA comes in her room, doesn't speak or say anything like how are you doing, and just throws her covers back. Resident #9 said instead S4 CNA comes in her room and just says, What's your trouble? Resident #9 explained if she had a bowel movement, S4 CNA would just cover her back up. Resident #9 reported one day she rang the call bell because she had vomited and waited for a while. Resident #9 reported when S4 CNA came in and saw she had vomited on herself, she just left and came back with a towel and sheet. She reported S4 CNA threw a towel and sheet to her. Resident #9 explained she still had vomit on the bed sheets and her clothes. Resident #9 reported she finally reported her when she told me, I'm going to break these legs. Resident #9 reported that made her so mad. Review of S4 CNA's personnel record revealed a Notice of Expected Improvement which was completed by S2 DON, with 07/17/2022 documented as the date of action. Further review of the form revealed this was the 2nd written notice regarding Residents complaining employee is rude and saying threatening things to them. Review of S4 CNA's personnel record revealed training upon hire on abuse and neglect. Review of the Monthly Staff In-service dated 06/07/2022 revealed the abuse and neglect policy was reviewed with all staff, including S4 CNA, who signed the attendance sheet. Review of the Monthly In-service dated 07/14/2022 revealed abuse and neglect and reporting of abuse or suspected abuse were covered at the meeting, but was not attended by S4 CNA. Review of the July 2022 In-services binder revealed no documented training/retraining of staff on abuse on, or after 07/17/2022, when the abuse complaints were made. In an interview on 8/09/2022 at 2:37 p.m., S9 SSD stated if she gets a complaint related to abuse or a complaint about a staff member, she immediately reports that to the DON or ADON. In an interview on 08/09/2022 at 11:43 a.m., S2 DON reported she and S3 ADON were working on 07/17/2022 covering the 6:00 a.m. to 2:00 p.m. shift. S2 DON confirmed they became aware of the complaints by residents about S4 CNA close to the end of their shift. S2 DON reported they could not reach S4 CNA by phone. S2 DON stated they also tried to call her on 07/18/2022 through 07/20/2022. S2 DON reported reaching S4 CNA by phone on 07/21/2022. S2 DON reported S4 CNA became rude and was cursing, we told her that her services were no longer needed and S4 CNA said to take me off the schedule. S2 DON confirmed S4 CNA worked the 10:00 p.m. to 6:00 a.m. shift on the nights of 07/17/2022 and 07/18/2022. S2 DON confirmed having counseled S4 CNA in May 2022 on being rude, and in June 2022 because she refused to change residents and told resident we didn't have gloves. S2 DON further confirmed S4 CNA had been written up in September 2021 for leaving assigned hall, turning lights off, refusing to help on other halls when needed. S2 DON reported she was unaware S4 CNA was scheduled to work on 07/17/2022 or 07/18/2022, and acknowledged that S4 CNA worked Hall A on the 10:00 p.m. to 6:00 a.m. shifts on 07/17/2022 and 07/18/2022, and should not have.

Based on interview and record review the facility failed to ensure an agency CNA provided one person assistance during a transfer for Resident #3 as indicated on the Comprehensive Person Centered Plan of care, for 1 (#3) of 5 (#1, #2, #3, #4 and #5) sampled residents. This failed practice resulted in an actual harm situation for Resident #3 on 04/29/2022 at approximately 9:15 p.m., when Resident #3 fell after S4 Agency CNA allowed Resident #3 to transfer himself from the wheelchair to the bed without one person physical assistance for transfers as indicated on his person centered plan of care. Resident #3 complained of pain to his left hip. A portable x-ray of Resident #3's Left Hip was done on 04/30/2022 at 12:15 p.m., with a finding of an Acute and Mildly Displaced Fracture of Left Intertrochanteric Region. Resident #3 was transported to a local emergency room , admitted to the hospital and had a Titanium Trochanteric Fixation of Left Intertrochanteric Proximal Femur Fracture on 05/01/2022. Findings: Review of Resident #3's clinical record revealed an admitted [DATE] with diagnoses that included: Fracture of Unspecified Part of Neck of Left Femur; Muscle Weakness; other Lack of Coordination; Unspecified Osteoarthritis; Unsteadiness on Feet; Muscle Wasting and Atrophy, Left Thigh; Muscle Wasting and Atrophy, Right Thigh; Cognitive Communication Deficit; History of Falling; Generalized Anxiety Disorder; Major Depressive Disorder; other Impulse Disorders; [CONDITION(S)] Type II; Delusional Disorders; and Schizophreniform Disorder. Review of Resident #3's Annual MDS with an ARD of 02/09/2022 revealed Resident #3 had a BIMS score of 08 (indicating moderate cognitive impairment), and required one person physical assist with bed mobility, transfer, dressing, and toilet use. Review of Resident #3's Comprehensive Care Plan with a target date of 05/09/2022 revealed the following problems: 1. ADL self-care performance deficit related to impaired decision making skills. Interventions included: I require limited assistance with one staff for transferring and I will be monitored/document/report as needed any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. 2. Risk for falls related to wheelchair being primary mode of transportation, and requires extensive assistance transferring from bed to wheelchair. Interventions included: educated resident to call staff when feeling weak, I need a safe environment, and resident educated on importance of staff assist with transfer to ensure safety. Review of Resident #3's nurses' notes revealed the following in part . 04/30/2022 at 10:33 a.m. - Resident in bed. When a CNA attempted a.m. care on resident, he yelled out in pain. The resident stated I fell last night. The resident was in bed at 6 a.m. when this writer and CNA arrived to work. Resident left hip painful and left foot noted with external rotation. Left leg appears swollen. Nurse Practitioner notified. New order for STAT X-ray left hip. 04/30/2022 at 10:45 a.m. - APAP 325 mg two po administered for left hip pain. 04/30/2022 at 3:45 p.m. - New order per Nurse Practitioner to send the resident to a local hospital for further evaluation due to radiology report showing mildly displaced fracture of left intertrochanteric region with slight angulation. Resident is own Responsible Party. DON made aware. Resident has been changed and dressed appropriately and radiology results given and explained to resident. Ambulance notified and is in route to facility. 04/30/2022 at 4:00 p.m. - Out per stretcher via ambulance going to local emergency room . Report called to emergency room nurse prior. Review of Resident #3's Radiology Report dated 04/30/3022 with a completion time of 3:21 p.m. revealed: Impression - Acute and Mildly Displaced Fracture of Left Intertrochanteric region with a recommendation for an Orthopedic consult. Review of the hospital's Discharge Summary dated 05/03/2022 revealed in part . Nursing home patient who presented status post fall with left hip pain. Status post TFN Left Intertrochanteric Proximal Femur Fracture 05/01/2022. Further review of Resident #3's nurses' notes revealed a note dated 05/03/2022 at 11:20 p.m., that documented Resident #3 was readmitted to the nursing facility on 05/03/2022 at 4:15 p.m. after discharge from the hospital. The note revealed in part resident readmitted to the nursing facility in stable condition .discharge diagnosis: Closed Intertrochanteric Fracture of Left Femur. Status post fall Resident #3 required 2x extensive assistance with bed mobility, transfers, brief changing, turning, repositioning .Unable to bear weight, and uses WC for mobility .has pain 7/10 in left thigh . Interview on 06/01/2022 at 8:27 a.m. with Resident #3 revealed he had a fall at the end of April 2022, and landed on his hip and buttocks. Resident #3 stated he was attempting to transfer himself from the wheelchair to the bed, and that three staff members (Resident #3 was unable to state who the staff members were) were in the room when he fell . Resident #3 stated he did not ask for assistance, and the three staff members were right next to him when he fell , and they just watched and did nothing. Resident #3 stated he complained of pain to the three staff members in the room, and they knew he was in pain after the fall. Resident #3 stated he got back in bed by himself after the fall. Resident #3 stated he did not tell the night shift nurse or the night shift CNA on duty that he fell that evening, or that he was in pain. Resident #3 reported he notified a CNA the following morning that he had fallen the night before, and was in pain. Interview on 06/01/2022 at 2:20 p.m. with S4 Agency CNA revealed she was present on the evening shift when Resident #3 fell to the floor. S4 Agency CNA stated Resident #3 was ready to go to bed, and she pushed his WC close to the bed and locked it. S4 Agency CNA stated Resident #3 lifted himself up while attempting to transfer and said he was feeling weak and to get him. S4 Agency CNA stated it happened so fast that when she went to help him, he had already fallen. S4 Agency CNA stated the resident said My hip hurts. I broke my f**** hip. S4 Agency CNA stated S3 LPN was on the hall doing a medication pass and came in, but could not help because she was pregnant. S4 Agency CNA stated S3 LPN said He don't know what he is talking about. and told her to put him in bed. S4 Agency CNA stated S5 TNA assisted her in putting Resident #3 back in bed, and Resident #3 was still hollering My hip. My hip. S4 Agency CNA stated she told S3 LPN that Resident #3 was still hollering, and S3 LPN told her to clean the resident up. S4 Agency CNA stated Resident #3 continued to complain of hip pain while being cleaned, so she again notified S3 LPN that the resident was still complaining about his hip. S4 Agency CNA stated S3 LPN said He has [CONDITION(S)] and doesn't know what he is talking about. S4 Agency CNA stated she could not recall if she told any CNAs coming in for the 10:00 p.m. to 6:00 a.m. shift about Resident #3's fall. Interview on 06/02/2022 at 2:09 p.m. with S3 LPN revealed she worked on 04/29/2022 from 2 p.m. to 10 p.m. S3 LPN stated that some time that night while she was on her medication pass, she heard a commotion and went to Resident #3's room. S3 LPN stated Resident #3 was on the floor, and S4 Agency CNA was in the room. S3 LPN stated S4 Agency CNA said Resident #3 slid to the floor when attempting to transfer by himself. S3 LPN reported she could not assist S4 Agency CNA to get the resident up because she was pregnant. S3 LPN stated she went back to doing her medication pass, and S5 TNA assisted S4 Agency CNA in getting Resident #3 off the floor and into bed. S3 LPN stated it slipped her mind to chart about the fall, and did not remember until the facility called her the next morning. S3 LPN Resident #3 did not complain of pain to her. S3 LPN stated Resident #3 was sleeping when she went back in to check on him, so she did not complete an assessment because she did not want to bother him. S3 LPN stated she did not notify anyone because she forgot, and did not remember until the following morning when she was contacted by the facility. S3 LPN stated Resident #3 normally transferred by himself. Interview on 06/02/2022 at 1:10 p.m. with S8 TNA revealed she worked with Resident #3 on the night shift from 04/29/2022 through 04/30/2022. S8 TNA reported she provided care to Resident #3 a few times on the shift. S8 TNA stated Resident #3 did not complain of pain, or mention he had a fall. S8 TNA stated Resident #3 talked with her just like he always does, and she did not notice anything different when providing care. Interview on 06/02/2022 at 1:14 p.m. with S5 TNA revealed she worked the 2:00 p.m. to 10:00 p.m. shift on 04/29/2022, and was called to Resident #3's room to assist S4 Agency CNA. S5 TNA stated S3 LPN was at the door of Resident #3's room, and instructed them to get Resident #3 off the floor and put him in bed. S5 TNA stated Resident #3 complained of his side hurting when she and S4 Agency CNA were getting him off the floor and putting him into the bed. S5 TNA stated S3 LPN was at Resident #3's door, and was aware Resident #3 was complaining about pain to his side. Interview on 06/02/2022 at 2:36 p.m. with S9 TNA revealed she has worked at the facility for four months. S9 TNA reported the care sheet above the residents' beds makes her aware of what each residents needed. S9 TNA stated a yellow circle with a 1 on the care sheet meant the resident required 1 person assistance for transfers. S9 TNA stated a yellow circle with a 2 meant the resident required 2 person assistance for transfers. S9 TNA reported a red circle meant to stop and get a lift. Interview on 06/02/2022 at 2:41 p.m. with S10 CNA revealed the care sheet above the resident's bed informed him if they are a lift, nothing by mouth, 2 person assist, etc. S10 CNA reported the care sheets are similar to the resident's care plan. S10 CNA reported a yellow circle with a 1 meant the resident required 1 person assistance for transfers and a yellow circle with a 2 meant the resident required 2 person assistance for transfers. Interview on 06/02/2022 at 2:50 p.m. with S11 CNA revealed the care sheet in a resident's room is there to let her know what the resident's needs are. Interview on 06/02/2022 at 2:50 p.m. with S1 ADM revealed after the fall occurred on 04/29/2022 with Resident #3, she opened a SIMS report and neglect was substantiated. S1 ADM stated the QA committee met and a root cause analysis was completed. S1 ADM stated the fall occurred due to Resident #3 transferring himself without waiting for assistance. S1 ADM stated education/monitoring were started; however, the QA committee failed to ensure the educational component was completed. S1 ADM confirmed not all staff had received the education and training, and they should have. Interview on 06/03/2022 at 8:58 a.m. with S6 RN revealed she worked with Resident #3 on 04/29/2022 from 10 p.m. to 6 a.m. S6 RN stated when she checked Resident #3's blood glucose at midnight and 4 a.m., he looked okay, was sleepy, and she didn't notice anything unusual for him. S6 RN stated Resident #3 answered her questions and did not appear to be in discomfort. S6 RN further stated Resident #3 did not tell her he fell or report pain. S6 RN reported she goes down the hall every few hours to check on the residents and was not aware that any resident was injured. S6 RN stated Resident #3 did not get up on her shift, and was in bed the entire time. S6 RN stated S3 LPN gave her a quick short report and could not recall if S3 LPN had notified her of Resident #3's fall. S6 RN further reported it was not written on the nurses' 24-hour report sheet or the resident's progress notes, and saw no vital signs on Resident #3. S6 RN stated Resident #3 transferred himself all the time prior to the fall on 04/29/2022. Interview on 06/03/2022 at 9:45 a.m. with S7 LPN revealed she was Resident #3's nurse on 04/30/2022 from 6 a.m. to 2 p.m. S7 LPN stated she was not notified of Resident #3 having a fall or injury during report, nothing was written on the 24-hour nursing report about Resident #3 having a fall, and there was no progress note written about a fall or injury. S7 LPN stated she was outside near Resident #3's room when the CNA went in to provide care and she heard Resident #3 holler out in pain. S7 LPN stated she went in to assess him and find out what happened. She stated Resident #3 told her he fell last night, but could not remember the time. S7 LPN stated the resident had pain when she attempted to move him, and she noticed his left leg was externally rotated. S7 LPN stated she notified the RN supervisor who was present in the facility, the nurse practitioner, and S2 DON. S7LPN stated she got an x-ray as ordered, notified the NP of the results and sent Resident #3 to the hospital as ordered. S7 LPN stated at the time of the fall on 04/29/2022, Resident #3 required one person to assist him with transfers. S7 LPN stated she did not want him transferring himself and she always told him to call for assistance. Interview on 06/03/2022 at 11:07 a.m. with S2 DON confirmed Resident #3's MDS with an ARD of 02/09/2022, indicated Resident #3 required 1 person physical assist for transfers. S2 DON confirmed Resident #3 was care planned on 04/05/2022 as requiring one person assistance with transfers. S2 DON stated S4 Agency CNA was in the room to assist Resident #3 on 04/29/2022 but he jumped the gun and started without her. S2DON stated S4 Agency CNA was there to assist him as care planned. Interview on 06/03/2022 at 1:20 p.m. with S2 DON revealed the Staff Developer was responsible for training all staff, which included training on over bed signs. Interview on 06/03/2022 at 1:38 p.m. with S1 ADM confirmed S4 Agency CNA and S6 RN did not receive any in-services after the incident involving Resident #3 on 04/29/2022 and they should have. Interview on 06/06/2022 at 12:44 p.m. with S4 Agency CNA revealed she had worked as an agency CNA at the facility frequently since January. S4 Agency CNA stated she was not trained at the facility, and the staff CNAs were only helpful sometimes. S4 Agency CNA stated she asked S5 TNA how Resident #3 transferred, and S5 TNA told her to put the wheelchair by his bed and he would transfer himself. S4 Agency CNA stated she sometimes asked another staff member on duty about the residents' needs if they were familiar with them, and also looked at the care sheets above the residents' beds. S4 Agency CNA stated Resident #3 probably had a care sheet above his bed, but she does not remember.

Based on observation, interview and record review, the facility failed to use a two-person transfer, as determined necessary by the resident's person centered comprehensive plan of care, during a transfer from the wheelchair to bed for 1 (#26) of 3 sampled residents reviewed for accidents (#26, #27, and #57) out of a sample of 33. This failed practice resulted in an actual harm situation on 04/18/2022 at 1:20 p.m., when Resident #26, who required two-person assistance for transfers, was transferred from the wheelchair to bed by S6 CNA without the assistance of another staff member. Resident #26 hit her leg on the foot pedal of her wheelchair during the transfer causing a large laceration that measure 10.55 cm X 3.23 cm. Resident #26 was transferred to the ER and received 17 sutures to her right lower leg. Findings: Review of Resident #26's Face Sheet revealed she was admitted to the facility on [DATE] with diagnoses that included: [CONDITION(S)], Parkinson Disease, Dementia, Unsteadiness on feet, Peripheral Vascular Disease, Muscle Weakness and Scoliosis. Review of the resident's Quarterly MDS with an ARD date of 02/09/2022 revealed BIMS summary score of 12 (which indicated no cognitive impairment). Review of Resident #26's Functional Status revealed the resident required extensive assistance of two persons for transfers and bed mobility. Review of Resident #26's Person Centered Comprehensive Plan of Care revealed a problem of ADL self-care performance deficit related to Parkinson Disease, Dementia and Scoliosis, with a problem onset date of 11/10/2020. Interventions included Resident #26 required extensive assistance with two staff for transfers. Observation of Resident #26 during the survey on 04/18/2022 at 12:30 p.m., revealed Resident #26 wheeling herself in her wheelchair from the dining room. Resident #26 was observed bumping into the wall at times while wheeling down the hall. Resident #26 was asked by the surveyor if she needed assistance to get back to her room, and Resident #26 stated no, I like to do it myself, because it keeps my strength up, and Resident #26 continued to wheel herself to her room. Further observation on 04/18/2022 at 1:25 p.m. revealed Resident #26 lying in her bed moaning and shaking, and EMT staff was in her room. The EMT staff was observed to remove a dressing from Resident #26's right lower leg to reveal a large gapping laceration to her posterior right leg. Resident #26 stated she bumped her leg on the wheelchair while transferring from her wheelchair to her bed. Resident #26 stated the foot pedal dropped, and she hit her leg on the foot pedal which caused the laceration. Interview with S5 LPN on 04/18/2022 at 1:25 p.m. revealed Resident #26 hit her leg on the foot pedal while trying to get in bed. S5 LPN stated Resident #26 was being assisted to the bed when it happened. She stated the laceration was deep and Resident #26 bled a lot. S5 LPN stated she called for an ambulance immediately after looking at the laceration. Review of the Wound Evaluation dated 04/18/2022 at 1:20 p.m. revealed Resident #26 had a laceration to her right lateral calf that occurred minutes ago. The laceration measured 10.55 cm X 3.23 cm, and her pain was assessed as a 4 on the pain scale of 1-10. Review of the nurses' notes dated 04/18/2022 at 6:43 p.m. revealed Resident #26 returned back to the nursing facility with orders to wash the area twice a day with warm soapy water, do not scrub or soak and to monitor for infection. Sutures to be removed in about 14 days. Interview with Resident #26 on 04/19/2022 at 2:00 p.m. revealed it scared her when she began bleeding a lot. Resident #26 stated the injury was caused by her foot pedal dropping when the wheelchair was bumped when the CNA was transferring her. Resident #26 stated that it hurt her leg badly, when it occurred. Resident #26 further stated she normally gets up and goes throughout the facility in her wheelchair, but just couldn't today because her leg was hurting. Interview with S6 CNA on 04/20/2022 at 10:45 a.m. revealed she was the CNA that transferred Resident #26 when the incident occurred. S6 CNA stated she had just locked the wheelchair and put the foot pedals up, so that Resident #26 could be assisted with a tilt/pivot transfer of one person assist. S6 CNA stated she had been transferring Resident #26 with a 1 person assist for a while, because Resident #26 could tilt and pivot to transfer. S6 CNA stated she was unsure how long a while was, and thought she had tranferred Resident #26 using one perso assist since she was discharged from therapy. S6 CNA stated Resident #26 must have knocked the foot pedal back down while the transfer was in progress, and hit her leg on the pedal. S6 CNA revealed there was blood everywhere and she immediately called for help. Review of the Therapy Discharge note dated 02/15/2022 revealed Resident #26 was a partial to moderate assist with chair to bed, or bed to chair transfers. Interview with S3 LPN/ADON on 04/20/2022 at 4:00 p.m. revealed she had noticed Resident #26 was care planned for a two person assist with transfers. S3 LPN/ADON stated she asked S6 CNA why she transferred Resident #26 with a one person assist. S3 LPN/ADON stated S6 CNA said Resident #26's over the bed care plan had changed to a one person assist after she was discharged from therapy. Observation of Resident #26's over the bed wall care plan on 04/20/2022 at 4:15 p.m. with S2 DON and S3 LPN/ADON present, revealed Resident #26 was care planned for a one person assist. Interview with S2 DON on 04/20/2022 at 4:15 p.m. revealed S4 RN/CCC was responsible for changing the over the bed care guide in Resident #26's room when, or if she changed the plan of care. Interview with S3 ADON/LPN at 4:20 p.m. revealed that partial to moderate assist meant Resident #26 required a two person assist with chair to bed, or bed to chair transfers. During a telephone interview with S3 RN/CCC on 04/20/22 at 4:45 p.m., she stated that whatever was on the care plan was supposed to match the over the bed wall care guide as well. If the care plan revealed a two person assist, then Resident #26's over the bed wall care guide should have indicated that Resident #26 was a two person assist. Interview with S2 DON on 04/20/2022 at 4:50 p.m. revealed Resident #26 had changed rooms many times over the past few months, and that the over the bed care guide may not have been Resident #26's over the bed care guide.

Based on observation, interview and record review, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical well-being of each resident, for 4 (#1, #2, #3, #5) of 8 sampled residents (#1, #2, #3, #5). An Immediate Jeopardy occurred when there were systemic failures to address the nutritional status and implement pertinent interventions when recommendations were made by the Registered Dietitian for residents #2, #3, & #5. Nursing staff did not communicate RD recommendations to the physician for residents #2, #3, & #5. Staff also failed to obtain daily weights as ordered by the physician for a resident who experienced several significant weight losses (#2). This Immediate Jeopardy was identified by the survey team on 12-20-2018. Resident #3 was admitted to the facility on [DATE] and weighed 116 lbs. physician's orders [REDACTED].#3 again on 10/24/18 and 11/29/18. On both dates, she again recommended 6 cans DiabetiSource per day for a significant weight loss of >7.5 % times 90 days. Review of the resident's MARs dated September, October, November, and December, (YEAR) revealed the DiabetiSource was never increased as recommended. Resident #5 was admitted to the facility on [DATE]. Review of the RD Progress Notes revealed the resident was assessed on 8/30/18, with a recommendation to increase the House Supplement to TID. Review of the MARs dated August, (MONTH) and (MONTH) (YEAR) revealed the House Supplement was not increased to TID until 10/20/18. The resident experienced a 10% significant weight loss from 7/3/18 to 12/5/18 (146 lbs to 130.2 lbs). The facility's system triggered the weight loss as significant; however, there was no referral to the RD per the facility's system for RD referrals. Resident #2 had an admission weight of 105 lbs. On 8/5/2018, the RD assessed the resident and made a recommendation to start the resident on 4 ounces of House Supplement TID. On 9/11/18, the RD assessed the resident and recommended 4 ounces of house supplement again, and [MEDICATION NAME] 1.5 Calorie, 1 can for any meal consumed less than 50% tid. The RD recommendations were never implemented. Resident #2 continued losing weight and had a hospital admit on 10/18/18 and upon readmission to the facility on [DATE] he weighed 83 lbs. He had another hospital admit on 10/31. He was readmitted to the nursing facility on 11/27/18, and was weighed on 11/28/18, and weighed 79.2 lbs. The RD assessed Resident #2 on 11/29/18 and recommended Two Calorie HN, 1 can BID either po or via peg tube. The RD recommendations were never implemented. Staff also failed to obtain daily weights as ordered by the physician. The resident was in the hospital during the survey. S1 Administrator was notified of the deficient practice at the Immediate Jeopardy level on 12/20/18 at 3:00 p.m. The Immediate Jeopardy situation was removed on 12/21/18 at 12:58 p.m. when the facility provided an acceptable I.J. plan of removal which included the following: 1. Residents #1 and #3 had RD recommendations ordered by the provider on 12/19/18 and added to their plan of care. 2. Resident #5 who experienced a significant weight loss was referred to the RD on 12/20/18 and her recommendations will be submitted to the NP/MD on 12/21/18 for review for new recommendations. 3. By 12/21/18 the facility will review all weights and report any significant changes to the RD. 4. Resident #2 is not presently in the facility. 5. A new baseline weight and the mode of taking the weight will be obtained and documented in the clinical record by 12/21/18. 6. The weight team policy and consultant dietician recommendations policy were reviewed and found to be adequate and does not need revision; however the policy was not followed. 7. The Director of Nurses and the Clinical Coordinators were in-serviced by the QI nurse on 12/20/18 regarding the monitoring of weights and ensuring they were appropriately taken and entered into the clinical record. 8. All weights will be reviewed for significant change after a new weight is taken on 12/21/18. 9. In-service on the proper obtaining of weights and to ensure consistency of the mode of weight taken was started on 12/20/18 for all CNAs with a posttest to be administered to ensure competency and they must have a 100% pass rate. 10. An in-service will be performed on 12/21/18 with the Clinical Coordinators and DON on following through with RD recommendations and ensuring the physician reviews the recommendation and either gives an order to carry it out or dictates his reasoning why he is not ordering it. 11. The in-service on 12/21/18 with the DON and the Clinical Coordinators also included information on when a resident should be referred for significant weight change which includes referring them if there is a weight loss of 5% at 1 month or 10% within 6 months. A posttest will be administered to the Clinical Coordinators and the DON to ensure competency and show their understanding and they must have a 100% pass rate. 12. The corporate QI nurse will monitor the DON and the Clinical Coordinators at a minimum on a monthly basis to ensure the processes are carried out correctly. 13. The DON or designee will supervise the weight program which will be administered by the Clinical Coordinators and CNA's and monitor weights of at least 3 random residents weekly for 4 weeks to ensure accuracy. This will include residents who are on weekly weights. The expected outcome is to ensure the accuracy of weights being obtained. 14. Weekly, the DON will review weights with the High Risk Committee to ensure any significant loss is added to the Referral Form for the RD. 15. The DON will monitor a random sample of dietary recommendations weekly for 4 weeks to ensure that recommendations were ordered by the provider. The Quality Assurance committee will meet weekly to ensure weights are being accurately obtained, the RD recommendations are being reviewed and addressed with the physician, and that orders are implemented and carried out. After each meeting the QA committee will evaluate the process for recommendations, revisions, or resolution. Upon evaluation, any non-compliance will be addressed. The deficient practice continued at a potential for more than minimal harm for all residents 99 residents residing in the facility. Finding: Cross Refer to F692. Review of the facility's policy entitled Weight Team and Weight, Height Management revealed the designated facility weight team was trained on safe, accurate height and weight measurements which included training on all equipment utilized for measurements as per manufacturer's guidelines, and that a weight team designee was to complete a Weight Evaluation Assessment for any resident with a significant weight change. Review of the facility's Guideline for Weighing Procedures in Nursing Homes, provided by S3 QI RN, on 12/20/18 at 2:30 p.m. revealed residents should be routinely weighed on the same type of scale and staff should ensure the scale is calibrated to zero prior to each weighing episode. Residents should be routinely weighed at the same time of day each month. Residents should be routinely weighed in their bed clothes for the most accurate body weight to avoid weighing errors due to additional items. If a resident has incontinence, staff should provide incontinent care prior to weighing. Staff members responsible for weighing residents should be trained in the operation of the facility scale (s) and the importance of using a standardized procedure to ensure accurate weight values. For auditing purposes, a supervisory level person should observe the staff while he/she is conducting residents' weights (e.g., approximately 5 residents per month) to ensure that standardized procedures are being followed consistently and weight values are being recorded accurately. Interview 12/18/18 at 1:15 p.m. with S2 DON revealed the following system for weighing residents: S13 CNA performed all monthly weights. However, daily or weekly weights were obtained by any available staff. Further interview revealed the staff obtaining the weight, would choose the wheelchair scale, full body lift scale or standing scale based on availability. She stated no one was monitoring staff to ensure weights were routinely obtained on the same scale and at the same time each day. She confirmed the above residents were not routinely weighed on the same scale or at the same time. S2 DON further stated that all employees are trained upon hire to the facility and annually on obtaining residents' weights. However, no one was monitoring to ensure weights were being obtained accurately. Interview with S2 DON on 12/19/18 at 9:10 a.m. revealed the following process for implementing dietary recommendations: The DON receives an email with the recommendations attached. The DON forwards the email to the assigned resident's clinical manager. The clinical manager will call the physician or his nurse practitioner to receive a new order or a rationale why the recommendations are rejected, and a new order is received and carried out by the nurses. Interview with S2 DON on 12/19/18 at 9:10 a.m. confirmed the RD recommendations for resident #2 were never implemented and she took full responsibility for the lack of communication between herself, the clinical managers, and the physician to ensure the Registered Dietician's recommendations were being implemented. Interview with S2 DON on 12/19/18 at 1:15 P.M. confirmed that RD recommendations for resident #5 dated 8/30/18 were not implemented until 10/20/18. S2 DON revealed the following system: the RD recommendations are sent to the DON. The DON then forwards them to the RN Clinical Coordinators, and the RN Coordinators are to contact the MD/NP to notify them of the RD recommendations. S2 DON stated the facility's system had not been followed, and the MD/NP had not been notified of the RD recommendations. Interview with S5 RD on 12/19/18 at 1:17 p.m. revealed she visited the facility one time a month. She stated she is made aware of consults by either an email with the physician's orders [REDACTED]. She stated she performs the consults by reviewing the electronic record, she writes her recommendations, and then sends an email listing her recommendations to the DON. She stated she also included a note in the electronic record and provided a Word document of recommendations to be forwarded to the physician. S5 RD further stated she had no system in place to ensure that the facility communicated her recommendations to the physician. Interview on 12/20/18 at 11:40 a.m. with S3 QI RN confirmed a Weight Evaluation Assessment as per policy was not completed for resident #3 when she experienced a significant weight change. Interview on 12/20/18 at 1:00 p.m. with S2 DON confirmed the facility failed to implement the RD recommendations dated 8/21/18, 10/24/18, and 11/29/18 for resident #3. Further interview with S2 DON and 3 QI RN on 12/20/18 at 10:25 a.m. revealed the facility's system did in fact trigger the weight loss as significant for resident #5; however, the RN Coordinators were not monitoring the report that triggered significant weight losses. S3 QI RN and S2 DON stated the RN Coordinators were responsible for ensuring residents with significant weight loss were seen by the RD. S3 QI RN and S2 DON provided a form to the surveyor entitled Weight and Vitals Exceptions, which revealed the resident had a 10% weight loss from 7/3/18 to 12/5/18. (146 lbs to 130.2 lbs). S3 QI RN stated the RN Coordinators should have seen this form; however, they did not see it in the system.

Based on observation, interview and record review the facility failed to ensure that 4 of 8 residents with weight loss received the care and services required based on their comprehensive assessment to reduce further unplanned weight loss and return to desirable body weight range for 4 (#1 #2, #3, #5) of 8 sampled residents (#1, #2, #3, #4, #5, #6, #7, and #8). An Immediate Jeopardy occurred when there were systemic failures to address the nutritional status and implement pertinent interventions when recommendations were made by the Registered Dietitian for residents #2, #3, & #5. Nursing staff did not communicate RD recommendations to the physician for residents #2, #3, & #5. Staff also failed to obtain daily weights as ordered by the physician for a resident who experienced several significant weight losses (#2). This Immediate Jeopardy was identified by the survey team on 12-20-2018. Resident #3 was admitted to the facility on [DATE] and weighed 116 lbs. physician's orders [REDACTED].#3 again on 10/24/18 and 11/29/18. On both dates, she again recommended 6 cans DiabetiSource per day for a significant weight loss of >7.5 % times 90 days. Review of the resident's MARs dated September, October, November, and December, (YEAR) revealed the DiabetiSource was never increased as recommended. Resident #5 was admitted to the facility on [DATE]. Review of the RD Progress Notes revealed the resident was assessed on 8/30/18, with a recommendation to increase the House Supplement from to TID. Review of the MARs dated 08/18, 09/18, and 10/18 revealed the House Supplement was not increased to TID until 10/20/18. The resident experienced a 10% significant weight loss from 7/3/18 to 12/5/18 (146 lbs to 130.2 lbs). The facility's system triggered the weight loss as significant; however, there was no referral to the RD per the facility's system for RD referrals. Resident #2 had an admission weight of 105 lbs. On 8/5/2018, the RD assessed the resident and made a recommendation to start the resident on 4 ounces of House Supplement TID. On 9/11/18, the RD assessed the resident and recommended 4 ounces of house supplement again, and [MEDICATION NAME] 1.5 Calorie, 1 can for any meal consumed less than 50% tid. The RD recommendations were never implemented. Resident #2 continued losing weight and had a hospital admit on 10/18/18 and upon readmission to the facility on [DATE] he weighed 83 lbs. He had another hospital admit on 10/31. He was readmitted to the nursing facility on 11/27/18, and was weighed on 11/28/18, and weighed 79.2 lbs. The RD assessed Resident #2 on 11/29/18 and recommended Two Calorie HN, 1 can BID either po or via peg tube. The RD recommendations were never implemented. Staff also failed to obtain daily weights as ordered by the physician. The resident was in the hospital during the survey. S1 Administrator was notified of the deficient practice at the Immediate Jeopardy level on 12/20/18 at 3:00 p.m. The Immediate Jeopardy situation was removed on 12/21/18 at 12:58 p.m. when the facility provided an acceptable I.J. Plan of Removal which included the following: 1. Residents #1 and #3 had RD recommendations ordered by the provider on 12/19/18 and added to their plan of care. 2. Resident #5 who experienced a significant weight loss was referred to the RD on 12/20/18 and her recommendations will be submitted to the NP/MD on 12/21/18 for review for new recommendations. 3. By 12/21/18 the facility will review all weights and report any significant changes to the RD. 4. Resident #2 is not presently in the facility. 5. A new baseline weight and the mode of taking the weight will be obtained and documented in the clinical record by 12/21/18. 6. The weight team policy and consultant dietician recommendations policy were reviewed and found to be adequate and does not need revision; however the policy was not followed. 7. The Director of Nurses and the Clinical Coordinators were in-serviced by the QI nurse on 12/20/18 regarding the monitoring of weights and ensuring they were appropriately taken and entered into the clinical record. 8. All weights will be reviewed for significant change after a new weight is taken on 12/21/18. 9. In-service on the proper obtaining of weights and to ensure consistency of the mode of weight taken was started on 12/20/18 for all CNAs with a posttest to be administered to ensure competency and they must have a 100% pass rate. 10. An in-service will be performed on 12/21/18 with the Clinical Coordinators and DON on following through with RD recommendations and ensuring the physician reviews the recommendation and either gives an order to carry it out or dictates his reasoning why he is not ordering it. 11. The in-service on 12/21/18 with the DON and the Clinical Coordinators also included information on when a resident should be referred for significant weight change which includes referring them if there is a weight loss of 5% at 1 month or 10% within 6 months. A posttest will be administered to the Clinical Coordinators and the DON to ensure competency and show their understanding and they must have a 100% pass rate. 12. The corporate QI nurse will monitor the DON and the Clinical Coordinators at a minimum on a monthly basis to ensure the processes are carried out correctly. 13. The DON or designee will supervise the weight program which will be administered by the Clinical Coordinators and CNA's and monitor weights of at least 3 random residents weekly for 4 weeks to ensure accuracy. This will include residents who are on weekly weights. The expected outcome is to ensure the accuracy of weights being obtained. 14. Weekly, the DON will review weights with the High Risk Committee to ensure any significant loss is added to the Referral Form for the RD. 15. The DON will monitor a random sample of dietary recommendations weekly for 4 weeks to ensure that recommendations were ordered by the provider. The Quality Assurance committee will meet weekly to ensure weights are being accurately obtained, the RD recommendations are being reviewed and addressed with the physician, and that orders are implemented and carried out. After each meeting the QA committee will evaluate the process for recommendations, revisions, or resolution. Upon evaluation, any non-compliance will be addressed. The deficient practice continued at a potential for more than minimal harm for all 99 residents residing in the facility. Findings: 1. Review of resident #3's Face Sheet revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS with an ARD of 11/14/18 revealed the resident was coded as having a BIMS of 2 (Severely Impaired); required limited one person physical assistance for bed mobility, transfers, locomotion on the unit, dressing, toilet use, and personal hygiene; was totally dependent and required one person physical assistance for eating; and had no ROM impairments for upper or lower extremities. Review of the resident's plan of care with a goal date of 2/18/19 revealed a problem of Potential for a Nutritional Problem. Interventions included: diet as ordered, document intake of meals, and registered dietician to evaluate and make changes to my diet as recommended and as needed. Review of physician's orders [REDACTED]. Review of the resident's Weights and Vitals Summary revealed the following weights: August 10, (YEAR) - 116 lbs August 20, (YEAR) - 93 lbs Warning: -10% change August 29, (YEAR) - 96 lbs Warning: -10% change September 4, (YEAR) - 95 lbs Warning: -10% change October 4, (YEAR) - . 106 lbs October 12, (YEAR) - 107.5 lbs October 12, (YEAR) - 107.5 lbs October 19, (YEAR) - 106 lbs October 26, (YEAR) - 99 lbs November 2, (YEAR) - 101 lbs December 5, (YEAR) - 101 lbs Review of the RD Progress Notes revealed the following nutritional assessments: 8/21/18 - Nutritional Admission Assessment: Resident's admission weight 116 lbs. Resident shows significant weight loss of 21# X 1 month, with recommendation to increase DiabetiSource to 6 cans per day. 10/24/18 - Resident shows significant weight loss > 7.5% X 90 days, with a recommendation to increase DiabetiSource to 6 cans per day. 11/29/18 - Resident shows significant weight loss > 7.5% X 90 days, with a recommendation to increase DiabetiSource to 6 cans per day. Review of the resident's MARs dated 09/18, 10/18, 11/18 and 12/18 revealed the resident received 5 cans DiabetiSource per day per G tube. There was no documentation that S5 RD's recommendations to increase the enteral feeding to 6 cans per day were implemented. The surveyor presented this information to the provider on 12/18/18, and the resident's tube feedings were increased to 6 cans per day as recommended and ordered. Review of the facility's Weight Team and Weight, Height Measurement Policy revealed that a weight team designee was to complete a Weight Evaluation Assessment for any resident with a significant weight change. Interview on 12/20/18 at 11:40 a.m. with S3 QI RN confirmed a Weight Evaluation Assessment as per policy was not completed for resident #3 when she experienced a significant weight change. Interview on 12/20/18 at 1:00 p.m. with S2 DON confirmed the facility failed to implement the RD recommendations dated 8/21/18, 10/24/18, and 11/29/18. 2. Review of resident #5's medical record revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Medicare 60 day MDS with ARD date of 10/14/18 revealed the resident was coded for a BIMS of 00 (Severely Impaired); total dependence with one person physical assist with bed mobility, dressing, and personal hygiene; required extensive assistance with one person physical assist with transfers; extensive assistance with two person physical assistance with eating and toilet use; ROM impairment on one side for upper extremities, and lower extremity impairment on both sides; and nutritional approach - mechanically altered diet. Review of the resident's plan of care revealed a problem of Potential for Nutritional Problems 9/5/18 - Dx: Severe Protein Calorie Malnutrition, goal date 3/10/19. Review of the resident's clinical record revealed he received a House Supplement BID. The RD Progress Notes revealed the resident was assessed on 8/30/18, with a recommendation to increase House Supplement to TID. Review of physician's orders [REDACTED]. review of the resident's medical record revealed [REDACTED]. There was no evidence in the medical record of a referral to the RD after the significant weight loss was documented on 12/5/18. Interview with S2 DON on 12/19/18 at 1:15 P.M. confirmed that RD recommendations dated 8/30/18 were not implemented until 10/20/18. S2 DON revealed the following system: the RD recommendations are sent to the DON. The DON then forwards them to the RN Clinical Coordinators, and the RN Coordinators are to contact the MD/NP to notify them of the RD recommendations. S2 DON stated the facility's system had not been followed, and the MD/NP had not been notified of the RD recommendations. Interview with S3 QI RN on 12/20/18 at 10:22 a.m. revealed the facility's system did not trigger for the resident to be seen by the RD after the significant weight loss that occurred from 7/3/18 to 12/5/18. She stated that the last assessment by the RD was dated 10/24/18. She stated the resident had a significant weight loss from 06/18 to 12/18, and the resident should have triggered for a referral to the RD. Further interview with S3 QI RN and S2 DON on 12/20/18 at 10:25 a.m. revealed the facility's system did in fact trigger the weight loss as significant; however, the RN Coordinators were not monitoring the report that triggered significant weight losses. S3 QI RN and S2 DON stated the RN Coordinators were responsible for ensuring residents with significant weight loss were seen by the RD. S3 QI RN and S2 DON provided a form to the surveyor entitled Weight and Vitals Exceptions, which revealed the resident had a 10% weight loss from 7/3/18 to 12/5/18. (146 lbs to 130.2 lbs). S3 QI RN stated the RN Coordinators should have seen this form; however, they did not see it in the system. 3. Review of resident #2's Face Sheet revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's clinical record revealed an admission weight of 105 lbs dated 7/29/18. Review of the resident's discharge MDS with an ARD of 10/31/18 revealed the resident was coded to have a BIMS of 00 (severely impaired); and required extensive one person physical assist with bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. Review of the plan of care with a goal date of 1/17/19 revealed the following problems: 1. Potential for fluid volume deficit with interventions that included: encourage to drink fluids, monitor Intake and Output, monitor/document/report signs and symptoms of dehydration. 2. Potential for nutritional problem with interventions that included: monitor/document/report to MD signs and symptoms of malnutrition including emaciation, muscle wasting, and significant weight loss, and perform weights per facility protocol and MD orders. Review of RD progress notes revealed the following recommendations: 8/15/18 - 4 ounces of house supplement three times a day to provide additional calories and protein. Continue to monitor weight, labs, and intake. Refer to RD as needed. 9/11/18 - 4 ounces of house supplement three times a day to provide additional calories and protein. PEG tube feeding supplement: [MEDICATION NAME] 1.5 - 1 can for any meal consumes less that 50% three times a day. Continue to monitor weight, labs, and intake. Refer to RD as needed. There was no documentation that the above RD recommendations were implemented. Review of the Weights and Vitals Summary revealed the following weights: 7/29/18 -105 lbs. 8/1/18 - 105 lbs. 8/13/18 - 105 lbs. 9/4/18 - 107 lbs. 10/4/18 - 110 lbs. 10/12/18 -96 lbs 10/14/18 - 100.5 lbs. 10/15/18 - 96.5 lbs. 10/16/18 - 94 lbs. The above weights revealed the resident experienced an 8.7% weight loss from 8/13/18 through 10/16/18. Review of the resident's clinical record revealed he was hospitalized from [DATE] to 10/26/18 with [DIAGNOSES REDACTED]. The resident was weighed on 10/26/18 and 10/30/18 at the nursing facility and weighed 83 lbs on both dates. Review of the physician's orders [REDACTED]. Review of the resident's clinical record revealed a daily weight was not obtained on 10/29/18 as ordered. Resident #2 was again hospitalized from [DATE] to 11/27/18, and readmitted to the nursing facility on 11/27/18. Review of physician's orders [REDACTED]. Review of the Weights and Vitals Summary revealed the following weights: 11/28/18 - 79.2 lbs 11/29/18 - 79 lbs 11/30/18 - 79 lbs 12/01/18 - 77 lbs 12/02/18 - 77 lbs. There was no weight documented for 12/3/18. Review of RD progress notes dated 11/29/18 revealed RD recommendations for Two Calorie HN, give one can twice a day either by mouth or peg tube (given between meals so he can still have meals by mouth as he tolerates). If resident becomes unable to consume meals by mouth and a tube feeding is the only source of nutrition, provide Two Calorie HN, 4 cans per day, continue to monitor weight, labs, intake, and refer to RD as needed. Review of the Medication Administration Record [REDACTED]. Review of physician's orders [REDACTED]. The resident was hosptalized on [DATE] and remained in the hospital during the survey. Interview with S16 LPN on 12/18/18 at 12:30 p.m. revealed the resident would eat independently a pureed diet with thickened liquids, but he would choke and spit up his food and drink. S16 LPN stated that she fed the resident bolus feedings through his peg tube. Interview with S16 LPN on 12/18/18 at 3:13 p.m. revealed she was mistaken in her earlier interview, then stated she wasn't sure if she had ever given a bolus tube feeding to resident #2. She stated she did provide 300 ml flushes of water each shift. Interview with S2 DON on 12/19/18 at 9:10 a.m. confirmed there was no documentation of a daily weight on 10/29/18 and 12/3/18 for resident #2. Further interview with S2 DON on 12/19/18 at 9:10 a.m. confirmed the RD recommendations for resident #2 were never implemented and she took full responsibility for the lack of communication between herself, the clinical managers, and the physician to ensure the Registered Dietician's recommendations were being implemented. Interview with S5 RD on 12/19/18 at 1:17 p.m. revealed visited the facility one time a month. She stated she is made aware of consults by either an email with the physician's orders [REDACTED]. She stated she performed the consults by reviewing the electronic record, writes her recommendations, and then sends an email listing her recommendations to the DON. She stated she also included a note in the electronic record and provided a Word document of recommendations to be forwarded to the physician. S5 RD further stated she had no system in place to ensure that the facility communicated her recommendations to the physician. Interview with S15 LPN on 12/19/18 at 2:45 p.m. revealed he gave resident #2 a 300 ml water flush through his peg tube every shift as ordered, but never gave any supplemental feedings through the peg tube or by mouth.

Based on observation, interview and record review the facility failed to ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 6 (#66, #136, #70, #28, #85 and #73) of 8 residents reviewed for pressure ulcers in a total sample of 29. The facility failed to: 1. Ensure residents (#66, #136, #70, #28, #85 and #73) with pressure ulcers were assessed weekly by an RN as stated in their policy and procedure; 2. Ensure the physician was consulted when changes in pressure ulcers occurred (#66, #136, #70, #28, #85 and #73); 3. Ensure changes in pressure ulcers were documented (#66, #136, #70, #28, #85 and #73); and 4. Ensure all physician orders [REDACTED].#66 and #73). An actual harm occurred for resident #66 when the facility failed to have an RN do weekly assessments for a resident with a right heel wound. The RN stage the right heel wound on [DATE]. The clinical record revealed the right heel pressure ulcer was not assessed by a RN again until [DATE]. As a result, the resident's right heel pressure ulcer worsened (increased in size, wound bed covered in 100% slough, and eschar noted). The Treatment Nurse on [DATE] while providing treatment to the existing pressure ulcer of the right heel discovered a new area of skin breakdown to the resident's heel. Findings: Review of the Skin and Wound Care Policy and Procedure (original effective date of [DATE]) provided by S17 RN revealed wound care staging was completed by a trained RN as assigned by the DON weekly, and to notify the treating clinician of new wounds and/or changes in an existing wound. 1. Review of the facility Admission Record for resident #66 revealed the resident's original admitted was [DATE]. Review of the April, (YEAR) MD Order Summary Report revealed the resident's [DIAGNOSES REDACTED]. Review of the 5 Day MDS assessment dated [DATE] revealed the resident had a Cognitive BIMS score of 00 (unable to complete interview), and displayed inattention and disorganized thinking that would come and go. Further review revealed the resident did not reject care, required extensive assistance of 1 person for eating and drinking, extensive assistance of 2 people for bed mobility and transfers, had a swallowing disorder and would hold food in her mouth and cheeks. The assessment revealed the resident's weight was 146 pounds, and she was on a Mechanically Altered Diet. The resident was assessed at risk for pressure ulcers and had unhealed pressure ulcers that included 1 stage 2 and 2 unstageable pressure ulcers. The skin and ulcer treatments listed in the assessment included the plan for nutrition and hydration interventions to manage skin problems. Review of the resident's nurses' notes revealed the resident was hospitalized on [DATE]. Review of the Physician's History of Present Illness report (from the hospital record) dated [DATE] revealed the resident was admitted to the hospital with [REDACTED]. The above report also provided documentation the resident had the problems of friction, shearing, deep tissue injury and excoriation of the coccyx, and an unstageable wound to the right heel. Review of the Comprehensive Plan of Care revealed the resident had the problem of potential for pressure ulcer development dated [DATE], and the approaches included skin check every shift, CNA to report any skin condition, and weekly body audits to be performed per nurse. The care plan also included the problem of actual impairment of skin integrity dated [DATE], and included the approaches for weekly documentation of each area of skin breakdown to include the width, length, depth, type of tissue, exudate and any other notable changes or observations. The care plan was revised on [DATE] with a stage 2 pressure ulcer on the right heel, and the approach for heel floats (dated [DATE]) was added. Review of the Hospital Discharge Summary dated [DATE] (for the discharge of [DATE]) revealed the resident was admitted to the hospital on [DATE] with the admission [DIAGNOSES REDACTED]. Review of the facility's PCC Skin and Wound - Wound Assessments of the pressure ulcer to the right heel revealed the following: [DATE] a DTI measured 1.8 cm length and 2.9 cm width, with an area of 2.8 cm. The nurse documented there was no depth; [DATE] improvement in the DTI of the right heel with edges intact, surrounding tissue intact and size of 1.4 cm x 2.4 cm, no depth; [DATE] the pressure ulcer of the right heel measured 1.5 cm x 2.6 cm with no depth; [DATE] the pressure ulcer of the right heel measured 1.1 cm x 1 cm with, 0.1 cm depth with an area of 1.1 cm. [DATE] revealed the condition of the wound had deteriorated, a stage 2 pressure ulcer that measured 1.9 cm x 1.3 cm, wound bed 20% [MEDICATION NAME] and 80% granulation tissue present, and MD notification. Review of the Wound Care Assessments of the pressure ulcer on the right heel revealed there was an assessment dated [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] (picture) and [DATE]. Further review of the assessments revealed there was no description or measurements recorded in the assessment of the right heel on [DATE] (picture), and the weekly pressure ulcer assessment dated [DATE] was done by an LPN. Review of the skin assessment dated [DATE], by S19 LPN, revealed the pressure ulcer to the right heel measured 1.8 cm x 1.7 cm, depth 0.2 cm and a wound bed of 100% slough tissue with a moderate amount of serosanguineous drainage. Further review of the assessment notes revealed the resident displayed signs of wound pain with facial grimacing and tenseness, and the nurse assessed the resident's pain level at a level of 4 (on a scale of ,[DATE]). There was no documentation in the note the NP or MD were notified of the change in the condition of the wound. Review of a skin assessment dated [DATE] revealed a new wound was identified to the right heel, 1 cm open, red fissure area of skin breakdown, NP notified. There was no documentation that an assessment of the primary pressure ulcer of the right heel had been completed by S5 treatment Nurse on that date. Review of the picture of the pressure ulcer of the right heel dated [DATE] revealed there were 2 wounds on the right heel (one significantly larger than the second), and the wound captured in the picture and attached to the file of pictures present for the pressure ulcer monitored did not match. Review of an assessment and picture conducted by the S3 Corporate RN on [DATE] revealed that an assessment of 1 of the 2 wounds was done; however, there was no documentation of an assessment of the larger primary pressure ulcer of the right heel (that had slough tissue) until [DATE]. Review of a skin assessment dated [DATE] revealed the size of the unstageable pressure ulcer of the right heel was 3.5 cm x 4.9 cm x 0.2 cm, and the wound had slough and a small amount of eschar tissue present. The assessment was completed by S2 DON. Review of the April, (YEAR) MAR and MD Orders revealed there were no changes in the plan of care documented after the [DATE] wound assessment, and there was no documentation Nutrition / Dietary Supplementation interventions were provided. Review of the Nutrition / Dietary Notes dated [DATE] and [DATE] revealed there was RD follow-up due to the resident's wounds, and the RD documented in her notes the resident was on Vitamin C, Zinc and MVI medications. Review of the (MONTH) and April, (YEAR) MD Orders and MAR revealed there was no evidence to support the resident had received the medications Vitamin C, Zinc and MVI. Observation on [DATE] at 9:06 a.m. revealed the resident was seated in a wheelchair in her room with both feet resting flat on the floor. Further observation revealed the resident had a tennis shoe and sock on the left foot, and a dressing and a cloth heel protector over her right heel with the front half of her right foot (and toes) bare and exposed on the floor. Observation on [DATE] at 11:57 a.m. revealed the resident was seated in a wheelchair in the dining room at a table with 3 other residents, with both feet flat on the floor. Observation on [DATE] at 1:00 p.m. revealed the resident remained in her wheelchair in the hallway by her room with her feet flat on the floor. Observation during incontinent care on [DATE] at 1:15 p.m. revealed the resident had red areas on the upper buttocks on the left side of the sacrum, with one dark red area approximately the size of a nickel present, that had defined edges. The CNAs positioned the resident on her left side with the resident's right lower extremity aligned on top of the left lower extremity, and they did not place anything between the resident's lower extremities to protect the knees and ankles from pressure, and did not float the resident's heels. Interview on [DATE] at 1:34 p.m. with S5 Treatment Nurse revealed she was new to the facility and was a contract nurse. She said she had done the treatment for [REDACTED]. She said the resident did not have any other areas of skin breakdown. Observation on [DATE] at 2:00 p.m. revealed the resident remained on the left side with her right leg on top of the left leg, without pressure relief measures between her lower extremities. Observation on [DATE] at 2:23 p.m. revealed the resident's eyes were closed and she remained on her left side with her legs on top of each other without the use of pressure relief measures. Observation on [DATE] at 2:45 p.m. revealed the resident had been repositioned on her left side, and was placed under the blanket and sheet. Interview on [DATE] at 2:55 p.m. with the resident's CNA, S10 CNA revealed the pressure ulcer to the resident's bottom had healed, and that the resident was dry when they checked her at the beginning of their shift Observation on [DATE] at 8:06 a.m. revealed the resident was in the dining room, at a table with 3 other residents seated in a wheelchair with O2 in progress per nasal cannula. Further observation revealed the resident had both feet resting on the floor, with a dressing and cloth heel protector to the heel of the right foot. Observation on [DATE] at 8:39 a.m. revealed the resident was seated in the day room with other residents with both feet resting on the floor. Observation of the resident's wounds on the right heel with S2 DON, S5 Treatment Nurse and S26 NP on [DATE] at 9:00 a.m. revealed there was a significant pressure ulcer on the lateral aspect of the right heel that had slough tissue, that appeared to be the size of a quarter. There was a second area centrally located on the posterior side of the heel that was an open area that was narrow and elongated. Further observation revealed the DON took a picture of the larger pressure ulcer and stated that was the wound that should have been captured as a follow-up assessment to the prior wound (primary wound) that was being tracked. Interview on [DATE] at 8:45 a.m. with S6 Treatment Nurse revealed [DATE] was his first day to work at the facility. He stated he was a contract nurse and came on duty at 8:00 a.m. S6 Treatment Nurse stated the facility had provided a computer, and the computer provided the information needed to provide treatments for the residents. S6 Treatment Nurse stated he did not get a verbal report from staff concerning resident #66 when he came on duty, but had the information in the computer for her treatment needs. S6 Treatment Nurse reviewed the information in the computer for the resident, and said the information in the computer indicated the resident had a wound to her left forearm, one stage 2 pressure ulcer to her right heel for treatment, and was to get a barrier cream to the sacrum as a preventive measure. Interview on [DATE] at 9:12 a.m. with the resident's CNA (S8 CNA) revealed this was her second week to work at the facility, and that she had instructions in the computer for the resident's care. She said the resident had a wound to her left arm and right foot, and had some redness to her buttocks from an old wound. Observation on [DATE] at 9:30 a.m. revealed S6 Treatment Nurse assessed the resident's arms and cleaned the wound on the left forearm with wound cleanser and applied triple antibiotic cream. S6 Treatment Nurse donned gloves and unwrapped and removed the bandage to the resident's right foot. A moderate amount of red drainage was noted on the layers of the dressing. S6 Treatment Nurse observed the wound and stated there were 3 separate areas of skin breakdown present on the heel. Further observation on [DATE] at 9:45 a.m. revealed S6 Treatment Nurse assessed a new area of skin breakdown on the left side of the resident's sacrum, and he stated the area was a stage 2 pressure ulcer. Observation on [DATE] at 1:20 p.m. of the resident revealed she was lying in bed slightly tilted to the left side with the HOB elevated 45 degrees. Eyes closed. Interview on [DATE] at 9:50 a.m. with S8 CNA confirmed the new area of skin breakdown identified on the left side of the sacrum by the treatment nurse on [DATE] was the same one she noted when they provided incontinent care on the afternoon of [DATE], but she thought it was an area the nurses were aware of, and did not report it to the nurses when she saw it on [DATE]. Review of the Wound Assessment of the sacrum dated [DATE] revealed a new stage 2 pressure ulcer was identified that was acquired in-house. Further review of the assessment revealed the size of the wound was 0.8 cm x 2.2 cm with 0.1 cm depth. S6 Treatment Nurse documented the education provided was not to stay up in the wheelchair for long periods, and to turn every 2 hours when in bed. Interview on [DATE] at 2:15 p.m. with S4 LPN revealed she was the resident's nurse and had the residents on 2 halls. She stated she had worked at the facility for 4 days, and was learning the facility procedures. S4 LPN said the CNAs did not report anything abnormal about the resident to her on [DATE] or [DATE]. Interview on [DATE] at 1:26 p.m. with S5 Treatment Nurse, after the resident's treatments were completed, revealed there was a second area of skin breakdown on the right heel that was not there when she treated the resident's wounds on Monday, [DATE]. S5 Treatment Nurse stated she was not aware there was a new area of skin breakdown on the right heel. Interview on [DATE] at 1:35 p.m. with S2 DON, after the DON observed the wounds, revealed the condition of the initial pressure ulcer on the right heel had deteriorated, and there was a second stage 2 pressure ulcer on the resident's right heel. S2 DON also confirmed there was a new pressure ulcer on the resident's sacrum in an area of a previously healed pressure ulcer. Interview on [DATE] at 1:38 p.m. with S2 DON revealed the pressure ulcer of the right heel was covered with slough and was unstageable, and that there was a new wound on the right heel. Interview with S2 DON revealed there should have been a full assessment and MD / NP notification of the second wound on the right heel when the new wound was first discovered by the treatment nurse, and was not. Interview on [DATE] at 3:10 p.m. with S2 DON revealed S5 RN Treatment Nurse (newly contracted nurse) completed an assessment of the resident's new wound on the right heel on [DATE]. Further interview with S2 DON revealed the full time facility RN Treatment Nurse had left her position on [DATE], and the last recorded comprehensive assessment by an RN of the pressure ulcer on the right heel was dated [DATE]. She stated there should have been a weekly RN assessment done. Interview with S2 DON confirmed there was a picture of the pressure ulcer (right heel) dated [DATE] but there was no documentation of the size or characteristics of the wound, and there should have been. Further interview with S2 DON revealed there was an assessment documented on [DATE], but the assessment was done by S19 LPN, and the LPN was not qualified to stage a pressure ulcer and the information in the assessment was not accurate. S2 DON confirmed there was documentation the size of the pressure ulcer had increased on [DATE], and the tissue in the bed of the wound had changed to 100% slough. S2 DON confirmed there was no documentation the MD / NP were notified of the deterioration in the wound, and should have been, and there were no changes documented in the plan of care after that assessment. S2 DON also stated she should have been notified of the change. S2 DON confirmed the information in the nurses' wound assessments dated [DATE] and [DATE], and the last 2 RD notes dated [DATE] and [DATE] that the resident was on Nutritional and Dietary Supplements was inaccurate. Further interview with S2 DON revealed the treatment nurses should have consulted the MD / NP to ensure the nutritional / dietary supplements were addressed, and had not. S2 DON confirmed she had seen the resident up in her wheelchair on [DATE], and stated the resident's right foot should not have been on the floor. S2 DON stated staff should have followed the plan of care and should have floated the resident's heels and provided measures to prevent pressure when positioning the resident. Interview on [DATE] at 8:55 a.m. with S2 DON revealed the resident's LPN was responsible for oversight of the resident's care to ensure staff followed the plan of care and that the plan of care met the resident's needs. She said the staff should have reported resident concerns to the resident's LPN. Further interview with S2 DON revealed the RN Clinical Care Coordinators for the halls were next in line to provide oversight for the care the residents received. S2 DON stated the RN Clinical Care Coordinator for the resident's hall had been off since [DATE], and the RN Clinical Care Coordinator for one of the other halls had helped to provide oversight for the resident's hall since that time, and the DON was next in line for oversight. S2 DON stated the resident should have had weekly RN wound assessments of her pressure ulcers according to facility policy and should have had new areas of skin breakdown assessed promptly, and had not. Interview on [DATE] at 8:45 a.m. with S2 DON revealed the assessment dated [DATE] that was attached to the file for the pressure ulcer of the right heel in their tracking system was not correct, and she would conduct an assessment of the wound with the wound care nurse at the time of the dressing change. Interview on [DATE] at 9:15 a.m. with S2 DON revealed the condition of the pressure ulcer of the right heel had deteriorated, the wound was larger and had slough tissue. S2 DON confirmed the assessment dated [DATE] completed by the DON was the first full assessment of the pressure ulcer completed by an RN since [DATE]. 2. Review of the Face Sheet for resident #136 revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Documentation also reflected he was admitted to the facility on Hospice care. Review of the wound assessments of the pressure ulcer of the coccyx revealed a wound assessment was documented on [DATE]. The assessment revealed the length of the wound measured 1.8 cm, width was 2.7 cm and no depth was documented. The wound bed was 70% slough according to the assessment. There was an assessment dated [DATE], and there was no further documentation of an assessment of the wound until [DATE]. Review of the assessment of the coccyx pressure ulcer dated [DATE], completed by S19 LPN, revealed the wound measured 2.7 cm x 2.3 cm x 0.2 cm, and the wound bed had 10% slough tissue present. Observation of the resident on [DATE] at 1:52 p.m. revealed the resident was in bed and non-responsive, and had oxygen in progress. Further review revealed the resident expired on [DATE] in the facility. Interview with S2 DON on [DATE] at 12:05 p.m. confirmed that skin assessments were not done weekly from [DATE] to [DATE]. She stated they did not have a Treatment Nurse during that time period. She also confirmed that the measurements done on [DATE] were completed by S19 LPN. She confirmed a facility RN had not assessed the wound since [DATE]. 3. Review of resident #70's medical record revealed an admitted [DATE]. Her admit [DIAGNOSES REDACTED]. Documentation revealed she was admitted on hospice. Review of her Quarterly MDS assessment dated [DATE] revealed the resident had a BIMS score of 00. Review of the resident's Plan of Care revealed interventions for skin integrity included assess, record and monitor wound healing weekly. Measure length, width and depth where possible and assess and document status of wound, wound bed and healing progress. Report improvements and declines to the physician. Review of the Order Summary Report dated [DATE] revealed Air mattress to bed related to wounds, Foley Catheter related to wounds and weekly body audits. Review of the resident's Skin Assessments dated [DATE] revealed the area of the wound to the sacrum was 4.8 cm squared, length - 4.1 cm, width - 1.6 cm and depth - 0.5 cm. Documentation of the assessment revealed it was completed by an LPN. There was no RN signature on the assessment. Further review of the Skin Assessments revealed there were no weekly measurements of the wound after [DATE] until [DATE]. Review of the measurements on the Skin assessment dated [DATE] revealed the pressure ulcer to the sacrum had an area of 5.7 cm squared, length - 3.5 cm, width - 2.0 cm and depth - 2.0 cm. The area of the wound, the width and the depth of the wound had increased since [DATE] according to the documentation. Further review of the Skin Assessment revealed documentation the pressure ulcer was assessed and measured by S19 LPN on [DATE]. There was no documentation that a RN had assessed the wound on [DATE]. Review of the Progress Notes revealed there was no documentation that the physician had been notified of the change in the status of the resident's wound on [DATE]. Review of the Physician's Progress Notes dated [DATE] revealed he had made rounds that date. According to documentation on the Progress Notes, there were no new orders. Further documentation revealed Stage 3 pressure ulcer to sacrum was stable, venous ulcer to right ankle was stable and DTI to left heel reportedly stable per staff. Observation on [DATE] at 3:15 p.m. the resident was in bed. Her heels were elevated, and there was an air mattress on her bed. Observation on [DATE] at 8:15 a.m. revealed that the resident was in bed on her back. She was asleep. Further observation on [DATE] at 9:40 a.m. revealed the Treatment Nurse performed wound care to the resident's sacrum. After wound care, the staff turned the resident and positioned her on her right side. Observation revealed there was no venous ulcer to the resident's right, or DTI to her left heel as documented in the Physician's Progress Note date [DATE]. Interview with S2 DON on [DATE] at 10:30 a.m. revealed that the Treatment Nurse quit on [DATE]. Since that date, the facility has used agency nurses, a Treatment Nurse from a sister facility and weekend RNs for treatments. She stated measurements were normally done on Fridays by one of the weekend RNs since the Treatment Nurse had left. She confirmed the resident's sacral wound was not measured from [DATE] to [DATE]. She stated the measurements of the wound on [DATE] were done by S19 LPN, and no RN had assessed the wound that date. She also stated there was no documentation the physician had been consulted regarding the change in the resident's wound. 4. Review of resident #28's medical record revealed she was admitted to the facility on [DATE]. The resident's admitting [DIAGNOSES REDACTED]. Review of her admit MDS Assessment revealed she had a BIMS score of 07. Review of the resident's skin assessment dated [DATE] revealed the measurements: area to ulcer on left heel was 3.0 cm in length, 4.1 cm in width and 0.3 cm in depth. Further review of the skin assessments revealed they were done weekly, and on [DATE] the measurements were: length 0.6 cm, width 2.0 cm, and depth 0.2 cm. There was no documentation of weekly measurements after [DATE] until [DATE]. Review of the skin assessment dated [DATE] revealed the measurements: length - 1.6 cm, width - 0.8 cm, and depth - 0.1 cm. Interview of S2 DON on [DATE] at 12:05 p.m. confirmed that skin assessments were not done weekly from [DATE] to [DATE]. The S2 DON stated they did not have a Treatment Nurse during that time period. She also confirmed that the measurements done to the resident's heel on [DATE] were completed by S19 LPN. She confirmed that no RN had assessed the wound since [DATE]. S2 DON also stated there was no documentation that the physician was consulted regarding the change in the wound on [DATE]. Observation on [DATE] at 12:45 p.m. revealed the resident as up in her wheelchair, and there was a cushion in the seat of her wheelchair. Also, the resident was observed to have heel protectors on both of of her feet at that time. 5. Review of resident #85's medical record revealed she was admitted to the facility on [DATE] with an Unstageable Pressure Ulcer to her sacrum and a Stage 2 Pressure Ulcer to her Right Ischium. Additional [DIAGNOSES REDACTED]. Review of the Plan of Care revealed an identified problem of impaired mobility related to [MEDICAL CONDITION] as a result of a spinal cord injury. Interventions included ROM during routine care, total assistance with ADLs and transfers, antipressure mattress and turn every two hours. Review of an Admission MDS assessment dated [DATE] revealed the resident had a BIMS score of 15 (cognitively intact). Review of the Skin Assessments revealed the resident developed a Stage 2 Pressure Ulcer to her Left Ischium on [DATE]. Review of the Departmental Notes revealed the resident was hospitalized for [REDACTED]. Review of the medical record revealed the facility assessed the wounds weekly, consulted with the physician and changed treatments as ordered from admission on [DATE] to [DATE]. Review of documentation throughout the Departmental Notes revealed the resident preferred to stay up in her wheelchair all day despite much encouragement from the staff to get in bed to relieve pressure from her wounds. The resident did have a pressure relieving device in her chair; however, her wounds were on her sacrum and both Ischium. Also, documentation revealed the resident smoked often despite the facility's encouragement for her to stop. The resident also refused some of her supplements that were ordered for wound healing. Review of a Physician's Progress Note dated [DATE] revealed the resident had a decubitus on her buttocks bilaterally that was worsening despite wound care efforts from the facility. He documented that the resident would go to wound care clinic on [DATE]. The note revealed the resident had been on an antibiotic, but it would most likely not control her decubitus infection. He documented that he discussed the importance of good nutrition and not smoking as factors for good wound healing. The resident was offered Chantyx to assist with her smoking, but she declined. Review of the Departmental Notes dated [DATE] revealed the resident began treatment of [REDACTED]. On [DATE]. the resident was seen again in the wound care clinic and was started on an antibiotic for infection in wound on her Right Ischium. Further review of the Departmental Notes dated [DATE] at 3:27 p.m. revealed the resident complained of feeling chilled and had a temperature of 101.2 orally. The physician was notified and ordered a flu swab, chest X-ray and urinalysis. The resident refused all of the labs and X-ray. Review of a Departmental Note dated [DATE] at 5:39 p.m. revealed the physician's nurse came to the facility to assess the resident. The resident had a blood pressure of ,[DATE], an apical pulse of 104 and a temperature of 101.7. The resident was advised by the nurse that her symptoms pointed to [MEDICAL CONDITION], and advised her to go to the ER. The resident refused to go to the ER at that time. On [DATE] (Friday), the resident went out to the wound care clinic. She returned with new orders, a [DIAGNOSES REDACTED]. Review of the Departmental Notes revealed the resident was hospitalized from [DATE] through [DATE]. Review of a hospital discharge summary dated [DATE] revealed the resident was admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]. She received IV antibiotics and aggressive wound care. Review of the record revealed the resident was readmitted to the facility on [DATE] with new wound care orders. Review of a wound assessment done by the facility and dated [DATE] revealed the resident had 3 pressure ulcers (Right Ischial Tuberosity, Left Ischial Tuberosity, and Sacrum). They were all assessed and measured by S27 RN on [DATE]. Review of the Wound Assessments dated [DATE] revealed the following measurements: Right Ischial Tuberosity - Unstageable - area 4.2 cm square, length - 3.1 cm, width - 1.7 cm and depth - 2.8 cm Left Ischial Tuberosity - Unstageable - area 2.0 cm square, length - 1.5 cm, width - 1.7 cm and no depth documented. Sacrum - Stage 3 - area 0.8 cm square, length - 2.0 cm, width - 0.6 cm and depth - 0.2 cm. Further review of the medical record revealed there was no documentation that the facility had measured any of the Pressure Ulcers after [DATE] until the resident was assessed at a wound care clinic on [DATE]. Review of the documentation from the wound clinic on [DATE] revealed the following measurements: Right Ischium - length - 4.9 cm, width - 3 cm and depth - 2.6 cm Left Ischium- length - 4.0 cm, width is 3 cm and depth - 0.3 cm Sacrum - measured 0 cm X 0 cm X 0 cm (healed) Documentation from the wound clinic only reflected the measurements of the wounds. There was no further description or assessments documented from [DATE]. Further review of the Skin Assessments revealed there was no documentation of weekly measurements done on any of the resident's Pressure Ulcers after [DATE]. Observation of the resident on [DATE] at 10:20 a.m. revealed the resident was paralyzed from the neck down. Further observation on [DATE] at 10:45 a.m. revealed the resident was up in a motorized wheelchair. Interview with the resident on [DATE] at 10:45 a.m. revealed that her chair was more comfortable than her bed. She stated her custom wheelchair had a pressure relieving device system. She stays up in her chair unless she is going to sleep, and then she gets in the bed. 6. Review of the facility Admission Record for resident #73 revealed the