Every finding on record at Valle Vista Rehabilitation and Nursing LLC

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to evaluate, monitor, and manage a chronic scalp lesion/wound despite changes in the wound condition, including documented drainage; and failed to ensure timely wound management prior to and following the identification of a maggot infestation1 for 1 (#3) of 7 sampled residents. This deficient practice resulted in a decline of the resident's scalp lesion/wound condition and the development of maggot infestation1 requiring additional wound management and evaluation. Findings include:During an observation and interview on 6/30/26 at 2:50 p.m., resident #3 was observed with multiple, black-colored lesions on the scalp. A large central lesion approximately the size of a tennis ball was observed on the scalp. The lesion was black in color and partially covered with a brown-colored material. Yellowish, foul-smelling fluid was present. Resident #3's hair surrounding the lesions was discolored and had crusted, dried material present. Resident #3 stated she had one of the lesions for years, but the smaller ones were newer. Resident #3 stated the lesions drained off and on. Resident #3 stated she was seen by a surgeon recently, and he cleaned the wound and placed a Band-Aid on the larger lesion.During an interview on 6/30/26 at 3:05 p.m. NF1 and NF2 stated resident #3 was admitted to the facility with the skin lesion/wound. NF1 stated [Staff Member D] was aware of the lesion upon admission but only saw [Resident #3] on occasion. During an interview on 6/30/26 at 4:01 p.m. staff member C stated skin assessments were completed weekly. Staff member C stated she did not complete a skin assessment after the maggots were removed from resident #3's skin lesion/wound area. During an interview on 7/1/26 at 7:40 a.m., staff member D stated he did not evaluate or reassess resident #3 after notification that maggots were present in the scalp lesion/wound because the resident had an appointment scheduled with a general surgeon.During an observation on 7/1/26 at 10:07 a.m., resident #3's scalp continued to show yellowish, foul-smelling fluid. The resident's hair surrounding the lesions was discolored and had crusted, dried material present.Review of resident #3's weekly skin assessments dated 7/6/25-6/14/26, showed continued documentation of the presence of the scalp lesion/wound.Review of resident #3's weekly skin assessments dated 11/23/25, 11/30/25, and 12/7/25, included documentation of drainage from the scalp lesion/wound.Review of physician orders dated 11/1/25- 6/12/26, showed no wound care orders for the scalp lesion/wound before 6/12/26.Review of resident #3's nurse progress notes dated 6/12/26 showed documentation that maggots were identified and removed from resident #3's scalp lesion/wound. There was no documentation of a comprehensive assessment of the lesion/wound following the removal of the maggots.Review of physician orders dated 6/12/26, showed wound care orders were initiated on 6/12/26 after maggots were identified and removed from the scalp lesion/wound. The orders were for staff to clean the wound daily with normal saline, pat dry, apply a generous amount of petroleum jelly, cover with an ABD pad, and secure with Kerlix.Review of resident #3's electronic medical record dated 6/12/26-6/17/26 showed resident #3 was evaluated by the general surgeon on 6/17/26, five days after the maggots were identified and removed from the scalp lesion/wound. During the five-day time frame following the identification of the maggots, there was no documentation of a physician or other provider evaluation or a comprehensive reassessment of the lesion/wound.Review of a document titled Consultation, dated 6/17/26, it showed resident #3 was evaluated by a general surgeon for the chronic scalp lesion/wound. The consultation noted, . fly laid maggots on it and has had drainage, odor, and growth occurring.has had occasion to be infected. biopsy taken.Review of the document titled Office/Clinic Notes, dated 6/25/26, showed the results of the biopsy were positive for basal cell carcinoma.Review of a facility policy titled Provision of Quality Care, dated 4/11/25, showed: . the facility will ensure that residents receive treatment and care by qualified persons in accordance with professional standards of practice.1. Each resident will be provided care and services to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being.Review of a facility policy titled Resident Change in Condition/Status, dated 3/3/26, showed: To address changes in a resident's condition or status, this facility will provide the necessary care and treatment, including medical and nursing care, consistent with professional standards of practice.1. The nurse will notify the resident's attending physician or physician on call when there has been a change in a resident's condition or status.1Medical Maggot Therapy and Wound Infestation.Medical maggot therapy, also known as maggot debridement therapy, is a controlled medical treatment in which specifically bred, sterile larvae of the green bottle fly (Lucilia sericata) are used on select wounds under clinical supervision to assist with the removal of necrotic (dead) tissue. Medical-grade maggots are produced under controlled conditions to reduce the risk of introducing pathogens.Accidental maggot infestation (myiasis) occurs when flies deposit eggs in or near a wound or body tissue, resulting in an uncontrolled larval infestation. These larvae are not sterile, medical-grade larvae, and may be associated with infection risk, tissue damage, wound contamination, and the need for clinical assessment and intervention.References:Centers for Disease Control and Prevention (CDC). Myiasis. cdc.gov/myiasisU.S. Food and Drug Administration (FDA). Medical Devices; Surgical Devices; Classification of Maggots for Debridement Therapy.fda.gov

Based on observation, interview, and record review, the facility failed to ensure Enhanced Barrier Precautions (EBP) were identified and initiated, including ensuring appropriate signage was posted and personal protective equipment (PPE) was readily accessible at the point of care for 4 (#s 1, 2, 3, and 7) of 7 sampled residents who either had wounds or an indwelling foley catheter; and the facility failed to ensure hand hygiene was completed in accordance with the Centers of Disease Control and Prevention (CDC) recommendations during the distribution of clean linen for 3 (#s 5, 6, and 7) of 7 sampled residents. These deficient practices had the potential to increase the transmission of infection throughout the facility. Findings include:1. Review of a facility document titled Residents on EBP, showed resident #1 had a wound, resident #2 had a wound and an indwelling foley catheter, resident 3 had a skin lesion, and resident #7 had a wound requiring enhanced barrier precautions.During an observation on 6/30/26 at 2:40 p.m., resident #3 had no enhanced barrier precautions signage outside the room or PPE readily accessible. There was one PPE caddy for the west hallway. Staff refers to this hallway as the SCU (Special Care Unit) hallway.During an observation on 6/30/26 at 2:43 p.m., resident #1 had no enhanced barrier precautions signage outside the room or PPE readily accessible.During an observation on 6/30/26 at 2:44 p.m., resident #2 was lying in bed and had an indwelling Foley catheter bag located in a basin on the floor. Resident #2 also had a documented wound. There was no enhanced barrier precautions signage outside the room or PPE readily accessible.During an observation on 6/30/26 at 2:50 p.m., resident #7 had no enhanced barrier precautions signage outside the room or PPE readily accessible.During an observation on 6/30/26 at 2:52 p.m., one PPE caddy was located in the hallway serving resident #s 1, 2, and 7. PPE was not located immediately outside or readily accessible.During an interview on 6/30/26 at 4:01 p.m., staff member C stated enhanced barrier precautions were to be used when a resident had an infection, wounds, or an indwelling Foley catheter. Staff member C stated she was verbally told which residents were on enhanced barrier precautions. Staff member C stated that residents on enhanced barrier precautions should have a sign showing a person with a shield posted on the door frame.During an interview on 7/1/26 at 12:15 p.m., staff member G stated she had not been working at the facility very long. Staff member G stated she was unsure which residents were on enhanced barrier precautions, and she did not know what the picture of the little man with a shield meant. Staff member G stated she had been educated on infection control during orientation.During an interview on 7/2/26 at 8:10 a.m., staff member M stated enhanced barrier precautions were to be initiated at the time of a qualifying event such as a wound or Foley catheter placement. Staff member M stated she notified staff of residents on enhanced barrier precautions verbally and tried to place a picture of a little man on the door frame. Staff member M stated she had missed placing enhanced barrier precautions signage for the four residents.2. During an observation on 7/1/26 at 12:25 p.m., staff member I was distributing clean clothing. Staff member I entered resident #5's room, opened the closet door, placed the clean clothing in the closet, and shut the closet door. Staff member I did not perform hand hygiene before entering or exiting resident #5's room. Staff member I walked back to the clean linen cart, and used her hand to move clean clothing down the rack to pick up resident #6's clothing. Staff member I picked up resident #6's clothing, entered the room, opened the closet, placed the clean clothing inside the closet, and closed the closet door. Staff member I exited resident #6's room and walked back to the laundry cart. No hand hygiene was performed before entering or exiting resident #6's room. Staff member I picked up resident #7's clean clothes from the linen cart, knocked on resident #7's door, opened the door, and entered the room. Staff member I walked over to the closet, opened the closet door and placed the clean clothing inside, shut the closet door and exited resident #7's room. No hand hygiene was performed prior to entering or exiting resident #7's room.During an interview on 7/1/26 at 12:33 p.m., staff member I stated she had been educated on proper hand hygiene and was to perform hand hygiene before entering a resident's room, after leaving a resident's room, and before touching any clean linen. Staff member I stated that she did not perform proper hand hygiene.Review of a facility document titled Enhanced Barrier Precautions, with a revision date of 5/14/26, showed: . Enhanced barrier precautions refer to an infection control intervention designed to reduce the transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. 2. Initiation of Enhanced barrier precautionsa. All staff receive training on enhanced barrier precautions upon hire and at least annually. b. An order for enhanced barrier precautions will be obtained for. wounds., indwelling medical devices such as . urinary catheters., even if the resident is not known to be infected or colonized with an MDRO.3. Implementation of Enhanced Barrier Precautions.a. Make gloves and gowns available immediately near or outside of the resident's room. d. Position a trash can inside the resident's room and near the exit for discarding PPE after removal prior to exiting. 10. Enhance barrier precautions should be used for the duration of the affected resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device. [sic]Review of a facility policy titled Hand Hygiene, with a revision date of 5/6/25, showed: Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility.1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice.

Based on observation, interview, and record review, the facility failed to notify the physician of a significant change in condition related to a chronic scalp lesion/wound, including new onset of drainage, for 1 (#3) of 7 sampled residents. This deficient practice resulted in the physician not being provided with timely information about a change in the resident's condition necessary to evaluate the need for additional assessment, treatment, or intervention. Findings include:During an observation on 6/30/26 at 2:50 p.m., resident #3 had a scalp lesion/wound with black discoloration, drainage, and a foul odor.Review of resident #3's weekly skin assessments dated 11/23/25, 11/30/25, and 12/7/25 showed there was documented drainage from the resident's scalp lesion/wound.Review of resident #3's nursing progress notes dated 11/23/25-12/9/25 showed no documentation that the physician was notified of the change in condition related to the development of drainage from the scalp lesion/wound.During an interview on 6/30/26 at 4:01 p.m., staff member C stated the physician should be notified of new skin concerns and changes in the size, shape, color, or drainage of a wound. Staff member C stated the physician was notified of changes on a case-by-case basis, and not every change in a wound was reported to the physician. Staff member C stated the physician was not notified of earlier changes to resident #3's lesion/wound because the physician was aware of the lesion when resident #3 was admitted to the facility.During an interview on 7/1/26 at 7:40 a.m., staff member D stated he did not recall being notified of concerns regarding resident #3's scalp lesion/wound before being notified of a maggot infestation.During an interview on 7/1/26 at 12:15 p.m., staff member G stated the physician should be notified of any change in a resident's condition or wound, including changes in size, color, shape, or drainage.Review of a facility policy titled Notification of Changes, dated 4/11/25, showed: Policy: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician. when there is a change requiring notification. Compliance Guidelines:The facility must inform the resident, consult the resident's physician and /or notify the resident's family member or legal representative when there is a change requiring such notification. 2. Significant change in the resident's physical, mental, or psychosocial condition such as deterioration in health, mental, or psychosocial status.3. Circumstances that require a need to alter treatment.a. New treatment. [sic]Review of a facility policy titled Resident Change in Condition/Status, dated 3/3/26, showed: The nurse will notify the resident's attending physician or physician on call when there has been a change in the resident's condition or status.

Based on interview and record review, the facility failed to ensure comprehensive wound assessment, monitoring, and documentation of a chronic scalp lesion/wound in accordance with accepted standards of nursing practice, including complete documentation of wound characteristics including size, shape, color, and drainage for 1 (#3) of 7 sampled residents. This deficient practice limited the ability to accurately monitor and evaluate changes in the resident's chronic scalp lesion/wound, identify changes in lesion/wound status, and determine when additional clinical evaluation or intervention was required. Findings include:Review of resident #3's weekly skin assessments dated 6/2/25-6/29/25, and 11/2/25-11/16/25, showed no documentation of the resident's chronic scalp lesion/wound.Review of resident #3's weekly skin assessment dated [DATE]-[DATE], and 12/14/25-6/14/26, showed the presence of a scalp lesion/wound. There was no documentation describing the scalp lesion/wound characteristics, including shape, size, and color.Review of resident #3's weekly skin assessment dated [DATE], 11/30/25, 12/7/25, 6/22/26, and 6/28/26, documented drainage from the scalp lesion/wound, but did not include a description of the lesion/wound characteristics, including size, shape, color, or characteristics of the drainage, including color, consistency, and odor.Review of resident #3's electronic medical record dated 6/12/26, showed no documentation of a comprehensive skin assessment of the scalp lesion/wound was completed following the identification and removal of maggots from the lesion/wound.During an interview on 6/30/26 at 4:01 p.m. staff member C stated skin assessments were completed weekly. Staff member C stated the physician should be notified of new skin concerns, and changes in the size, shape, color, or drainage of a wound. Staff member C stated the physician was notified of changes on a case-by-case basis and not every change in a wound was reported to the physician. Staff member C stated the physician was not notified of the earlier changes to resident #3's lesion/wound because the physician was aware of the area when resident #3 was admitted . Staff member C stated staff member D was notified of the infestation of maggots in the lesion/wound. Staff member C stated she did not complete a skin assessment after the maggots were removed.During an interview on 7/1/26 at 12:15 p.m., staff member G stated the physician should be notified of any change in a resident's skin condition or wound, including changes in size, color, shape, or drainage.During an interview on 7/1/26 at 1:22 p.m., staff member B stated the facility did not have a dedicated wound nurse and nursing staff completed wound care on the residents. Staff member B stated nursing staff were educated on skin and wounds by watching a wound series and completing Relias training. Staff member B stated the expectation was skin and wound assessments were completed and documented.During an interview on 7/1/26 at 2:54 p.m. staff member E stated the expectation for skin and wounds was to be assessed upon admission to determine whether skin concerns were present. Staff member E stated the nurse completes a full head-to-toe assessment and documents any findings. Staff member E stated if a resident had a wound the wound would be documented on the skin assessment and a separate wound assessment would be completed. Staff member E stated this allows the facility to follow the progression of the wound, good or bad. Staff member E stated the expectation was for nursing staff to document, at minimum, a description of the skin concern, wound measurements or size, shape, color, drainage, (including color, consistency, and amount) and odor.Review of a facility policy titled Resident Change in Condition/Status, dated 3/3/26, showed: To address changes in a resident's condition or status, this facility will provide the necessary care and treatment, including medical and nursing care, consistent with professional standards of practice.1. The nurse will notify the resident's attending physician or physician on call when there has been a change in a resident's condition or status.Review of a facility policy titled Wound Treatment Management, stated 5/6/26, showed: 1. Wound treatments will be provided in accordance with physician orders.2. In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. [sic]

Based on observation, interview, and record review, the facility failed to ensure physician supervision and ongoing clinical oversight following notification of a significant change in condition involving a maggot-infested scalp wound for 1 (#3) of 7 sampled residents. There was no documented physician assessment or reassessment of the resident's condition or additional clinical guidance to address the significant change in condition while the resident awaited outpatient surgical evaluation. Findings include:During an observation and interview on 6/30/26 at 2:50 p.m., resident #3 had multiple black-colored skin lesions on her scalp. Resident #3 had a large central lesion about the size of a tennis ball, black in color, and was partially covered with a brown-colored material. There was a yellowish, foul-smelling fluid present. During an interview on 6/30/26 at 3:05 p.m. NF1 and NF2 stated resident #3 was admitted to the facility with the skin lesion. NF1 stated [Staff Member D] was aware of the lesion upon admission but only sees [Resident #3] on occasion. NF1 stated the lesion drained intermittently.During an interview on 6/30/26 at 4:01 p.m., staff member C stated resident #3 was admitted with a large skin lesion on her head. Staff member C stated the lesion often had a foul odor. Staff member C stated on 6/12/26, a staff member told her resident #3 had maggots in her wound. Staff member C stated she assessed the resident and found the lesion to have a foul odor, and maggots were present. Staff member C stated she called staff member D. Staff member C stated staff member D told her to clean the area with soap and water, apply petroleum jelly, and cover the wound. Staff member C stated resident #3 received a shower and the lesion was dressed per the orders. Staff member C stated staff member D did not come to the facility to assess resident #3 following notification of the maggot infestation.During an interview on 7/1/26 at 7:40 a.m., staff member D stated he did not evaluate or reassess resident #3 after notification that maggots were present in the scalp wound because the resident had an appointment scheduled with a general surgeon.Review of physician progress notes dated 2/4/26 and 4/15/26 showed no documentation of a scalp lesion.Review of a physician progress note dated 6/10/26 showed, . Scalp lesion. The lesion on her scalp continues to enlarge in size. She denies any pain. There is [sic] been a strong odor. Assessment/Plan. 3. Lesion of the scalp.Concerning squamous cell carcinoma. Nursing staff discussed with family if they desire biopsy and potential treatment. This would need to be done by general surgery. They would like to have this evaluated. Will place referral to general surgery. [sic]Review of resident #3's electronic medical record dated 6/12/26-6/17/26, showed no documentation of a physician progress note following the notification of the maggot infestation on 6/12/26 until the resident's outpatient surgical evaluation on 6/17/26.Review of a facility policy titled Resident Change of Condition/Status, with an implementation date of 3/3/26, showed: To address changes in a resident's condition or status, this facility will provide the necessary care and treatment, including medical and nursing care, consistent with professional standards of practice.

Based on interview and record review, the facility failed to maintain complete and accurate medical records by failing to ensure the resident's medical record accurately reflected the presence, characteristics, and changes in a scalp lesion/wound for 1 (#3) of 7 sampled residents. This deficient practice resulted in an incomplete medical record that did not accurately reflect the resident's condition or provide a complete picture of the wound status, or care provided.Review of resident #3's weekly skin assessments dated 6/2/25- 6/29/25 and 11/2/25-11/16/25, showed no documentation of the resident's chronic scalp lesion/wound.Review of resident #3's weekly skin assessments dated 7/6/25-9/28/25 and 12/14/25-6/14/26, showed documentation of the presence of a scalp lesion/wound, but the record did not include complete documentation of the lesion/wound characteristics, including size, shape, color, and drainage characteristics.Review of resident #3's electronic medical record dated 6/12/26 showed no documentation that a comprehensive assessment of the chronic scalp lesion/wound was completed following the identification and removal of maggots from the lesion/wound.During an interview on 6/30/26 at 4:01 p.m. staff member C stated skin assessments were completed weekly. Staff member C stated she did not complete a skin assessment after the maggots were removed.During an interview on 7/1/26 at 1:22 p.m., staff member B stated nursing staff were expected to complete and document skin and wound assessments.During an interview on 7/1/26 at 2:54 p.m., staff member E stated the expectation was for nursing staff to document, at minimum, a description of the skin concern, wound description or measurements, shape, color, drainage, and odor. Staff member E acknowledged the medical record did not contain all the information necessary to provide a complete picture of resident #3's wound status and related care provided.

Based on observation and interview, the facility failed to ensure staff follow safe food labeling and storage processes in accordance with standards for food service safety and failed to maintain sanitary conditions, including employee hygiene. These deficient practices affected all residents receiving food services from the facility's kitchen and dietary staff, and the deficient practices would continue if not addressed. Findings include: 1. During an observation and interview of the kitchen, on 6/1/26 at 11:42 a.m., the following conditions were present:- The maroon cereal bowls were stored upright in a bus tub. Staff member W said the bowls should be turned over when stored so stuff does not fall into the bowl.- Four large metal bowls were observed sitting upright on wire shelves. - A large unlabeled tub of dried beans was noted near the stove. Staff member W identified the contents of the container as pinto beans. Staff member W said the beans should have been thrown away.- Two opened plastic squeeze bottle of Smucker's strawberry jam were on the shelf near the stove. The label said keep refrigerated after opening. Staff member K said she had removed the jam from the cooler before breakfast in the morning.- Delicatessen ham and turkey were in separate plastic bags placed together in a large tub. The turkey was not dated, and the package was not open wide and not sealed. The ham package was not closed securely. - In a large tub on the bottom shelf of the cooler, what appeared to be thawed chicken was stored in plastic vacuum bags. There was no label to identify what was in the bag and the date the contents were removed from the freezer was missing. - On the third shelf from the bottom in the cooler, a large tub contained a tube of meat which looked like hamburger. The tube was not labeled with the contents or the thaw date. The meat was thawed out, and the tube was laying with one end of the tube hanging over the edge of the tub.- In a tub in the cooler, on the bottom shelf there were several packages of meat products. The meat was thawed but did not have a thaw date or a label identifying the meat product.- A large unlabeled and undated container full of a ground yellow meal was observed outside the cooler. Staff member W said the tub was full of cornmeal.- A large unlabeled and undated container full of white looking grain was observed outside the cooler. Staff member W said the contents of the container was rice.- The microwave interior was soiled with flecks of brown and white material. - The underside of the large stand mixer was soiled with brown and white dried debris.- Hot chocolate machine nozzles and the plate the nozzles were secured to was heavily soiled with dried hot chocolate. When staff member W was asked about the cleaning schedule, she said the nozzles were not cleaned often enough due to the amount of dried hot chocolate. - Juice nozzles on the juice dispenser were soiled and sticky from dried juice. When asked how often they were cleaned, staff member W said, Not often enough.- The following containers were open and not dated: soy sauce, vanilla, a gallon of vegetable oil, and a gallon container with butter/oil substitute. A bottle of vinegar was not dated, and the cap was off. - The walk-in freezer had several large mounds of ice on the shelves and on the floor.- Staff member T entered the kitchen without a hair net on. Staff member T walked through the kitchen to the juice machine. After the juice was obtained, she walked back through the kitchen and left through the door near the hand-washing sink. At no time did staff member T have a hair net on during the observation.- Staff member M did not have a beard cover on while working in the kitchen. Staff member M had a beard and mustache.During an interview during the kitchen walk-through, staff member W said she had just started working there a little over a month ago. Staff member W said she was not sure of all the facility policies. Staff member said she was one of three new employees in the kitchen, and there had not been time to do all the education yet. 2. During an observation on 6/1/26 at 12:50 p.m., in the large dining room, staff member M was wearing a beard net, which was not covering his mustache.3. During an observation on 6/1/26 at 12:57 p.m., the noon meal service started in the large dining room. Staff member K wore the same pair of gloves throughout the entire meal service. Staff member K touched the outsides of the bun bags and moved the tubs of soup bowls to the back table. Staff member K took the temperature of the food and the soup. Staff member K paged through a three-ring binder to find the appropriate place to document the temperatures. Staff member K picked up a pen that was lying on the counter and wrote the temperatures in the binder. Staff member K then got the soup bowls out with gloved hands, putting her thumbs in the bowls when dishing up the soup. Staff member K was observed wearing the same gloves. Staff member K picked up the hamburger bun with her gloved hands and then placed condiments on the burger with the same gloved hands.4. During an observation on 6/2/26 at 8:40 a.m., staff member W was washing dishes. Staff member W was wearing gloves and placed dirty dishes into the dishwasher trays. Without removing her gloves and sanitizing her hands, staff member W picked up a clean cutting board and placed it in the cutting board rack. Staff member W began filling more dirty tray racks with water pitchers. After the dishwasher completed the cycle, staff member W, using the same dirty gloves, pulled the clean dishes out of the dishwasher. Staff member B noted the practice, identified that it was incorrect, and educated staff member W.5. During an observation on 6/2/26 at 8:47 a.m., staff member U had a mustache and was not wearing a beard net. Staff member U was also not wearing a hair net in the food service area. Staff member B said he should have a beard and a hair net on.6. On 6/03/26 at 8:37 a.m., staff member Y said the company would have a dietary manager from another facility come and spend some time training their dietary manager and the rest of the staff. 7. During an observation on 6/3/26 at 12:31 p.m., staff member M was serving food in the small dining room. Staff member M adjusted his beard cover while wearing gloves. Staff member M served food to the residents and pushed the food around with contaminated gloves. Staff member M, while wearing the same gloves, put his fingers inside the bowls when dishing up the soup.

Based on observation, interview, and record review, the facility failed to develop and maintain a comprehensive care plan, which included the presence of a resident's hearing aids and the need for staff to assist the resident with putting the hearing aids in his ears, for 1 (#6) of 18 sampled residents. Findings include:During an observation and interview on 6/2/26 at 10:50 a.m., resident #6 was lying in bed, not wearing his hearing aids. When asked why he was not wearing his hearing aids, the resident stated he was not sure where they were. Resident #6 stated he thought they may have been missing for approximately six months. The charger for resident #6's hearing aids was plugged in and sitting on the bedside table next to the sink in the resident's room. One hearing aid was found charging. During an observation and interview on 6/2/26 at 11:06 a.m., staff member X was asked about #6's hearing aids. Staff member X stated there was one in the charger, and he will have to ask the nurse if she knows where the other one was located. Staff member X returned to resident #6's room and stated the nurse did not know anything about the missing hearing aid.During an interview on 6/2/26 at 2:20 p.m., NF6 stated resident #6 had two hearing aids but was not able to put them in by himself. NF6 also stated that resident #6 was not good at asking for help. During an observation and interview on 6/3/26 at 9:39 a.m., resident #6 was lying in bed and did not have either of the hearing aids in place. There were no hearing aids in the charger, which was plugged in next to the sink in resident #6's room.During an interview on 6/3/26 at 9:43 a.m., staff member R stated she believed resident #6's hearing aids had been missing since the first week he was at the facility. Resident #6 was admitted to the facility in December 2025.Review of resident #6's Inventory of Personal Effects, dated 12/8/25, showed under the section Hearing Aid: Right and Left were circled. The Make, Model, and Serial Number were blank on the form.Review of resident #6's current care plan, initiated on 12/11/25, failed to show the presence of hearing aids or the need for staff to assist the resident with putting them in daily.

Based on observation, interview, and record review, the facility failed to ensure the comprehensive care plan was reviewed and revised to accurately reflect individual resident-centered care needs for 3 (#s 4, 18, and 61) of 18 sampled residents. Findings include: 1. Review of resident #61's EHR, dated from admission on [DATE] to discharge on [DATE], showed the resident displayed frequent behaviors, which included refusing care, refusing to eat, refusing to use the call light, and yelling out for help for extended periods of time. The resident's refusals of care and yelling behavior continued throughout the resident's stay. The nursing notes showed the staff attempted to meet the resident's needs without a corresponding decrease in behaviors. During an interview on 6/1/26 at 12:30 p.m., NF4 stated resident #61 was admitted to the facility for strengthening physical therapy with a goal to return home with her spouse. NF4 stated he did not remember the facility discussing behavioral health services in an effort to manage resident #61's disruptive behaviors. When staff responded to resident #61, she did not always have an identifiable need and would become verbally abusive towards staff. During an interview on 6/4/26 at 11:11 a.m., staff member B stated NF4 refused to allow a mental health consultation to be done for resident #61, and the resident was not always compliant with taking lactulose (a medication used to decrease ammonia levels in the blood). The elevated ammonia levels were related to resident 61's diagnosis of chronic liver disease. Staff member B stated the resident's care plan addressed her behaviors for pain, nutrition, and functional status. Review of resident #61's Significant Change MDS, with an ARD of 9/8/25, showed areas triggered for care planning were behaviors and cognitive loss. Resident #61 was documented as having a BIMS of 11 out of 15, correlating to moderate cognitive impairment. The analysis of findings for the care area assessments of behaviors and cognitive loss showed, . She has behaviors of yelling for staff and not using the call light at times. She knows to use the call light and chooses to yell. She also refuses cares and often refuses to eat. [sic] The observable characteristics and extent of resident #61's cognitive loss showed, . confusion, disorientation, forgetfulness (observation, clinical record). Review of resident #61's care plan from 6/2/25 to 10/19/25 failed to show disruptive behaviors as focus areas. There were no interventions identified to address the resident's behaviors, and there were no revisions when interventions were not effective in reducing the frequency or severity of behaviors. The care plan failed to show the presence of disruptive behaviors or interventions implemented as a result of the resident's disruptive behaviors. 2. Review of resident #18's IDT (interdisciplinary team) progress notes, dated 5/12/26, showed that resident #18 had a fall on 5/7/26. The interdisciplinary team identified the root cause of the fall for resident #18, the feet and floor were wet in front of the toilet. A recommended intervention to prevent further falls was to place grippy strips in front of the toilet. Review of resident #18's care plan, dated 5/11/26, showed the care plan was updated after the fall. The interventions showed, Since [Resident #18's] fall, he has been utilizing a wheelchair. He (resident #18) is able to operate with set up, please assist him if needed. The active care plan, dated 4/2/26, showed that resident #18 was often able to ambulate independently. The care plan did not include the grippy strips for the floor, which were placed in front of the toilet to prevent further falls. The care plan did not show that resident #18 used a walker for mobility/ambulation. During observations made on 6/1/26 at 3:45 p.m., 6/2/26 at 9:20 a.m., 6/2/26 at 9:20 a.m., and 6/3/26 at 12:26 p.m., resident #18 was observed using a walker when ambulating in the halls. During an interview on 6/4/26 at 8:45 a.m., staff member B said much of resident #18's variation in physical ability was due to fluctuations in his mental health. Staff member B stated resident #18 had told the staff he had been in the military and was shot (gunshot injury) in his hip. Resident #18 said that because of being shot, he had to use a walker. There was no evidence in the health record showing resident #18 was in the military. 3. During an interview on 6/4/26 at 11:18 a.m., staff member G stated that if a change occurred with a resident's plan of care, the CNA would be notified by the nurse on shift. Staff member G stated that resident #4 had tried glasses with colored vision lenses. Staff member G stated the glasses were in the social services office, and she was not sure if the resident was still using them. During an interview on 6/4/26 at 11:22 a.m., staff member J stated nurses could not change resident care plans, and the interdisciplinary committee was responsible for updating a resident care plan if a change occurred. Staff member J stated resident #4 was evaluated by outpatient services for vision issues and had trialed glasses with colored vision lenses. Review of resident #4's nurse progress note, dated 4/18/26 at 12:41 p.m., showed, . staff worked with [Resident #4] over lunch testing out filtered lenses . [Resident #4] used them for about ten minutes before she removed them and commented that she'd like to try them again in the morning. [Resident #4] said that the glasses worked, were durable, and they made a difference in one of her eyes. Review of resident #4's current care plan showed a referral was made for a vision evaluation. The care plan did not reflect the use of colored lenses as a new intervention for the resident. Review of a facility document titled, Care Plan Revisions Upon Status Change, revised 5/7/26, showed the following: . d. The care plan will be updated with the new or modified interventions.

Based on observation, interview, and record review, the facility failed to provide the needed assistance with completing Activities of Daily Living (ADL's) for 1 (#6) of 18 sampled residents. The deficient practice resulted in a resident not wearing his hearing aids or dentures. Findings include:During an observation and interview on 6/2/26 at 10:50 a.m., resident #6 stated he had upper and lower dentures, but was not sure where they were. Resident #6 was not wearing any dentures or hearing aids at the time of the observation.During an observation and interview on 6/3/26 at 9:39 a.m., resident #6 stated the staff did not offer to put in the resident's dentures or hearing aids. Resident #6 stated he needed help but did not like asking for help. The resident's upper and lower dentures were in a dry denture cup on the sink; the dentures were not in any water or cleanser. The upper denture had a dried pink substance on it. The hearing aid charger was on the nightstand next to the sink in the resident's room. There were no hearing aids in the charger.During an interview on 6/3/26 at 9:43 a.m., staff member R stated she had helped resident #6 with his morning cares and did not know the resident had dentures. Staff member R did not offer to assist the resident with his dentures or his hearing aids.Review of resident #6's Inventory of Personal Effects, dated 12/8/25, showed the resident had upper and lower dentures and two hearing aids.Review of resident #6's Quarterly MDS assessment, with an ARD of 5/6/26, showed the resident required substantial to maximal assistance with oral care and personal hygiene.

Based on observation, interview, and record review, the facility failed to provide a resident with necessary respiratory care and services as per physician orders and failed to ensure a portable oxygen tank was replaced when the metered volume indicated empty for 2 (#s 36 and 54) of 19 sampled and supplemental residents for oxygen therapy. This deficient practice increased the risk of negative outcomes stemming from respiratory complications due to a lack of provision of oxygen. Findings include:1. During an observation and interview on 6/2/26 at 3:36 p.m., resident #36 was sitting in her room watching television. Resident #36 was wearing oxygen via nasal cannula which was attached to a portable oxygen tank on the back of her wheelchair. The oxygen was set at two liters of oxygen, but the metered volume on the oxygen tank showed the oxygen tank as empty. When staff member N checked resident #36's oxygen saturation level, it showed at 87%. Staff member N said resident #36 was usually on two liters to keep her oxygen level above 90%.During an observation on 6/3/26 at 3:00 p.m., resident #36 was sitting in the dining room in her wheelchair. The metered volume on the oxygen tank showed the portable oxygen tank was empty.Review of resident #36's physician order, dated 3/26/24, showed resident #36 was to use three liters of oxygen per minute per nasal cannula to keep her oxygen saturation level over 90%.Review of resident #36's care plan showed the resident had heart failure and chronic obstructive pulmonary disease. The care plan directed the staff to administer oxygen.2. During an observation and interview on 6/3/26 at 2:55 p.m., resident #54 was sitting in her wheelchair in her room. Resident #54's oxygen tank was set at two liters; however, the oxygen tank was empty. Staff member J said she wore oxygen for comfort. Staff member J checked resident #54's oxygen saturation level and it was 88%. Resident #54 was agitated and swatted at the nurse attempting to take her oxygen saturation level.Review of resident #54's physician order, dated 4/14/26, showed resident #54 was to receive oxygen at two to four liters per minute to keep her oxygen level above 90%. This was to be done every shift related to chronic respiratory failure with hypoxia.

Based on the interview and record review, the facility and staff failed to provide the necessary behavioral health services and oversight for a resident who displayed disruptive yelling, refusals of care, and verbal abuse toward staff regularly, and failed to document the resident's responsible party's refusal of behavioral health services. The medical record did not include evidence to show the facility consistently attempted to identify, trend, implement, monitor, or modify behavioral interventions consistently as the behaviors continued without change, to assist the resident with maintaining or improving her mental health and well-being, for 1 (#61) of 18 sampled residents. Due to these failures, the resident continued her disruptive yelling and refusals of care. Findings include:Review of resident #61's EHR, dated from 6/2/25 to 10/19/25, showed the resident displayed frequent behaviors, which included refusing care, refusing to eat, refusing to use call light, and yelling out for help for extended periods of time. Refusals of care and yelling behaviors continued to occur. The nursing notes showed the staff attempted to meet the resident's needs without a corresponding decrease in behaviors.Review of resident #61's physician progress notes, dated 6/4/25, 8/4/25, and 10/10/25, failed to address the disruptive behaviors documented by the nursing staff.During an interview on 6/1/26 at 12:30 p.m., NF4 stated resident #61 was admitted to the facility for strengthening physical therapy with a goal to return home with her spouse. NF4 stated he did not remember the facility discussing behavioral health services in an effort to manage resident #61's disruptive behaviors. When staff responded to resident #61, she did not always have an identifiable need and would become verbally abusive towards staff.During an interview on 6/4/26 at 11:11 a.m., staff member B stated one of the challenges in caring for resident #61 was NF4 wanted many of the medications discontinued. Staff member B stated NF4 refused to allow a mental health consultation to be done for resident #61 and the resident was not always compliant with taking lactulose (medication used to decrease ammonia levels in the blood). The elevated ammonia levels were related to resident 61's diagnosis of chronic liver disease.A request was made for any documentation related to the refusal of a behavioral health services consultation. No documentation was provided prior to the end of the survey.

Based on interview and record review, the facility failed to provide a quadriplegic resident with a wheelchair after discharging and transferring him to an Adult Services Residential Program facility on the East coast and failed to document the transfer discharge of the resident in the medical record, for 1 (#2) of 4 sampled residents. This deficient practice resulted in a resident not having his main mode of locomotion. Findings include:During an interview on 11/5/25 at 8:00 a.m., NF3 stated when his ambulance service picked up resident #2, there was no wheelchair included in the resident's belongings that were to go with him on the transport to the Pennsylvania facility.During an interview on 11/5/25 at 8:32 a.m., staff member D stated having a wheelchair for mobility was important for resident #2 to get up to go to meals and sit at the nurses' station for extra supervision. During an interview on 11/5/25 at 8:59 a.m., NF5 stated he came to the facility a few days before resident #2 was to discharge to the Pennsylvania facility, to fit him for a new power wheelchair. NF5 stated when he found out resident #2 was transferring to a facility in Pennsylvania in a few days, he told facility staff there would not be enough time, and the Pennsylvania facility should start the process of ordering a new power wheelchair with another company in that area. NF5 further stated he was told there was not enough room in the ambulance for resident #2's current power wheelchair. Staff member B told him they were going to send a manual wheelchair with resident #2 on the transport to the Pennsylvania facility.During an interview on 11/5/25 at 9:16 a.m., staff member B stated the Pennsylvania facility did not want resident #2's power wheelchair, and she offered to send one of the facility's standard wheelchairs with the resident on discharge. Staff member B stated, To my knowledge, the standard wheelchair got on the ambulance with the resident (#2). Staff member B further stated, she had no documentation the standard wheelchair was sent on the ambulance with resident #2 to the Pennsylvania facility. Staff member B stated all the discharge documentation for resident #2 was through email and TEAMS (network communication and collaboration program) meeting discussions and not in the medical record as the facility normally would. During an interview on 11/5/25 at 10:25 a.m., NF7 stated she had a communication from the Pennsylvania facility, and resident #2 arrived at the Pennsylvania facility without a wheelchair (manual or electric).A review of resident #2's care plan, with a revision date of 10/14/25, showed, [Resident # 2] has limited physical mobility r/t spastic quadriplegic cerebral palsy requiring use of wheelchair for primary mobility.Review of resident #2's electronic medical record showed it did not have a discharge progress note the day of discharge, recapitulating his stay or what occurred during the discharge to include the resident did discharge from the facility, education of medications and treatments, belongings of the resident, who picked up the resident and when, and his reason for discharging. A review of a facility policy, titled, 'Transfer and Discharge (including AMA), with a revised date of 4/30/25, showed: Policy:It is the policy of this facility to permit each resident to remain in the facility and not transfer or discharge the resident from the facility, except in limited circumstances. This policy applies to all residents regardless of their payment source.8. For a transfer to another provider, for any reason, the following information must be provided to the receiving provider: .e. All special instructions and/or precautions for ongoing care, such as:i. Treatments and devices (oxygen, implants, IV's, tubes/catheters); .[sic]

Based on observation, interview, and record review, the facility failed to ensure an adequate infection prevention and control program was maintained, to include appropriate cleaning of facility equipment, and an annual review of all policies and procedures including the facility's water management system and Legionella surveillance. This deficient practice increased the likelihood of residents acquiring a healthcare-associated communicable disease or infection in the facility. Findings include: During an observation and interview on 5/19/25 at 4:26 p.m. with staff member E, the North hallway common bathtub was observed during a tour of a shower room. The bathtub had multiple long streaks of dark, rust color stains on the sides and floor of the tub. The drain had dried dark brown sediment around it. The bathtub did not have signage or a cover which notified staff and residents it was not to be used. Staff member E stated she had not cleaned the North hallway bathtub in maybe five or six months. Staff member E stated the bathtub was not being used by residents. She stated the only equipment used in the North hallway bathroom was the toilet and the sink. Staff member E stated she thought housekeeping audits were being done once a month by staff member A. Review of a facility policy titled, Cleaning and Disinfection of Resident-Care Equipment, dated 4/11/25, showed: . Resident Care equipment can be a source of indirect transmission of pathogens. Reusable resident-care equipment will be cleaned and disinfected in accordance with current CDC recommendations in order to break the chain of infection . Follow manufacturer recommendations for cleaning equipment. Review of a facility policy titled, Water Management Program Policy, showed an effective date of April 2020, with no subsequent annual revision or review dates. Review of a facility policy titled, Legionella Surveillance Policy, showed an effective date of April 2020, with no subsequent annual revision or review dates. Review of a facility document titled, Facility Assessment, dated 8/7/24, showed: .Physical equipment .Resources .bathing tub .If applicable, process to ensure adequate supply, appropriate maintenance .Routine maintenance and cleaning schedules exist for most equipment. Non-routine maintenance or cleaning will be conducted as needed . . The facility maintains an aggressive infection prevention and control program . The program includes . policies and procedures based on CDC guidance. The infection prevention and control program is discussed regularly by the QAA committee . and appropriate action taken as needed . A request was made to the facility on [DATE] at 9:35 a.m. for cleaning/deep cleaning documentation of the North hallway tub from June 2024 to present, and no documentation was received by the end of the survey. A request was made to the facility on [DATE] at 1:00 p.m. for housekeeping audits of cleaning and disinfecting practices, and no documentation was received by the end of the survey.

Based on interview and record review, the facility failed to maintain complete medical records, including medical provider visit notes, for 4 (#s 2, 17, 23, and 32); and failed to ensure a resident's Provider Orders for Life-Sustaining Treatment (POLST) was signed by a medical provider for 1 (#33) of 15 sampled residents. Findings include: 1. Review of resident #2's electronic medical record, accessed 5/17/25 through 5/20/25, showed a lack of medical provider visit notes. Resident #2 was admitted to the facility in April of 2025. 2. Review of resident #17's electronic medical record, accessed 5/17/25 through 5/20/25, showed a lack of medical provider visit notes. Resident #17 was admitted to the facility in January of 2025. 3. Review of resident #23's electronic medical record, accessed 5/17/25 through 5/20/25, showed no medical provider visit notes. Resident #23 was admitted to the facility in February of 2025. 4. Review of resident #32's electronic medical record, accessed 5/17/25 through 5/20/25, showed no medical provider visit notes in resident #32's chart after December of 2024. Resident #32 was admitted to the facility in January of 2023. During an interview on 5/20/25 at 12:06 p.m., staff member B stated medical provider visit notes were received via facsimile from the medical provider to the facility. Staff member B stated the charge nurse reviewed the medical provider visit notes and placed the notes in a black file at the nurses desk which would then be scanned into the resident's electronic medical record. Staff member B stated after scanning had occurred the faxed copy was placed in the resident's paper chart file in a drawer at the nurse's desk. Staff member B stated the most recent medical provider visit notes had not been scanned into the resident's electronic medical record but could be found in the resident's paper chart in the drawer at the nurse's desk. Staff member B stated they were currently working on a process for the medical provider to directly enter the resident's medical provider visit note into the residents' electronic medical record in order for the information to be immediately accessible. Staff member B stated a facility nurse was always present with the medical provider during resident visits but did not document any information from the visit in the resident's electronic medical record. A review of resident #s 2, 17, 23, and 32's paper charts, located in a drawer at the nurse's desk, was completed on 5/20/25. No facility medical provider visit notes were located in resident #s 2, 17, and 23's paper charts. Resident #32's paper chart showed facility medical provider notes up to December of 2024. No facility medical provider visit notes were found after December of 2024 for resident #32. A request for documentation of medical provider visit notes was made on 5/19/25 for resident #s 2, 17, and 23, for the period from admission to May 2025. The medical provider visit notes for resident #32 were from January 2025 through May 2025. The medical provider visit notes were received from the medical provider's office via facsimile for the following dates: -Resident #2: 4/29/25. -Resident #17: 1/8/25, 2/6/25, 4/29/25, and 5/15/25. -Resident #23: 2/13/25, 3/13/25, 3/18/25, 3/27/25, 4/17/25, and 4/24/25. -Resident #32: 2/20/25 and 4/29/25. Four residents currently residing at the facility did not have medical provider visit notes available in the resident's electronic medical record or in the paper chart located in a drawer at the nurse's desk. 5. Review of resident #33's POLST, dated 3/1/23, failed to show a physician's signature on the bottom of the form. During an interview on 5/19/25 at 3:10 p.m., staff member C stated she was responsible for ensuring the resident's POLST was completed correctly. Staff member C stated the POLST document in resident #33's medical record was completed when the resident was at a different facility. When shown a copy of resident #33's POLST, without a physician signature, staff member C stated, I can't believe I missed it. Better get that taken care of. Review of the facility's policy titled, Residents' Rights Regarding Treatment and Advance Directives, dated 4/11/25, showed: . 3. Upon admission, should the resident have an advance directive, copies will be made and placed on the chart . The policy also showed: . 8. Decisions regarding advance directives and treatment will be periodically reviewed as part of the comprehensive care planning process . The facility failed to identify the missing signature on resident #33's POLST.

Based on interview and record review, the facility failed to ensure consent for the use of psychotropic medications was obtained prior to starting a psychotropic medication for 2 (#s 33 and 48) of 18 sampled and supplemental residents. Findings include: 1. Review of resident #48's physician order, dated 2/21/25, showed an order for citalopram hydrobromide, 10 mg, one tablet daily. The diagnosis associated with the order was, unspecified dementia, severe, with other behavioral disturbance. Review of resident #48's Informed Consent for Anti-depressant Medication Use, dated 2/24/25, showed, Note: All information must be explained, and consent obtained PRIOR to administering medication. The consent was signed by the resident's spouse on 2/24/25, after the medication was started. Review of resident #48's MAR, dated February of 2025, showed the first dose of citalopram hydrobromide, 10 mg, was given on 2/22/25, two days before the consent was completed. 2. Review of resident #48's physician order, dated 4/25/25, showed an order for sertraline HCl, 100 mg, one tablet daily. The diagnosis associated with the order was, Unspecified dementia, severe, with other behavioral disturbance and major depressive disorder, recurrent, moderate. Review of resident #48's Informed Consent for Anti-depressant Medication Use, dated 4/28/25, showed the consent was signed by the resident's spouse and dated three days after the medication order was received. Review of resident #48's MAR, dated April of 2025, showed the first dose of sertraline HCl, 100 mg, was given on 4/26/25, two days before the consent was completed. 3. Review of resident #33's physician order, dated 1/7/25, showed an order for citalopram hydrobromide 10 mg one tablet daily. The diagnosis associated with the order was depression related to vascular dementia, unspecified severity, with agitation and delusional disorders. Review of resident #33's MAR, dated January of 2025, showed the first dose of citalopram hydrobromide, 10 mg, was given on 1/8/25. Review of resident #33's EHR, accessed on 5/19/25, failed to show a completed consent for the use of citalopram hydrobromide. 4. Review of resident #33's physician order, dated 4/29/25, showed an order for haloperidol, 5 mg, every eight hours, as needed, for behavioral disturbance and agitation. Review of resident #33's Informed Consent for Anti-Psychotic (Neuroleptic) Medication Use, dated 5/1/25, showed the consent was signed by the resident's guardian two days after the medication order was received. During an interview on 5/20/25 at 10:18 a.m., staff member B stated staff member C was responsible for obtaining the consents for psychotropic medications. Staff member B was not able to explain why the consents were not completed prior to starting the psychotropic medications. Review of the facility's policy titled, Use of Psychotropic Medication(s), last revision dated 4/28/25, showed the resident or the resident's representative must be informed of the risks and benefits of the proposed treatment prior to initiating a psychotropic medication.

Based on interview and record review, the facility failed to ensure as needed psychotropic medications were limited to 14 days, unless the rationale for continuing the medication was documented by a medical provider, for 2 (#s 33 and 48) of 18 sampled and supplemental residents. Findings include: 1. Review of resident #33's physician order, dated 1/7/25, showed an order for olanzapine, 5 mg, every six hours, as needed, for agitation or delusions related to vascular dementia and delusional disorders. The as needed order failed to include the 14 day duration for antipsychotic medications. Review of resident #33's medication regimen review, dated 1/9/25, showed no irregularities and failed to show the need to monitor the use of olanzapine after 1/21/25 (14 days). Review of resident #33's medication regimen review, dated 2/26/25, showed the pharmacist notified the attending physician about the as needed olanzapine order. The form showed, . CMS doesn't allow for PRN (as needed) antipsychotics for more than 14 days. Consider discontinuing this medication to comply with CMS guidelines. The form showed the provider agreed with the recommendation and signed the form on 3/5/25. Review of resident #33's MAR, dated January of 2025, showed the olanzapine order remained active until it was discontinued on 3/7/25. 2. Review of resident #48's physician order, dated 2/6/25, showed an order for quetiapine fumarate, 25 mg, every 24 hours, as needed, for agitation or anxiety related to severe dementia with other behavioral disturbance. The as needed order failed to include the required 14 day duration for the antipsychotic medication. Review of resident #48's medication regimen review, dated 2/26/25, showed the pharmacist notified the attending physician about the as needed quetiapine fumarate order. The form showed, . has an order for PRN (as needed) Seroquel (quetiapine fumarate) that started on 2/6 and only two doses have been needed. CMS prohibits the use of PRN antipsychotics for more than 14 days. Consider discontinuing this medication. The form showed the physician agreed with the recommendation and signed the form on 3/5/25. Review of resident #48's MAR, dated February of 2025, showed the quetiapine fumarate was active until it was discontinued on 3/7/25. During an interview on 5/20/25 at 10:18 a.m., staff member B stated staff member D was responsible for managing the monthly medication regimen review process. Staff member B stated staff member D was not available for an interview. Staff member B was not able to explain why the as needed antipsychotic medications were not reviewed for continued use after 14 days. Review of the facility's policy titled, Use of Psychotropic Medication(s), last revision dated 4/28/25, showed, . b. PRN orders for antipsychotic medications only, shall be limited to 14 days with no exceptions. If the attending physician or prescribing practitioner believes it is appropriate to write a new order for the PRN antipsychotic, they must first evaluate the resident to determine if the new order for the PRN antipsychotic is appropriate.

Based on interview and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for 1 (#46) of 18 sampled and supplemental residents. This deficient practice increased the risk of allowing resident #46's further potential misappropriation of property when allegations were not reported and investigated with facility oversight. Findings include: Review of resident #46's electronic medical record showed an admitted [DATE]. Resident #46 had a diagnosis of [NAME] encephalopathy, with a family member as an appointed conservator. Review of resident #46's social services progress note, dated 3/6/25, showed involvement of an assigned APS investigator to investigate possible misappropriation of property, and IDT discussed the possible allegation. During an interview on 5/20/25 at 9:50 a.m., staff member C stated resident #46's conservator had been notified of a bill owed to [Facility - state hospital]. Staff member C stated she had been working with a former business office manager employee to stay in contact with resident #46's conservator for payment of the bills. Staff member C stated the former employee had terminated their employment with the facility recently and without much notice. Staff member C stated the concern with resident #46's conservator not paying bills owed to [Facility - state hospital] and the current facility was discussed in an IDT meeting. Staff member C stated she was not sure if a staff member had been assigned to follow-up with the concern after it was discussed in the IDT meeting. Staff member C stated resident #46's conservator stated he had to spend his own money to pay bills owed for resident #46. Staff member C stated she was concerned resident #46's conservator was spending the resident's funds for his own personal use. Staff member C stated resident #46's conservator was digging in his heels about what he felt was owed to the facility. Staff member C stated she notified the local APS supervisor on 3/5/25 with a referral concerning resident #46's funds being used by the conservator. Staff member C stated APS notified her on 3/6/25, of an assigned case worker to investigate the concern for resident #46's finances being used by his conservator. During an interview on 5/20/25 at 12:39 p.m., staff member A stated he was aware of staff member C's discussion of a concern with resident #46's conservator and handling of finances to pay bills owed by resident #46. Staff member A stated he was aware of involvement by an APS case worker. Staff member A stated, from his standpoint, the issue was more to do with payment of monies owed by the resident to several care facilities. Staff member A stated the issue with resident #46's conservator was needing to stay on top of him regarding payment of the bills owed by resident #46. During an interview on 5/20/25 at 1:11 p.m., staff member A stated staff member C might have had the impression resident #46's conservator was exploiting the resident. Staff member A stated the IDT believed the conservator for resident #46 was competent, and was just stubborn with money and did not want to pay resident #46's bills, unless he absolutely had to. Review of the State Survey Agency reporting portal failed to show a report of the allegation of exploitation involving resident #46. The facility was not able to provide any documentation of an investigation done by the facility with regard to the exploitation allegation. Review of the facility's policy titled, Abuse, Neglect and Exploitation, dated 4/16/25, showed: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property . 2. The facility will designate an Abuse Prevention Coordinator in the facility who is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state survey agency and other officials in accordance with state law . 3. The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written . III. Prevention of Abuse, Neglect and Exploitation . F. Providing residents, representatives, and staff information on how and to whom they may report concerns .and providing feedback regarding the concerns that have been expressed . V. Investigation of Alleged Abuse, Neglect and Exploitation A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur . VII. Reporting/Response . 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g. law enforcement when applicable) within specified timeframes: . b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury .

Based on interview and record review, the facility failed to notify the resident and or the resident's representative, in writing, of the reason for transfer when transferring a resident to the hospital, for 1 (#23) of 15 sampled residents. Findings include: During an interview on 5/19/25 at 2:37 p.m., staff member B stated the facility did not have a transfer notice for resident #23's hospitalization s on 3/7/25 and 5/9/25. Staff member B stated the nurse on duty was responsible for completing the transfer notice prior to a resident's transfer to a hospital. Review of resident #23's electronic medical record failed to include a transfer notice for resident #23's facility-initiated transfer on 3/7/25 and 5/9/25. On 5/20/25 a request was made for a copy of resident #23's Notice of Transfer, for the 3/7/25 and 5/9/25 facility-initiated transfers. No documentation or records were received from the facility by the end of the survey. Review of the facility policy titled, Transfer and Discharge (including AMA) Policy, dated 4/11/25, showed: - . Policy Explanation and Compliance Guidelines: - . 3. The facility's transfer/discharge notice will be provided to the resident or resident's representative in a language and manner in which they can understand.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive care plan based on resident activity preferences and physical abilities, for 1 (#2) of 15 sampled residents. Findings include: During an observation on 5/17/25 at 12:15 p.m., resident #2 was lying in bed with the head of the bed elevated. The resident appeared to be sleeping. During an observation and interview on 5/18/25 at 8:00 a.m., resident #2 was lying in bed with the head of the bed elevated. The resident appeared awake and was wearing glasses, and the resident was staring forward at the television which was not turned on. Resident #2 stated she did not participate in activities because her vision was poor, and her hands did not work very well anymore. Resident #2 stated she had attended church service one time since she was admitted (4/17/25) to the facility. Resident #2 stated staff did not come into her room to do one-on-one visits and have never offered her activities or other things to do in her room. Resident #2 stated she would have liked staff to come into her room and visit with her since she was in her room most of the time. During an interview on 5/20/25 at 1:00 p.m., staff member E stated she was responsible for the residents' activity preferences and care planning. Staff member E stated the facility had changed computer applications, and the current program did not allow to customize resident interventions on the care plan. Staff member E stated activities documentation had been identified as an issue, and she needed to train her assistants on how to properly document activities in the resident's electronic medical record. Staff member E stated she was working in two different positions and had not been documenting as much as she had in the past due to limited time. Review of resident #2's Admission MDS section F, with an ARD of 4/23/25, showed under the Interview for Activities Preferences the questions and responses for the residents interests, and showed: -A. How important is it to you to have books, newspapers, and magazines to read? The response was marked as Somewhat important. -B. How important is it to you to listen to music you like? The response was Very important. -C. How important is it for you to be around animals such as pets? The response marked was Somewhat important. -D. How important is it for you to keep up with the news? The response marked was Somewhat important. -E. How important is it for you to do things with groups? The response marked was Somewhat important. -F. How important is it to you to do your favorite activities? The response marked was Very important. -G. How important is it to you to go outside to get fresh air when the weather is good? The response marked was Very important. -H. How important is it for to you to participate in religious services or practices? The response marked was Very important. Review of resident #2's care plan, dated 5/17/25, showed: Focus: I exhibit independence in leisure activities manifested by my: My ability to choose group activities of interest. Interventions: - . Please encourage and support the continuation of my life roles. -Please encourage me to participate in activities of interest. - . Supply me with independent leisrure materials PRN. -Support my independent leisure choices. [sic] The care plan failed to identify and show resident #2's life roles, activities of interest, or provide one-on-one visit information. Review of resident #2's Admission MDS section GG, with an ARD of 4/23/25, showed the resident's functional abilities were primarily maximal assistance to dependent on staff for mobility and self-care. Eating was the exception and showed resident #2 required assistance with set-up and clean up from staff. The resident was not able to be independent with her leisure activities as shown in the resident's care plan.

Based on interview and record review, the facility failed to monitor a resident for change of condition and follow through to obtain physician consultation, which resulted in a delay in treatment and ultimately a hospitalization , for 1 (#1) of 5 sampled residents. Findings include: During an interview on 1/28/20 at 12:24 p.m., NF1 stated he had noticed a difference in resident #1's cognition and status the two days prior to the hospitalization . NF1 stated he was in to see resident #1 on Saturday, 1/4/20, around one or two in the afternoon. NF1 stated he noticed a puddle on the floor around resident #1's foot and thought it was urine. He notified the nurse, and the nurse took resident #1's sock off, and NF1 immediately noted resident #1's foot was swollen like a balloon, and the fluid matter on the floor was not urine but was coming from resident #1's foot. NF1 stated he asked the nurse if he should take resident #1 to the hospital. The nurse stated no we have a wound nurse consult scheduled for Monday (six days later). NF1 stated it should have been obvious resident #1's foot was infected. NF1 stated he had not been notified of the swelling on resident #1's foot prior to seeing it in person. NF1 stated he received a phone call around 4:30 a.m., on Sunday 1/5/20, notifying him resident #1 was being sent to the emergency room . NF1 stated resident #1 was septic (infection) by the time he was admitted to the hospital, and the resident had [MEDICAL CONDITION]. During an interview on 1/28/20 at 1:27 p.m., staff member B stated she was not present in the facility when resident #1 had been sent out to the hospital. During the weekend it was the Registered Nurse that was in charge of overseeing cares. Staff member B stated the facility had been aware of the redness and swelling of resident #1's foot on 1/3/20. On 1/4/20 it was assessed, but resident #1 did not have a temperature until 1/5/20. Staff member B stated it would be alarming if a resident presented with a swollen foot with drainage, and she would have cleaned the wound then notified the doctor and wound care nurse. During an interview on 1/28/20 at 2:25 p.m., staff member E stated resident #1 was neither resistive, nor refused cares, when provided to the resident. During an interview on 1/28/20 at 2:46 p.m., staff member A stated, during the time of resident #1's admission, since the Director of Nursing was gone, the floor nurse was in charge of overseeing and ensuring cares. Staff member A stated if there were any issues, the floor nurse could not handle the Regional Clinical Nurse would have consulted in the matter. Staff member A stated he was confused on the matter of resident #1's foot, as it was noted the resident had a fall with mention of resident #1's socks, and all extremities were checked, but there was no mention of swelling noted. It was noted on 1/3/20 and 1/4/20 the resident experienced leg pain, and the foot was swollen red and hot to the touch. Staff member A stated he did not know what happened. During an interview on 1/28/20 at 3:50 p.m., with staff member A, B, and C, staff member B stated all skin checks would be either Braden scale assessments or documented in the progress notes if they occurred. Staff member B stated there was not a physician note for 1/3/20 or 1/4/20 to show facility staff made contact with a doctor to get direction on what to do with resident #1's foot condition. Staff member B stated on 1/3/20, a wound nurse consultation had already been set up, due to the resident's avoidable pressure ulcer to his buttocks, and back. Staff member B stated there was not an official process to document the completion of a head to toe assessment after falls to ensure they were completed. Staff member B stated she did not find any other skin checks for the resident, except the skin checks completed on admission, and 1/2/20. Staff member B stated she had just implemented skin checks on bath days. Staff member C stated she was in the facility for a few hours on 1/4/20, Saturday morning. She stated she performed catheter care and wound care for the resident and did not recall if the resident had socks on or not. Staff member C stated she could not recall looking at resident #1's foot. A review of resident #1's care plan, with a last revision date of 12/31/19, showed no documentation for catheter care, wound care, or skin checks to be performed. A review of resident #1's skin and wound assessments, dated 12/12/19 and 1/2/20, showed no documentation of resident #1's foot or swelling. A review of resident #1's Nursing progress notes, showed the following: - On 1/3/20 - Residents foot is red swollen and red to the touch. Will be trying to be getting ahold of the doctor to possibly get ABX (antibiotics). - On 1/4/20 at 2:14 p.m. - Pt very lethargic and unable to perform therex to lower ext 's., R. foot is badly swollen and in need of wound care. Nurse redressing foot and calling doctor.(sic) - On 1/4/20 at 3:15 p.m. - Res (family member) in today. He is Concerned that (resident) is declining. Res has been hiccupping again this day. Upon assessing res, RLE has +3 [MEDICAL CONDITION]. R foot hs developed 4 fluid filled blisters on top of foot and one blister on sm toe that has popped. There is necrotic tissue present on toe. R foot is seeping large amounts of fluid. Tissue under blisters appears to be very dark below fluid. Foot cleansed with normal saline and super absorbent pads placed on foot, then wrapped with gauze. Foot is elevated at this time. Will send note to provider and wound care nurse. (sic) - On 1/5/20 at 4:00 a.m. - CNA reports that this resident has a temp of 101. Temporal P 110 BP 110/57 R17. Resident is very confused .MD notified, and orders received to transfer to ER for evaluation and treatment. A review of resident #1's hospitalization documentation, dated 1/5/20, showed the following: - Resident #1 was noted to have had confusion, by family, on Friday the third and Saturday the fourth, of January. - (Family Member) saw (resident #1's) right foot yesterday the surface of the little toe was blackened, swollen, and red. Family member was told by nurse they would rewrap toe and get Wound Care involved Monday (the 6th). (sic) - Resident #1 was admitted to the hospital with [REDACTED]. A request for all physician communication for resident #1's length of stay was made on 1/28/20, and no further documentation was provided by the facility. A phone call was placed to staff member F, the floor nurse during the time of resident #1's stay, on 1/28/20 at 3:17 p.m A message was left for a return call. The phone call was not returned.

Based on observation, interview, and record review, the facility failed: to use root cause analysis to identify direct causes of repeated falls which resulted in two fractures and multiple head injuries, and implement effective interventions for the causes of these falls; failed to update and modify the resident's plan of care for fall prevention as the resident's status changed; failed to provide ongoing attempts to determine underlying conditions that were contributing to the falls when the resident had a change in behavior and cognition; and failed to effectively communicate within the IDT necessary information relating the resident's status, a potential fall, and concerns with an inaccurate care card and care plan for falls, for 1 (#5); failed to follow up and document actions taken to identify contributing factors, fall risk hazards, and steps taken for fall prevention for a resident who reported multiple falls, and was later found to have a urinary tract infection for 1 (#6); failed to utilize implemented interventions, and provide assistance to a resident who had severe cognitive deficits, and who was unable to comprehend fall prevention efforts, but had repeated falls for self -transferring, for 1 (#12); and failed to implement interventions, and update the resident's care plan for the prevention of falls, to include a fall with a hip fracture for 1 (#2) of 13 sampled and supplemental residents. Findings include: On 7/7/16 at 1:30 p.m., the facility administrator was notified that an immediate jeopardy situation existed for 1 of 10 sampled residents. PLAN TO REMOVE THE IMMEDIATE JEOPARDY The facility submitted an acceptable plan to remove the immediacy on 7/7/16 at 5:55 p.m. The deficient practice remained at the scope and severity of G once the immediate jeopardy was removed. A summary of the facility's plan to remove the immediate jeopardy was as follows: 1. All falls for the last 6 months will be reviewed for trending and causative factors. 2. 15 minute checks were implemented. 3. Education was provided to staff on fall prevention, supervision and interventions. 4. New fall risk assessments will be completed, and appropriate interventions implemented. 1. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. pain, restless leg syndrome, major depression, [DIAGNOSES REDACTED], and chronic kidney disease. A review of the resident's Admission MDS, with an ARD of 12/11/15, showed the resident had moderately impaired cognition, and was coded as a 12. The resident was not documented as having any behavioral symptoms or rejection to care during the assessment period. The resident was coded as needing supervision of set up help for bed mobility and transfers, and limited assistance of one person assistance for ambulation. The resident was not coded as having a restorative program in place. During an observation on 7/5/16 at 2:25 p.m., the resident was sitting on the edge of the bed. The resident's bed was in a high position. The resident's legs were hanging off the bed, and one foot was touching the floor. The resident had bare feet. Her upper body was turned to the left side, and she was laying crooked across the top part of the edge of the bed. The top part of the resident's buttocks were on the bed, and the rest of her buttock area was off the edge of the bed. A wheelchair was sitting between the closet and the bed's footboard. A tray table was next to the bed with the resident's belonging on it. A platform walker was on the opposite side of the tray table, by the entrance door. The resident was dozing. A review of the resident's Care Plan showed the resident had a history of [REDACTED]. The problem showed, I am at risk for falls. I had falls prior to my admit. My balance is not always steady, and unable to stabilize self. Contributing factors included medications, her disease process, pain, assistive devices, a history of fractures, and non-compliance with therapies. Seven falls were listed below the fall problem. The goal was to maintain the resident's mobility, and decrease the risk for falls over the quarter. The care plan showed interventions implemented on or shortly after her admission included assessing footwear for fit and non-skid soles, keeping equipment in easy reach, encouraging the resident to take her time when sitting, standing or turning, and to keep a clear path to the bathroom. Interventions added after admission included: educating the resident to call for assistance; front wheel walker in room for ambulation and assistance with safety; keep the bed in the low position; keep wheelchair by bed with brakes locked when bringing back to room from meals to assist her in self-transfers; keep wheelchair and walker in reach; the resident did not use the call light reliably so staff should anticipate her needs; educate her on safety awareness; provide one staff assist to toilet. A review of the resident's Medicare 30 Day MDS, with an ARD of 6/13/16, showed the resident's cognition remained the same, she had no behaviors documented on the MDS, and had started to display rejection of care at least 4-6 days of the assessment period. The resident's ADL status declined, and she was coded as needing extensive assistance of two plus persons for bed mobility, transfers, and toileting. The resident was not coded as having a restorative program in place on the Significant Change assessment dated [DATE], or the assessment completed on 6/13/16. A review of the resident's Fall Risk Assessment, dated 12/5/15, showed the resident was scored as a 15. A score of 10 or above indicated the resident was at risk for falling. Interventions were implemented at the time. The resident was coded as having intermittent confusion, and the resident's gait was not steady. A review of the resident's CMS 700 Therapy Form, dated 12/10/15, showed the resident had generalized weakness. The goal was to work on back pain and bed mobility. The resident was modified independent with use of the front wheel walker, and with walking. The therapist documented under the Initial Assessment section that the resident had an extensive fall history. During an observation on 7/5/16 at 3:40 p.m., the resident was in bed with the covers over her head. The bed remained in the high position, although the care plan stated it should be in the low position. The wheelchair was turned facing the door, and was at the end of the bed out of reach. The brakes on the wheelchair were not locked. The walker was on the opposite side of the tray table, out of reach. During an observation on 7/6/16 at 7:15 a.m., the resident was sitting crooked on the edge of the bed with her feet hanging to the floor. Her torso was laying on the bed's edge where the head of the bed was raised up. She stated she always sat in this position, although she stated, It is not comfortable. The resident explained she did not think it was a problem because she was used to it. Her bed was not in the low position. She stated she was waiting for her meal. At 7:47 a.m., the resident's bed remained in the same position. The wheelchair was now sitting at bedside. The platform walker was close to the entrance door. A review of the facility Pocket Care Plan, dated 6/15/16, showed the resident was a 2p max assist for transfers. Under the Additional Instructions section it showed the resident was a 2-person stand pivot to commode, and a one person stand pivot wheelchair to bed. Staff were to use the platform walker to ambulate the resident to the bathroom. When in bed, the resident's wheelchair was to be by the bed in a locked position so she could self-transfer safely. On 4/20/16, the resident's care plan was updated to reflect an intervention for a bedside commode. Staff was to provide assist of one to transfer with a platform walker. During an observation on 7/6/16 at 8:10 a.m., staff member J put a gait belt on the resident. The wheelchair was at the bedside locked, so she moved it out of the way. Staff member J was on the side of the resident and used the gait belt to stand/pull the resident to a standing position. Staff member J then put the platform walker in front of the resident, and the resident was assisted to the bathroom. No other staff was present to assist. When exiting the bathroom, the resident used the platform walker again. About 1/2 way back to the bed the resident began to stumble, and started to fall to the left side. Staff member J then grabbed the resident, and stabilized her position. Staff member J stated it took about half of her own weight to prevent the resident from falling. Staff member J stated she had reviewed the care card and did not understand what the resident's transfer status was supposed to be due to the information being different. She stated the resident's bed was not in the low position because the resident was going to eat breakfast, and it would be moved down after the meal. The bed was in the same position as during the observation earlier that morning, when the resident was not preparing for a meal. A commode was not observed in the resident's room. Staff member J stated the resident no longer used the commode. During an interview on 7/6/16 at 1:10 p.m., staff member B was notified of the resident's near fall earlier that day. She stated she had not been made aware of the event. She stated the resident was fiercely independent, and the pharmacy had made recommendations to change the resident's Zoloft dose (occurred 4/6/16). She stated each fall was reviewed in the morning meeting. Staff member B stated the IDT fall meeting did not occur each week as planned. Other than the packet of forms which the nurses fill out, staff member B stated no other information was available to the nurses to refer to for fall prevention, or possible interventions to utilize if the resident was having a specific problem. Staff member B stated the facility had problems with the fall program which, Were across the board; it was not just one thing. She stated the facility was thinking when the anesthesia wore off from the resident's surgery (after 3/31/16 hip fracture), then the falls would improve, but had not. Staff member B stated the resident's transfer status on the care plan, which the CNAs used, was not accurate for her transfer status, and needed updated. Staff member B stated the facility did not comprehensively review all the resident's falls in an attempt to determine potential interventions, or trending concerns. She stated each fall was looked at individually. A review of the resident's Interdisciplinary Notes, Fall Scene Investigation Reports, and Neurological Assessments showed the resident had seven falls prior to the survey. Details included: - 3/8/16 - 11:45 a.m. The resident was found on the floor. The wheelchair was on the opposite side of the recliner, and not by the bed. The resident stated she was just getting up and going, and she had an incontinent product in her hand. She had a medium hematoma to left temple and her blood pressure was slightly elevated. Documentation does not show if the resident's range of motion was assessed after the fall. The medical record documentation on the resident's injury stopped on 3/10/16, although she still had bruising to the left forehead on this day. Neurological checks were initiated at the time of the fall, but the neurological assessment form was incomplete. The nurse did not document in the medical record if a full physical assessment of the resident was completed after the fall. The nurse documented the resident lost strength and became weak prior to the fall. The interdisciplinary team reviewed the fall (date not documented on form, but was documented on 3/24/16 in IDT notes) and the plan was to monitor for depression, and that the resident was going to potentially discharge soon. The cause of weakness and loss of strength was not addressed by the facility after the fall. On 3/25/16, the resident was complaining of leg tremors that caused pain. She stated she felt better when lying without movement. - 3/28/16 - 7:40 a.m. The resident was found on the floor in her room after walking to her bed without the walker. She landed on her left wrist, hit her anterior head and cheek area. It was later found she had a distal radius fracture to the wrist. The resident was sent to the emergency room for treatment. The investigation did not show if the resident's wheelchair or walker was in place or utilized for the transfer. The root cause was, She lost her balance during a transfer. The facility did not show the care plan was reviewed or modified after the fall. On 3/9/16 the care plan was updated to show the wheelchair should be locked at bedside for self-transfers. The neurological form was initiated, and the resident was sent to the ER, but then on return the neurological assessment form was not completed although the resident hit her head. - 3/31/16 - 8:38 p.m. The resident was found on the floor. She had a laceration to the back of her head, and a potential hip fracture, which was confirmed later. The resident was transferred to the emergency room for an evaluation. The resident returned to the facility on [DATE] after a surgical repair to the left intertrochanteric fracture. After the fall, the resident was assessed to have slight confusion, but she had been normally oriented. The resident had been toileted before dinner. Dinner service began at 5:30 p.m. On her return from the hospital she was moved to a room closer to the nursing station to provide more oversight to the resident. After the falls on 3/28 and 3/31/16, the resident's refusals of care became more frequent, and her mood symptoms were exhibited more often. She made comments of wanting to die. A therapy evaluation was attempted on 4/5/16 but the resident had been combative, was hallucinating, and unwilling to participate in treatment. On 4/29/16, the resident was re-evaluated by physical therapy for treatment. Occupational therapy was reinitiated on 5/3/16. On 5/8/16 the therapist documented the resident will continue to be on a restorative program, although a restorative plan had not been updated since her admission to reflect the resident's current abilities or ADL changes. - 5/18/16 - 6:45 a.m. The resident was found sitting on the floor in her room after she had been ambulating. She had bare feet, and was Going to the bathroom. The investigation showed the wheelchair and walker were not in reach. The intervention to prevent future falls was to keep the wheelchair within reach, although keeping the chair at bedside was already on the care plan. The IDT documented on 5/18/16 that not having the wheelchair or walker resulted in the fall. The resident stated after the fall that she Hurts all over. The nursing documentation lacked if the resident's skin was assessed for injury after the fall, or what interventions were implemented for the reported pain, or potential contributors to the fall. The medical record did not show why the resident's equipment was not in reach. Therapy services ended on 5/28/16, and the resident was returned to the restorative program. An updated restorative plan was not available for review. During an interview on 7/7/16 at 2:20 p.m., staff member K stated she had not received training for falls when she was hired. She was only aware of a packet of fall forms which had to be completed with each resident fall, and stated she felt she needed more training on the prevention of falls, documentation for falls, fall policy, and implement interventions. Staff member K had not been informed that the resident had almost fallen the day prior (7/6/16) when being transferred. Beginning on 5/31/16 the following was documented in the nursing notes: - The resident was in the dining room. She began to pick up a wet floor sign and was hitting it off the dining room floor. She was threatening to break out the facility windows with the sign. On 6/1/16 The resident alleged someone was calling her names, but would not cooperate with the nurse when seeking information on the concern. The resident did not want further care, stating she was going to die from cancer. On 6/3/16, the resident reported bugs on the bed and floor. She exhibited a flat affect. She stated people thought she was crazy. The nurse encouraged fluids because the resident's urine was dark in color. No further follow up was completed on the dark urine, or change in behavior. - 6/5/16 - 12:00 p.m. The resident was found on the floor in her room. The walker was laying on the floor. Her wheelchair was close to the door of the room, not by the bed. The resident was self-transferring, and stated, I was trying to get to my wheelchair so I could go to the bathroom. The last time the resident had been toileted was at 10:00 a.m. The resident's skin was not assessed after the fall. The nurse documented that she educated the resident on using the call bell to ask for help during transfers, although the resident was displaying confusion, and hallucinations, and had been resistant to care. The interdisciplinary team documented the wheelchair brakes were not on during the resident's self-transfer, causing the wheelchair to roll while she was holding onto it. Staff was instructed to lock the wheelchair brakes once the resident was in the bed or recliner in case she did not use the call light for assistance. - 6/7/16 - 3:00 p.m. The nursing notes showed the resident was witnessed falling to the floor. The resident had been ambulating and lost her balance. She hit her head during the fall. Neurological checks were initiated, but were not evident in the medical record. The assessments were requested, but not received prior to the end of the survey. The Investigation Report showed the resident was bending over the walker, and began to lean forward on the walker and it tipped causing the fall. The nurse reinforced with the resident the therapy rules, and calling for assistance prior to walking although the resident's cognition level had changed, and educating the resident prior for fall safety was not successful. The nurse documented the resident's orientation was 1-2. The interdisciplinary team documented the resident Continues to remain non-complaint with pulling call light and self-ambulating. The resident was to continue to work with therapy services although the programs ended at the end of the prior month. The facility did not address how they would meet the resident's needs for the lack of call light use, or if the resident was able to retain the information she was educated on. During an interview on 7/7/16 at 10:30 a.m., staff member I stated the resident had difficulty retaining information she was educated on. Staff member I had been working with the resident since she was admitted to the facility. Staff member I stated when the resident was in bed, the walker and the wheelchair were to be moved out of the resident's path to the bathroom, and away from the bed because she would attempt a self-transfer. The care plan reflected the equipment was to be at bedside and in reach. On 6/8/16, the resident was thinking she was caged up. She was upset and began growling at the nurse. The resident got upset with having to wait so long for the meal, and left the dining room prior to eating. On 6/9/16, the resident refused all of her medications for one shift, and medication refusals became more frequent after this. On 6/14/16 the resident's behavior was reviewed. The IDT documented she had an increase in paranoia and delusional thoughts. Interventions were documented as validating her feelings and activities of choice. The staff would offer snacks, and notify activities or social services if one to one care was needed. The IDT documented that it was found that validating the resident's feelings was a beneficial intervention, but no documentation was completed on what steps were taken to identify the potential cause for the change in behavior, or delusions. On this day, she refused her medications because she stated she was going to die. On 6/15/16, the resident was crying when the nurse entered the room. She wanted to know where a staff member was. She again asked what she was dying from. On 6/20/16, the resident used the call bell to tell the nurse she was going to be killed that night. She was worried about what would happen with the bugs that were in her room, and they got on her bed at night. Her behavior continued throughout the day. - 6/22/16 - 2:55 p.m. The resident was found on the floor after she was ambulating. The walker was standing next to her. She stated she was picking things up from the floor. She denied hitting her head. Skin was not shown to be assessed after the fall. She had been toileted the last time at 12:00 p.m. The interdisciplinary team documented the resident was non-compliant with the call light and self-transferring. They facility questioned if the event was a fall because of the resident's comments. Staff were to monitor the resident's anxiety and restlessness after the fall. The prevention efforts lacked information for how the non-compliance and failure to use the call light would be addressed. The care plan did not show it was modified to reflect the new intervention for monitoring the anxiety and restlessness identified by the IDT. On 7/2/16 a butter knife was found in the resident's wrist splint, which she had hidden. The knife was removed, but the nurse found the resident had threatened a staff member which had not been reported at the time. On 7/3/16, the resident requested a shot to be put out of her misery. The nurse observed pronounced tremors in the resident's arms and legs. On 7/4/16 she stated to the nurse, You should just go get a needle and do me in. A review of the resident's Physician order [REDACTED]. - Sinemet (Carbidopa-Levodopa) was ordered on [DATE]. The dosage was 10-100 mg, one tablet, by mouth, two times a day. The medication was given for Parkinson's disease. The resident was also given a 25-100 dose, one tablet, by mouth, at bedtime. Warnings and adverse reactions for the medication showed: use caution with people who have prior mental health problems, such as depression; and adverse reactions may occur with hallucinations, fatigue, insomnia, memory loss, ataxia, and dystonic movements. - Zoloft, an antidepressant, was ordered on [DATE]. The medication was given three times a day, at 50 mg for major depressive disorder. Warnings for the medication showed the individual should be closely monitored for worsening depression, suicidal, or unusual changes in behavior. The medication should be used with caution in the elderly. - Hydrocodone-Acetaminophen was ordered on [DATE], and given 5-325 mg, by mouth, at bedtime, for pain. The resident also had 5-325 mg, 1-2 tablets for pain, every four hours, as needed. - Fentanyl Patch was ordered on [DATE]. Two doses were in place to be given. The first was a 12 mcg patch to be placed every 72 hours, and the second was a 50 mcg/hr patch to be placed every 72 hours. The elderly population was found to be more sensitive to the medication. Adverse reactions may include depression, constipation, weakness, confusion, abnormal dreams, agitation, dizziness, hallucinations, nervousness, and paranoid reactions. The resident's clinical record lacked evidence to show the medications were reviewed as possible contributors to the resident's change in behaviors which began after her hip surgery, and may have contributed to her repeated falls. During an interview on 7/5/16 at 4:00 p.m., the resident's IDT notes for the falls was requested. On 7/5/16 staff member D provided two documented medical record entries for the resident's falls which had been completed by the interdisciplinary team on 7/5/16. The first note addressed the falls in March 2016, and the second note addressed the falls in June 2016. Both of the entries included details that the resident was educated on calling for assistance with transfers. The progress note made at 8:16 p.m. (on 7/5/16) showed the resident had difficulty following safety awareness instructions. - 7/7/16 - 1:45 a.m. (during the survey) The resident was found on the floor with a shirt in front of her. The nurse documented she did not know what the resident was doing prior to the fall, but she had been sleeping earlier in the night. The resident had been toileted at 12:00 a.m. The nurse documented the Amount of assistance in effect was a contributing factor to the fall. The nurse reminded the resident to call for assistance, although she had not called previously. The interdisciplinary team documented the resident had delusions about the time of day and situations. During an observation on 7/7/16 at 7:05 a.m., the resident was sitting on the edge of her bed. The bed was not in the low position. The resident's walker was behind the entrance door. The wheelchair was not locked and sitting by the resident's bed, and had been pushed over by the closet with the brakes not locked. The resident was barefoot. The resident stated she had fallen that night prior, and put her hand to her forehead. As she pulled her hand away a red area was visible on the right side of the forehead, which was approximately 1.5 x 1.5 inches in size. The resident stated her head hurt, and happened during the fall. She did not recall what she was doing when she fell , but said she did not have slippers on at the time it happened. During an interview on 7/7/16 at 7:07 a.m., staff member K stated she did not know much about the resident's fall. She was assigned to care for the resident on this day. She had begun her shift about an hour prior to this, and not much information had been given during rounds because the nurse was still completing the paperwork for the fall (the fall was at 1:45 a.m.). During an interview on 7/7/16 at 7:10 a.m., staff member I stated the resident had a shirt by her when she was found on the floor. She stated the resident had been sleeping prior to the fall, and as an intervention for fall prevention she Reminded her to call for assistance. Staff member I was unable to state further what interventions would be utilized for the fall because she had to finish the fall paperwork. During an interview on 7/7/16 at 7:30 a.m., staff member J stated she was assigned to the resident's care, and knew she had fallen, but did not know any specifics about the fall. She had not been told anything on what could be done to prevent future falls. She had seen a red mark on the resident's head, and had taken vital signs that day which were within normal limits. Staff member J began her shift at 6:00 a.m. During an interview on 7/7/16 at 10:30 a.m., staff member L stated he picked up a resident care card that morning when he started his shift. He stated the resident's walker and the wheelchair should not be by the resident's bed because the resident attempted to self-transfer. He stated if he saw the resident sitting on the edge of the bed he would ask her what she needed help with. He stated he provided her with verbal cues, and she had poor safety awareness. When reviewing the care card, staff member L pointed to the transfer status, which showed the resident was a two person max assistance, and the plan had not been updated. During an interview and observation on 7/7/16 at 2:25 p.m., staff member N stated the resident's walker and wheelchair would be moved away from the bed when the resident was in bed. This was to help prevent falls. During the interview, staff member N pushed the wheelchair by the closet door, and moved the walker up behind the door. When referencing the low bed, she stated the resident's bed was not in a low position, and then she used the controller to move the bed down to the low position. Staff member N stated she used the pocket care plan when she needed to know how to care for the resident, but she did not have one with her at the time of the interview. The resident was started on 15 minute checks at 4:30 p.m. on 7/7/16, until it was determined that the fall interventions were effective for the prevention of falls. A review of the Provider's Encounter Summary - Progress Notes showed: On 4/15/16 - The resident's fractures, which were caused by the resident falling, were reviewed. No documentation was completed on the resident's fall risk, or potential interventions for falls. On 6/1/16, the physician documented the resident was refusing to participate in therapies. The provider reviewed the fentanyl, hydrocodone, and potassium chloride medication use. No changes were made, and no concerns were documented with the resident's status, behavior changes or repeated falls. A review of the Fall Prevention policy showed: - Fall precautions will be reviewed and appropriate precautions will be implemented after a fall occurs, and as needed. - Initiate Neuro checks if resident hit head or if unwitnessed fall. - Once a week, the IDT will meet and complete a fall review on each resident who has fallen the preceding week. The care plan will be updated with any new or decided upon interventions. This will continue for three weeks post - fall or until the resident no longer has falls for 30 days. - The policy also included Fall Prevention Strategies the staff could utilize as needed, which included medication surveillance, and early recognition of an underlying condition. 2. Resident #6 was admitted to the facility on [DATE]. A review of the resident's Nursing Notes showed: - On 4/22/16, the resident reported to the therapist that she had several falls. The staff member checked the resident's back, and found bruising to it. The therapist documented the interaction. - On 4/29/16, the resident was sent to the emergency room for a possible urinary tract infection. During an interview on 7/6/16 at 4:50 p.m., the resident stated she just did not tell the staff at the time, and had no reason for it. She stated therapy has helped her, and she is not as bad as she was then. She stated she could not walk or do anything at the time, and it was found the resident had an infection at the time, which was treated. She stated, I was just weak. The resident reported a male staff person helped her off the floor one time, but she could not recall his name. Further review of the medical record lacked evidence to show the steps taken for follow up regarding the resident's reported falls, the steps taken for fall prevention or for a comprehensive skin assessment to identify any other potential injuries. During an interview on 7/6/16 at 5:05 p.m., staff member B stated the resident had numerous health issues going on at the time of the reported falls to include: fluid restrictions, dehydration, constipation, weight loss, and edema. She stated the underlying issues were addressed, and she recalled speaking to staff about who may have assisted the resident with her falls, but no one had knowledge of them. She stated this was not documented in the resident's record. A review of the resident's Care Plan lacked evidence to show she had a history of [REDACTED]. 3. Resident #12 was admitted to the facility on [DATE] with dementia without behaviors. A review of the resident's Fall Care Plan, initiated on 4/7/16, showed the resident had four falls, and all were when he was self-transferring. The care plan also showed the resident would be assisted to the toilet following dinner, then to his recliner; the intervention was dated 4/11/16. Another intervention, initiated on 6/19/16, was a fall mat which was to be placed by the bed when the resident was in bed. During an observation and interview on 7/7/16 at 3:50 p.m., the following occurred: the resident had just been assisted out of bed by two caregivers, and put in his wheelchair. The resident's bed was unmade. A fall mat was not present in the room. Staff members O and P were unable to locate the fall mat, although it was listed as an intervention on the care plan. Both staff members O and P stated they had never se

Based on interview and record review, the facility failed to prevent the development of 2 stage III pressure ulcers, for 1 (#1) of 10 sampled residents. Findings include: Resident #1 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of resident #1's Progress Notes, dated 1/2/16, showed the resident was observed with a 0.6 x 1 x 0.2 stage III ulcer to right trochanter. Area is 95% covered with slough. When resident sits in wheelchair, pressure is placed on area where wound is located. Cushion placed in wheelchair. Review of resident #1's Progress Notes dated 1/4/16, showed Resident found to have a second stage 3 ulcer on sacrum (1 cm x 1 cm x 0.4 cm). Review of resident #1's Progress Notes, dated 1/7/16, showed CNA reported airflow mattress to {resident's} bed did not look like it was holding air. On exam of the mattress setup noted control was set almost full on max setting. Upon applying pressure to mattress, noted bed frame could be felt though the mattress with no cushion present. On inspection of control box, noted there was poor air flow being produced. Control box for alternating air flow mattress located and applied. Mattress filling with air. Will need to monitor effectiveness of this setup. During an interview on 7/6/16 at 1:30 p.m., staff member D stated the facility originally thought the pressure ulcers were from the wheelchair, but discovered 5 days later the cause was the bed. The mattress was literally sitting on the bed frame. She also stated the nurses did not complete a routine weekly skin check. During an interview on 7/6/16 at 4:30 p.m., staff member B stated resident #1's air mattress was the best in the house, and it had always worked without any difficulties. She stated the CNAs do skin checks during the residents' baths. Review of the bath record dated 12/28/15 showed no skin problems were observed. Review of the admission MDS, with the ARD of 10/12/14, showed a weight of 174 pounds, and a stage III pressure ulcer on the heel. It also showed he was at continued risk for pressure ulcers. Review of the quarterly MDS, with the ARD of 4/1/16, showed a current weight of 109 pounds. This weight loss was documented as expected due to his terminal diagnosis. Review of the current care plan for resident #1 showed he was at risk for breakdown related to his need for extensive assist with bed mobility, weight loss, falls, and a history of a stage III pressure ulcer. During an observation on 7/6/16 at 11:00 a.m., resident #1 required extensive assist with his dressing, peri care and transfers. During an interview on 7/6/16 at 11:00 a.m., staff member H stated the resident's pressure ulcers kind of snuck up on them.

Based on record review, observation and interview, the facility failed to identify and prevent a severe weight loss for 1 (# 9); and failed to reweigh a resident in a timely manner when an inaccurate weight was obtained, and the weight showed a significant weight loss had occurred, for 1 (#5) of 10 sampled residents. Findings include: 1. Resident #9 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of the admission MDS with the ARD of 4/7/16 showed a weight of 153 pounds. Review of the Weights and Vitals sheet dated 6/09/16 showed a weight of 139.5 pounds. This was an 8 percent severe weight loss in 2 months. Review of the Weights and Vitals sheet dated 7/01/16 showed a weight of 125 pounds. This was a 28 pound weight loss from admission, and was a severe weight loss. During an interview on 7/6/16 at 11:00 a.m., staff member H stated resident #9 had eaten about 40 percent of his breakfast, which was pretty good for him. During an observation on 7/6/16 at 11:25 a.m., resident #9 was sleeping at the dining room table, with his head down. Staff member H cut up the resident's meat, and assisted the resident with his meal. The resident ate his meal with his head down. Review of the diet order for resident #9 showed he was on a regular textured diet. During an interview on 7/6/16 at 1:50 p.m., staff member H stated he had noticed the resident had been holding food in his mouth lately. It did not occur to him to report this information to the nurse. He stated the resident had eaten about 30 percent for lunch. Review of a physician order, dated 6/21/16, showed weigh patient today (emphasis added); office weight down 55 pounds from April. Call me with weight. During an interview on 7/7/16 at 1:30 p.m., staff member G stated she did not know about the physician order, or the weight loss.It did not show up in our weight report. During an interview on 7/6/16 at 4:00 p.m., staff member B thought the dietary manager had mentioned resident # 9 in a recent weight meeting. No further information was provided regarding resident #9's weight loss or the follow-up for the physician order. Review of resident #9's admission MDS, with the ARD of 4/7/16, showed the resident could feed himself, was continent of bowel, and had clear speech. During an interview on 7/6/16 at 2:10 p.m., staff member S stated the resident was incontinent all the time, extensive assist to dependent for all care, and could not make his needs known. During an observation on 7/6/15 at 4:00 p.m., the resident was weighed by staff member H, for a current weight of 128.5 pounds. 2. Resident #5 was admitted to the facility on [DATE]. During an interview and observation on 7/6/16 at 8:05 a.m., the resident was sitting in her room unattended. A tray of food was on the tray table. The meal consisted of two pancakes, a sausage patty, and prunes. The resident was not using a utensil, but had picked up a pancake and taken a bite while holding it with her hand. The resident exhibited dissatisfaction with the meal as she picked up a pancake, looked at it, and put it back on the plate while making a grimacing expression. She stated she did not need assistance with condiments for the pancakes, and was left alone to finish the meal. When done, the resident had consumed less than 50% of the meal. A review of the resident's Nursing Notes showed the resident had randomly refused meals after she had several falls in March 2016. The resident sustained [REDACTED]. The hip was surgically repaired. A review of the resident's weight records showed the following: - 12/6/15 102# - 1/8/16 101.5# - 2/16/16 105# - 4/8/16 114# - 4/26/16 114# - 5/27/16 93# The resident's medical record lacked evidence to show the facility attempted to determine why a weight increase occurred on 4/8/16 or that a re-weigh was obtained in a timely manner. When the resident was weighed on 5/27/16 a 21 pound weight decline had occurred. During an interview on 7/6/16 at 1:10 p.m., staff member B stated the facility had identified a problem with obtaining accurate weights, but nothing had been done to correct the problem as of the date of the interview. A review of the facility policy for weights lacked evidence to show how soon a re-weigh should be obtained when a discrepancy was identified. During an interview on 7/5/16 at 3:20 p.m., staff member C stated the facility had tried alternate options to prevent weight loss, such as Liquicell and Resource, which provided more protein. She stated the resident refused the supplements, was not going to meals or eating well. She stated she was provided a tray in her room, and did not want to be bothered. She stated when in the dining room, the resident's paranoia was a problem because she thought people were laughing at her. A review of the resident's Care Plan showed the plan had not been updated for the resident's current weight status, risk factors for weight loss, or current nutritional approaches.

Based on clinical record review, observations, and staff interviews, the medical record did not include evidence that necessary care and services were provided in accordance with the comprehensive assessment and plan of care for 1(#6) resident of 29 sampled residents. Findings include: Resident #6 was readmitted on [DATE] after right hip surgery with [DIAGNOSES REDACTED]. A. Documentation on the twenty-four hour discharge records from the hospital dated 12/7/12 indicated resident #6 was receiving therapies daily, was out of bed three times per day, and was assessed for pain control every thirty minutes. Documentation on this form also showed resident #6's weight to be 118 pounds on admission 12/01/12. Upon discharge her weight was recorded on the same form as 125 pounds. Resident #6's physician documented on the discharge summary, "Currently her therapy orders include non-weight bearing, as she is not mentally capable of approximating 50% weight bearing. She is going to need to be transferred using a lift." Documentation on facility admission records showed resident #6 arrived via wheelchair, was calm and oriented to person, with [MEDICATION NAME] to a wound on mid back, and required a two-person transfer. There was an admission nurse's note stating, "Skin assessment complete, uncooperative at this time due to extreme pain. Medicated per R.N." Included within the mobility section of the initial care plan, dated 12/7/12, were directions that resident #6 required moderate assistance and PT. The transfers section of the care plan shows that resident #6 was able to pivot transfer. The skin section of the care plan had the following notations: at risk; current decubitus; and reposition every two hours. A statement that the resident was non-weight bearing with the right leg was found at the bottom of the form in the Notes section. On the updated Care Plan Report dated 12/26/12-Present documentation included, "resident #6 uses a walker for locomotion around facility. Resident will ambulate with walker on her own to meals". This is inconsistent with the physician's discharge note stating, "Currently her therapy orders include non-weight bearing, as she is not mentally capable of approximating 50% weight bearing. She is going to need to be transferred using a lift." There is no documentation on the updated Care Plan Report dated 12/26/12-present showing resident is to be transferred using a lift. On 2/11/13 at 7:15 a.m. the surveyor observed staff members K and U transfer resident #6 from the bed to the wheelchair using a gait belt. Resident #6 was cooperative during transfer without any distress noted by the surveyor. Resident appeared to be standing on both legs during the transfer. B. Documentation on the updated Care Plan Report dated 12/26/12-present showed, "Assist (resident) to complete scheduled shower/bath and provide nail care twice per week starting 12/26/12." On 2/13/13 at 7:20 a.m., the surveyor interviewed staff member B, and asked for the documentation regarding baths/showers given. Staff member B reported the information was kept in the electronic medical record under caregiver documentation. Staff member B assisted the surveyor in locating the bath/shower schedule for resident #6. No documentation showing the resident received a bath/shower per facility policy and resident #6's Care Plan from 12/7/12 to 12/22/12 was present. C. On the updated Care Plan Report, dated 12/26/12, there was documentation under the nutrition intervention to: "monitor resident's weight weekly. Report weight loss/gain greater than 5 pounds to nursing. Nursing to assess; if indicated contact MD/Dietician for recommendations/orders". Review of the Individual Weight Chart dated 2012 lacked documentation of weights for November and December 2012, and January 2013. On 2/12/13 at 10:30 a.m., the surveyor interviewed staff member D and asked for the weight documentation for resident #6. Staff member D reported, "The weights should be recorded in the computer under (facility) weights and other Vital signs. The Dietician makes copies of her assessments, and they are in the chart also". On 2/12/13 at 10:40 a.m., the surveyor interviewed staff member Q regarding the weights for resident #6. Staff member Q reported that she, "checks every resident every month. If I am having a hard time getting weights, I talk to the MDS coordinator and the DON. I turn in a report every time I am here as a written notification also." Staff member Q gave the surveyor a blank form labeled Consulting Dietitian Report and stated that she completes it for every resident she assesses. Staff member Q stated she notified the Administrator and the DON that she was unable to find resident #6's weights for November 2012, December 2012, and January 2013. Record review of staff member Q's monthly notes for October 23 showed documentation of, "...wt loss risk; moderate-high; weight: (10/12) none yet; no weight for October at this time; will ask to reweigh resident." During the interview with staff Q on 2/12/12 at 10:40 a.m., the surveyor asked staff member Q why she never received a weight for resident #6 after repeated requests. Staff member Q stated, "It was difficult over those months from October until some time in December. I did speak with the DON and she reported something about staff turnover". On 2/12/12 at approximately 9:00 a.m., the surveyor asked staff member B, the DON, for the records containing the weights recorded for resident #6 for the months of November 2012, December 2012, and January 2013. Staff member B, DON, reported later that day during the exit meeting, "there are no weights for the months of November 2012, December 2012, or January 2013. She (resident #6) was very difficult to get up at that time and refused being weighed". There were no interventions added to the Care Plan Report, dated 12/26/12-present, addressing what interventions the facility attempted to obtain a weight for resident #6. There was a hand written note showing on the updated Care Plan Report dated 12/26/12-present stating, "2/8/12-wt review monitoring for wt loss". On 2/13/13 the surveyor reviewed a note written that day by staff member Q which stated, "wt/intake f/u: wt (1/13) 0 (2/13) 96# (12/12) 0 75% IBW; last wt (10/13) 108# 12.55 wt loss which is significant". D. On 2/12/13 at 9:45 a.m., the surveyor reviewed documentation on the hospital's Patient Transfer form. Documentation on this form under Condition of Skin section stated, "Open area mid back; [MEDICATION NAME] applied." On the hospital's Resident Assessment form under the Skin Condition section, there was a labeled diagram showing the resident had a wound in the mid back with the words, "4x4 [MEDICATION NAME] to mid back." On 12/14/12 there was an MDS Significant Change assessment with the ARD of 12/14/12 documented under section M0100; wounds - Determination of pressure ulcer risk - that resident #6 had a stage one pressure ulcer. No other documentation, related to the stage of the wound, was present in resident #6's medical record until 12/24/12 when two stage 2 wounds were recorded on the MDS PPS 14 day assessment ARD date of 12/24/12. The Clinical Notes report dated 12/24/12 stated, "Drsng to back changed at 1600 (4:00 p.m.) for saturation. Draining tan fluid, strong odor. Surface red, moist w/slough in center of wound. Area appears superficial in depth but drains large amt". This note did not mention the two stage 2 wounds as did the MDS PPS 14 day assessment for this date. The medical record for resident #6 did not include notes/assessments or interventions to address the wound from deteriorating from one wound at stage 1 to two stage 2 wounds between 12/14/12 and 12/24/12. The Care Plan report lists the interventions as: "...observe skin for redness, skin tears, swelling, or pressure areas. Encourage (resident #6) to het(sic) up to the recliner and change positions q2h". On 2/13/13 at 9:00 a.m. the surveyor interviewed staff B regarding monitoring of the wounds. Staff B stated, "the wound was not staged until 1/8/13. Record review shows the form labeled Pressure Ulcer Healing Chart has a start date of 1/8/12.

Based on clinical record review and staff interview, the facility staff failed to prevent the development of additional pressure ulcers for 1 (#6) of 29 sampled and supplemental residents. Findings include: Resident #6 was readmitted on [DATE] after right hip surgery with [DIAGNOSES REDACTED]. On 11/25/12 a note was entered in the Clinical Record report that resident #6 was found at 9:00 a.m. on her back by two CNAs and reported she had slid out of bed, and described a, "one inch red bump to low back." There was also an entry on the facility form labeled Non-pressure skin condition report, describing a "2 cm red raised round/circular abrasion to lower back". At the top of the form were directions: Fill in the appropriate boxes and spaces. *Use one form for each skin condition. Further documentation on this form appears to include two different wounds. On 12/1/12 documentation in the Clinical Notes showed that resident #6 was found on the floor in her room and sent to the ER for an evaluation. Resident #6 was diagnosed with [REDACTED]. On 12/7/12 resident #6 returned from the hospital to the facility status [REDACTED]." On the hospital's Resident Assessment form under the Skin Condition section, there was a labeled diagram showing the resident had a wound in the mid back with the words, "4x4 [MEDICATION NAME] to mid back." The facility form labeled Non-pressure skin condition report had documentation of a, "1 cm purple raised round/circular abrasion to low back when rec'd from (hospital). Allevyn applied." Documentation on the initial care plan, dated 12/7/12, under the skin section showed, "at risk, current decubitus, reposition every two hours." On the Care Plan report dated 12/26/12-present the medical record did not include evidence of entries or additions addressing the wound discussed in the MDS dated for 12/14/12 and 12/24/12 which had deteriorated from one wound at stage 1, to two stage 2 wounds. On the Care Plan report interventions were listed as, "...observe skin for redness, skin tears, swelling, or pressure areas. Encourage (resident #6) to het(sic) up to the recliner and change positions q2h". On 12/14/12 there was an MDS Significant Change assessment with documentation under section M0100, Skin Conditions, Determination of Pressure Ulcer Risk, that resident #6 had a stage one pressure ulcer. The medical record did not include evidence of documentation related to the stage of the wound in resident # 6 medical record until 12/24/12 which was reported on the MDS PPS 14 day assessment ARD date of 12/24/12 where two stage 2 wounds were reported, and the Clinical Notes report. The Clinical Notes report dated 12/24/12 stated, "Drsng to back changed at 1600 (4:00 p.m.) for saturation. Draining tan fluid, strong odor. Surface red, moist w/slough in center to wound. Area appears superficial in depth but drains large amt". The note did not contain documentation related to the change in the status of the wound(s), and did not match the information documented in the MDS PPS 14 day assessment for this date. On 2/13/13 at 7:30 a.m., staff member B, the DON, gave the surveyor an MDS assessment note showing, "Reentry/Admission MDS Assessment-ARD 12/8/12-12/14/12". The note contained reference to "...a pressure area on the bony prominence of her spine that is opening." The surveyor interviewed staff member G, the MDS coordinator, and she reported that the above report was written on 12/20/12 and was part of the MDS assessment. Documentation on the Clinical Notes report for December 15, 17,19, 20, 24 (noted above), and 25, 2012 addressed if the dressing was intact or changed. On 12/19/12, the note included, "dressing changed to back as it was saturated from 2 open areas on spine." The medical record lacked adequate documentation and staff were unable to provide additional information to the surveyor related to the wounds for the dates ranging from 12/25/12 to 12/28/12. On 12/29/12 documentation in the Clinical Notes report included, "bath this am, dressing to back changed, small red drainage observed." Neither the medical record nor staff were able to provide additional information, related to the wounds from 12/29/12 to 1/3/13. On 1/4/13 documentation in the Clinical Note report, the Non-Pressure Skin Condition report, and on a fax sent to the resident's physician contained the following summary of information related to the wound on the mid back. "... superficial wound to mid back wound bed 3.2 cm x 1.9 cm beefy red, serosanguineous exudate of moderate amount, draining with odor... surrounding skin bright red, non-blanching and measures 12.7 cm long x 5.3 cm wide." On 1/8/12 documentation on the Clinical Note showed, "rsdt with back pain rated severe do to wound area, wound cleansed, patted dry and covered with [MEDICATION NAME], scant red tinged drainage area tender to touch/ 0.9 open area/red colored center surrounding skin edges wound .04 cm white in color." The medical record did not include evidence of any entries in the resident's medical record describing the change of the wound from 1/4/12 to 1/8/12. The physician order [REDACTED]. Cut hole in 1st Allevyn before placing over wound area. Leave 2nd Allevyn whole and place over top of 1st Allevyn to provide extra cushion to area. Change every 4 days. Complete PUSH (pressure ulcer scale for healing) tool w/each change." The treatments were documented on the dates of: 1/12/13, 1/16/13, 1/20/13, 1/24/13, and 1/28/13. Documentation on the facility form labeled Pressure Ulcer Healing Chart to monitor PUSH (pressure ulcer scale for healing) scores showed the following dates the PUSH tool score was recorded: 1/8/13, 1/13/13, 1/20/13, 1/28/13, 2/1/13, and 2/5/13. The PUSH tool was not documented as being completed with each dressing change as ordered by the physician. On 2/13/13 at 9:00 a.m., the surveyor requested all medical records related to wound care for resident #6 from staff member B, the DON, and staff member C, the ADON. On 2/13/13 at 9:45 a.m. the surveyor interviewed staff member P, one of the nurses who cared for resident #6's wound sites. Staff member P reported she believed she had treated two separate wounds for resident #6. The medical record did not include evidence of any further notes in resident #6's medical record submitted to the surveyor that documented the time period from 12/7/12 to 12/14/12 regarding the condition or treatment of [REDACTED]. The medical record did not include evidence of notes/interventions in resident #6's medical record or Care Plan report dated 12/26/12 to present addressing the wound above deteriorating from one wound at stage 1 to two stage 2 wounds from 12/14/12 to 12/24/12. On the Care Plan report dated 12/26/12-present the interventions were listed as: "...observe skin for redness, skin tears, swelling, or pressure areas". "Encourage (resident #6) to het(sic) up to the recliner and change positions q2h". On 2/13/13 at 9:00 a.m., the surveyor interviewed staff B regarding the monitoring of the wounds. Staff B stated, "the wound was not staged until 1/8/13." Record review shows the form labeled Pressure Ulcer Healing Chart with a start date of 1/8/13.

Based on record review, and interview the facility failed to maintain acceptable parameters of nutritional status, such as body weight and protein levels, for 1 (#6) of 29 sampled and supplemented residents. Findings include: Resident #6 was readmitted on [DATE] after right hip surgery with [DIAGNOSES REDACTED]. On the updated Care Plan Report, dated 12/26/12, documentation under the nutrition intervention included: "monitor resident's weight weekly. Report weight loss/gain greater than 5 pounds to nursing. Nursing to assess; if indicated contact MD/Dietician for recommendations /orders". Review of the Individual Weight Chart dated 2012 lacked documentation of weights for November and December 2012, and January 2013. On 2/12/13 at 10:40 a.m., the surveyor interviewed staff member Q regarding the weights for resident #6. Staff member Q reported that she, "checks every resident every month. If I am having a hard time getting weights I talk to the MDS coordinator and the DON. I turn in a report every time I am here as a written notification also." Staff member Q gave the surveyor a blank form labeled Consulting Dietitian Report stating to the surveyor she completes it for every resident she assesses. Staff member Q stated she notified the Administrator and the DON that she was unable to find resident #6's weights for November 2012, December 2012, and January 2013. Record review of staff member Q's monthly notes for October 23 showed documentation of: "...wt loss risk; moderate-high; weight: (10/12) none yet; no weight for October at this time. Will ask to reweigh resident." During the interview with staff Q on 2/12/12 at 10:40 a.m., the surveyor asked staff member Q why she never received a weight for resident #6 after repeated requests. Staff member Q stated, "It was difficult over those months from October until some time in December. I did speak with the DON and she reported something about staff turnover". On 2/12/12 at approximately 9:00 a.m., the surveyor asked staff member B, the DON, for the records containing the weights recorded for resident #6 for the months of November 2012, December 2012, and January 2013. Staff member B, DON, reported later that day during the exit meeting, "there are no weights for the months of November 2012, December 2012, or January 2013. She (resident #6) was very difficult to get up at that time and refused being weighed". The medical record did not include evidence of interventions added to the Care Plan Report, dated 12/26/12-present, addressing techniques the facility had tried with the resident to obtain a weight for resident #6. There was a hand written note showing on the updated Care Plan Report dated 12/26/12-present stating, "2/8/12-wt review monitoring for wt loss." On 2/13/13 the surveyor reviewed a note written that day by staff member Q which stated, "wt/intake f/u wt (1/13) none (2/13) 96#(12/12) none 75% IBW ast wt (10/13) 108# 12.55 # wt loss which is significant." Resident #6 had a total weight loss percent of 11.10% from 12/7/12 to 2/3/12. According to the facility policy submitted to the surveyor on 2/12/13 at 1:35 p.m., by staff B, DON, labeled Significant Weight Changes, anything greater than 7.5% in three months is defined as severe change. Resident #6's lab report in the chart dated 10/25/12 showed an [MEDICATION NAME] level of 3.6 and a total protein level of 7.1. The reference range for total protein is 6.4-8.2 g/dL, and the reference range for [MEDICATION NAME] is 3.4-5.5 g/dL. The lab report dated 12/17/12 showed an [MEDICATION NAME] level of 2.3 L-low, and a total protein level of 5.7 L-low. The facility failed to recognize, evaluate, address, and monitor the nutritional needs of resident #6.