Every finding on record at Willow Creek Post Acute

Based on interview and record review it was determined the facility failed to monitor and maintain refrigerator and dishwasher temperatures for 1 of 1 kitchen reviewed for sanitary conditions. This placed residents at risk for food borne illnesses. Findings include: Review of the facility's kitchen Equipment Temp Log on 10/8/24 for the refrigerator, freezer, dishwasher and dish rinse revealed the following: - The log included entries from 9/17/24 through 9/30/24. There was no record of temperatures taken prior to 9/17/24. - The log included entries from 10/1/24 through 10/4/24. On 10/5/24 the refrigerator and freezer temperature was documented but the dishwasher temperature was not documented. There were no documented temperatures after 10/5/24. On 10/8/24 at 8:18 AM Staff 7 (Dietary Manager) acknowledged the temperature logs were incomplete and not up to date.

Based on observation, interview, and record review it was determined the facility failed to ensure medications and biologicals were secured and accessible only to authorized personnel for 1 of 2s medication cart observed for secure medication carts. This placed residents at risk for misappropriation of medications and adverse medication consequences. Findings include: The facility's Storage of Medication Policy revised 4/2007 stated, The Facility shall store all drugs and biologicals in a safe, secure, and orderly manner. 1. On 10/7/24 at 7:16 PM the medication cart near the nurses' station was unlocked and unattended by staff. On 10/7/24 at 7:18 PM Staff 9 (RN) confirmed the cart was left unlocked and unattended. On 10/9/24 at 10:07 AM Staff 2 (DNS) stated the medication cart was to be secured when unattended. 2. On 10/8/24 at 6:57 AM a bottle of Omeprazole (a stomach acid medication) was on the top of the medication cart near the nurses' station. The medication cart was unattended by staff. On 10/8/24 at 7:09 AM bubble-pack cards containing medications for Resident 6 were left on top of the facility medication cart located near the nurses' station. The medications were unattended by staff. On 10/8/24 at 7:18 AM Staff 3 (RN) confirmed the medications were not secured and were unattended by staff. On 10/9/24 at 10:07 AM Staff 2 (DNS) stated the medication cart was to be secured when unattended. 3. On 10/9/24 at 7:33 AM the medication cart near the nurses' station was unlocked and unattended by staff. On 10/9/24 at 7:35 AM Staff 8 (RN) confirmed the cart was unlocked and unattended by staff. On 10/9/24 at 10:07 AM Staff 2 (DNS) stated the medication cart was to be secured when unattended.

Based on interview and record review it was determined the facility failed to notify a physician and obtain orders for a worsening pressure ulcer for 1 of 3 sampled residents (#6) reviewed for pressure ulcers. This placed resident at risk for worsening wounds. Findings include: Resident 6 was admitted to the facility in 12/2023 with diagnoses including dementia and peripheral vascular disease. A 12/30/23 Admission Skin Observation Tool assessment revealed Resident 6 had a right heel Stage 1 (intact skin with non-blanchable redness) pressure ulcer which measured 0.1 cm x 0.1 cm. The resident's skin was warm, dry, and intact. Both heels were dry and scaly. A care plan initiated 1/2/24 revealed Resident 6 required one-person extensive assistance with repositioning in bed every two hours. The care plan had no information regarding Resident 6's risk of pressure ulcers or any interventions to address pressure ulcer risk. The Admission MDS dated [DATE], with a review date of 1/6/24, revealed Resident 6 had severe cognitive impairment and was at risk for pressure ulcers. A 1/11/24 physician order directed staff to cleanse the right heel with wound cleanser, paint with betadine, and cover with a silicone dressing every night shift for wound care. A review of the TARs from 1/11/24 through 2/5/24 revealed staff provided wound treatments as ordered. A 2/1/24 Weekly Wound Observation revealed Resident 6 admitted with a Stage 1 pressure ulcer to the right heel. The wound measured 2.0 cm x 3.0 cm x 0.1 cm. The wound had maceration (breaking down of the skin) on the immediate perimeter, and was red and boggy but blanchable outside the maceration. The wound worsened since admission with offloading using a pillow to float the heel. Staff were to place a wedge to elevate the heels and special boots were en route. A report was sent to the physician, Staff 4 (Medical Director), and the family was notified. A 2/6/24 physician order directed staff to cleanse the right heel with wound cleanser, fill the open area with Medi honey (aids and supports debridement), cover with Hydrofera (topical adhesive) blue, apply u-shaped foam around the perimeter, and cover with a 5 x 5 foam dressing. Staff were to wrap with Kerlex (dressing) and Coban (wrap) for light compression. Staff were to change the dressing when three-quarters of the dressing showed drainage and as needed for soiling. A review of the TAR from 2/6/24 through 2/19/24 revealed staff provided wound treatments as ordered. A 2/7/24 Weekly Wound Observation revealed Resident 6's right heel worsened to a Stage 3 (full thickness tissue loss) pressure ulcer. The wound measured 3.5 cm x 4.5 cm x 0.1 cm and indicated, Suspected cellulitis [bacterial] infection with increased heat, redness, shiny appearance and painful to touch. Closed DTI [deep tissue injury] open with fluid filled pockets that drained down to heel. Those had been debrided [removal of dead tissue] and painted with iodine. Staff were to place a wedge to elevate the heels, utilize special boots and open heel foam to prevent pressure. Staff faxed a report of the heel to Staff 4 and notified family. A 2/8/24 Physician Visit note, by Staff 4, revealed Resident 6 had a Stage 2 (partial thickness loss of dermis) pressure ulcer over the entire heel, with edema, bruising, and erythema (reddening of the skin) up to the mid-shin. A referral to the wound clinic was initiated. There were concerns of cellulitis to the bilateral lower extremities and antibiotics were initiated for 10 days to treat the cellulitis. A facility 2/14/24 Weekly Wound Observation revealed Resident 6's right heel worsened to an Unstageable (full thickness tissue loss) pressure ulcer, with 100% necrotic (dead) tissue, without drainage or odor. The wound measured 4.5 cm x 5.0 cm. Inflammation was present and treated with antibiotics for cellulitis. There was maceration around the wound with boggy, blanchable skin outside of the macerated area. The wound was debrided with wound cleanser and gauze to remove non-viable skin, from the foot and leg. A report of the heel was sent to Staff 4 and family was notified. Progress Notes revealed the following information regarding the right heel pressure ulcer: -2/11/24 The right heel had a large blister which extended from the pressure ulcer to the top of the foot. When changing the dressing, one section of the blister was open with drainage proximal to the open area on the medial foot. The dressing was fitted to cover the whole area with Medi honey. The heels were floated in bed to alleviate pressure off the heels. -2/16/24 The large blister that extended from the pressure ulcer to the top of the foot was all open with mostly dry drainage on the dressing. The open areas were mostly dark red and drying. -2/17/24 The large blister on top of the foot had yellow drainage on the dressing. It was turning dark and drying except for a new moist edge that was red. -2/18/24 The large blister on the top of the foot had yellow drainage on the dressing. It was turning dark like necrotic (dead) tissue, except for a moist edge which was red at the top of the foot. A review of Resident 6's medical record from 2/9/24 through 2/18/24 (ten days) revealed no indication that staff communicated or notified Staff 4 of Resident 6's worsening wound. On 2/19/24 (11 days after the resident's wound was last seen by a physician), Resident 6 was sent to the hospital regarding the worsening wound. On 2/22/24 Resident 6 returned from the hospital on hospice services with diagnoses including atherosclerosis (build-up or blockage), venous (improper functioning of the vein valves in the leg) of the lower extremity, and dry gangrene (when the blood supply to the tissue is cut off). On 7/8/24 at 11:30 AM Witness 17 (Complainant) and at 11:35 AM Witness 18 (Complainant) stated Resident 6's right heel wound was not addressed timely, and the resident was sent to the hospital due to her/his worsening wound. Interviews on 7/9/24 revealed the following: -9:51 AM Staff 5 (Former LPN) stated Resident 6 had a pressure ulcer to her/his right heel and she recalled a huge blister on the top of her/his foot. The wound on the right heel and leg progressed quickly, and the resident was sent to the hospital for further evaluation. Staff 5 stated the resident was not painful and she recalled offloading the resident's heels with pillows but did not recall utilizing the wedge or boot protectors. -6:47 PM Staff 6 (Former LPN) stated Resident 6's heels were boggy and got dark quickly. Staff 6 stated she attempted to float the resident's heels as she/he allowed. She did not recall any other interventions for the resident's wound to the heel. -9:27 PM Staff 8 (RN) stated she did not provide wound treatment to Resident 6's right heel but recalled offloading the heels as the resident allowed. The resident had pillows but she did not recall any boot protectors or a wedge. On 7/10/24 at 4:00 PM and 7/11/24 at 9:45 AM Staff 2 (DNS) stated she completed weekly wound observations but was unaware of the new blister on the top of Resident 6's foot. Staff 2 stated she expected staff to notify the physician or her regarding Resident 6's worsening wound. Staff 2 acknowledged the care plan had no information or interventions regarding Resident 6's risk for pressure ulcers. Staff 2 stated Resident 6 was supposed to go to the wound clinic on 2/19/24 but went to the hospital due to the wound worsening. On 7/11/24 at 8:59 AM Staff 13 (Former LPN) stated she recalled Resident 6's right heel wound and the large blister that appeared on top of the resident's foot, which progressed quickly. Staff 13 stated she reported her concerns numerous times to the charge nurse but did not inform Staff 4 or Staff 2 regarding the worsening of the wound because she worked night shift. Staff 13 stated the resident did not report pain and allowed her to provide treatments to the area. On 7/11/24 at 9:00 AM Staff 4 stated she saw Resident 6 on 2/8/24 due to concerns with her/his wound to the right heel and possible cellulitis. Staff 4 stated the resident had edema since admission, her/his right ankle had bruising, erythema and was a Stage 2 pressure ulcer. Staff 4 stated the resident had good capillary refill with no acute ischemia and was started on an antibiotic. Staff 4 further stated she had no correspondence related to the resident's worsening wound to the right heel and staff should have informed her of the worsening wound.

Based on interview and record review it was determined the facility failed to ensure a resident's ordered pain medication was available and effectively managed resident's severe pain for 1 of 1 sampled resident (#18) reviewed for pain management. This resulted in Resident 18 having unrelieved, unmanageable pain and treatment at the hospital Emergency Department. Findings include: Resident 18 admitted to the facility in 4/2023 with diagnoses including chronic pain and osteoarthritis. A 5/10/23 Behavioral Symptoms and Pain CAA revealed Resident 18 had episodes of cursing, yelling and became agitated at staff notably when she/he had extreme pain while pending hip surgery. When Resident 18's pain was managed she/he was in a pleasant mood. A message was sent to the IDT (Interdisciplinary Team) and requested a follow up with the physician for pain management improvement. A 5/13/23 physician order directed staff to administer oxycodone-acetaminophen 5-325 mg one tablet by mouth every four hours for chronic pain. A review of Resident 18's Weights and Vital Report from 6/12/23 through 6/15/23 revealed her/his pain ranged anywhere from three to a six out of 10 on a pain scale. A review of the 6/17/23 and 6/18/23 Weight and Vital report revealed the following: -On 6/17/23 Resident 18's pain level was 10 out of 10 at 7:49 PM -On 6/18/23 Resident 18's pain level was 10 out of 10 at 6:54 AM and 2:36 PM. A 6/18/23 Medication Error Report revealed on 6/17/23 Resident 18 had enough of her/his oxycodone 5-325 mg to administer at 12:00 AM on [6/18/23]. The pharmacy indicated the medication was about to run out and requested a new prescription from the provider, since they had not received the prescription they could not give a code to retrieve the medication from the Cubex (dispenses medications). Resident 18 was very painful and distraught when informed she/he took her/his last dose until a prescription could be sent to the pharmacy. It was Sunday and clinics were not open. Resident 18 rated her/his pain 10 out of 10 on a pain scale and complained of increased pain. The 6/18/23 MAR revealed Resident 18's pain level was 10 out of 10 at 12:00 AM when she/he received the last dose of her/his oxycodone. Resident 18 did not receive her/his 4:00 AM dose. A 6/18/23 Emergency Hospital Discharge Summary revealed Resident 18 was in the emergency department because the facility ran out of her/his usual pain medications and missed two doses after which her/his chronic pain increased. On exam Resident 18 moved all four extremities spontaneously, though very painful with passive range of motion of the bilateral hips. Resident 18 was treated with intramuscular fentanyl and oral oxycodone with significant improvement in her/his pain. On 6/26/23 at 2:14 PM Resident 18 stated she/he had chronic hip pain and missed dosages of her/his pain medications on 6/18/23 and was in terrible pain because the facility ran out of pain medication. Resident 18 stated she/he went to the emergency department because of her/his increased chronic pain. On 6/28/23 at 11:41 AM Staff 13 (RN) stated Resident 18 struggled with pain and discomfort and on 6/18/23 the resident missed one dose because staff was unable to refill her/his prescription. Staff 13 stated Resident 18's physician did not respond to refills or pain medication requests. Staff 13 stated they only received 14 days worth of narcotics at a time for residents and were expected to request pain medication when there were only five days remaining. On 6/29/23 at 9:52 AM Staff 12 (RN) stated she was present on 6/18/23 when the resident was crying and in pain. Staff 12 stated Resident 18 had horrible pain in her/his right hip and was waiting for a hip replacement. Staff 12 stated her/his pain medication ran out and staff were unable to fill the prescription Resident 18 went to the emergency department to address her/his pain. Staff 12 stated it was difficult at times to get prescriptions refilled because either Resident 18's physician did not respond or there were delays with the pharmacy. On 6/29/23 at 11:41 AM Staff 11 (CNA) stated Resident 18 struggled with extreme pain and receiving the regular scheduled pain medications every four hours helped her/him tremendously. On 6/29/23 at 12:55 PM Staff 14 (NA) stated Resident 18 struggled with chronic pain but if her/his pain medications were late she/he struggled with increased pain, was moody and more agitated. Staff 14 stated her/his pain was more controlled with pain medications being administered on her/his regular scheduled times. On 6/29/23 at 1:17 PM Staff 2 (DNS) stated she was aware of the missed dose on 6/18/23 and faxed Resident 18's outside provider/physician multiple times with no response. Staff 2 stated Resident 18 went to the emergency department for the missed dose on 6/18/23 and her/his oxycodone order was changed from a scheduled pain medication to a PRN upon her/his return from the hospital. Staff 2 acknowledged pain medications were not in place appropriately for Resident 18 and the resident struggled with her/his pain. On 6/30/23 at 9:39 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 4 (Regional Director of Operations) acknowledged pain medications were not ordered appropriately for Resident 18 and the facility struggled with communication to ensure Resident 18's physician responded appropriately to pain medication requests.

Based on interview and record review it was determined the facility failed to ensure an RN was available for at least eight consecutive hours for 16 of 30 days reviewed for RN coverage. This placed residents at risk for delayed nursing assessments. Findings include: Direct Care Daily Staff Reports indicated there was no RN coverage on the following dates: -9/2/22 -9/3/22 -9/4/22 -9/8/22 -9/9/22 -9/10/22 -9/11/22 -9/15/22 -9/16/22 -9/17/22 -9/18/22 -9/23/22 -9/24/22 -9/25/22 -9/29/22 -9/30/22 On 6/28/23 at 2:37 PM Staff 1 (Administrator) and Staff 4 (Regional Director of Operations) confirmed the dates with no RN coverage.

Based on interview and record review it was determined the facility failed to ensure call lights were functioning for 1 of 1 facility and 2 of 3 sampled residents (#s 22 and 23). This placed residents at risk for delayed care and unmet needs. Findings include: On 6/28/23 at 10:28 AM Staff 4 (Regional Director of Operations) provided a call light replacement document that indicated the following: -On approximately 8/15/22 the facility call lights became non-functional; -Attempts were made to fix the call lights and were unsuccessful; -On 9/21/22 a quote was obtained for a replacement call light system and it was ordered; -The new call light system was installed on 9/27/22 [43 days later]; -During the time the call system was not working manual bells were provided to the residents and 15-minute checks were initiated. A review of the 15-minute call light log book from 8/25/22 through 9/23/22 (30 days) revealed the log was incomplete with no room numbers, names of residents or initials of staff who had completed the 15-minute checks. On 6/28/23 at 9:06 AM Staff 15 (CNA) stated in September 2022 the call light system was not working for some time. Staff 15 stated the residents used the tapping call bells to get assistance. Staff 15 stated staff were expected to do 15-minute checks for the residents who were not able to use the call lights but were not always able to do so. Staff 15 further stated if the residents' doors were closed staff could not hear where the call bell was coming from because then the residents stopped tapping on the manual call bell so it could take a while to figure out who tapped on the bell. Staff 15 stated residents were frustrated with staff not hearing the call bells. On 6/29/23 at 9:31 AM Staff 18 (Housekeeping) stated she remembered the call light system not functioning and residents were provided bells. Staff 18 stated residents were very upset because staff were unable to hear the call bells when the residents' doors were closed. a. Resident 23 admitted to the facility in 2022 with diagnoses including muscle weakness and pain. The 8/8/22 Admission MDS indicated Resident 23 was cognitively intact. A progress dated 8/29/22 indicated Resident 23's call bell was in reach, but the resident stated, does no good to ring that, no one ever comes. On 6/26/23 at 2:51 PM Witness 6 (Complainant) sated in 9/2022 the call light system did not function and Resident 23 was provided a call bell and staff could not hear the call bells when Resident 23 wanted assistance. Witness 6 indicated the call light system was out for sometime. b. Resident 22 admitted to the facility in 3/2022 with diagnoses including chronic heart failure and anxiety. The 3/8/22 Admission MDS indicated Resident 22 was cognitively intact. On 6/29/23 at 11:03 AM Staff 6 (CNA) stated the call light system was not working for a while. Staff 6 stated residents were provided bells. Staff 6 stated it was difficult to hear the bell when she was in a resident's room. Staff 6 stated she told residents to just keep ringing the bell until staff came to assist. Staff 6 stated Resident 22 complained about using the call bell and whistled to get assistance as it was louder than the bell. On 6/28/23 at 10:28 AM and 6/30/23 at 10:25 AM Staff 1 (Administrator) and Staff 4 (Regional Director of Operations) acknowledged the facility call lights became non-functional on approximately 8/15/22 and the new call system was installed on 9/27/22. On 9/27/22, the Past Noncompliance was corrected when the facility replaced the call light system. 1. A quote on 9/21/22 was obtained for replacement of the call light system. 2. The new call light system was installed on 9/27/22 and was working appropriately.

Based on observation and interview it was determined the facility failed to provide secured handrails in all corridors for 2 of 2 halls reviewed for environment. This placed residents at risk for accidents. Findings include: On 6/28/23 at 10:20 AM Resident 15 was observed using the handrail to self-propel from the living room common area to the [NAME] hall with the handrail loosely attached to the wall. On 6/28/23 at 12:52 PM Staff 21 (Maintenance Director) acknowledged multiple handrails were unsecured to the walls in the facility. On 6/28/23 at 12:56 PM Staff1 (Administrator) stated she was aware the handrails in the facility were unsecured to the walls throughout the facility.

Based on observation and interview it was determined the facility failed to ensure resident equipment was maintained and sanitary for 2 of 3 sampled residents (#s 1, and 16) and flooring was safe in the living room reviewed for environment. This placed residents at risk for injury and unhomelike environment. Findings include: 1. On 6/26/23 at 1:06 PM Resident 16's wheelchair was observed to have a large amount of dry crusted food debris on the base of the wheelchair. On 6/29/23 at 3:37 PM Staff 2 (DNS) observed Resident 16's wheelchair and acknowledged it had dry crusted food debris at the base of the wheelchair. Resident 16 stated staff generally did not have time to clean it. Staff 2 stated night shift staff were to clean the wheelchairs. 2. On 6/26/23 at 2:06 PM Resident 1's wheelchair was observed to have dry crusted food on the base of the wheelchair. Resident 1 stated staff did not clean her/his wheelchair. On 6/29/23 at 3:36 PM Staff 2 (DNS) observed Resident 1's wheelchair and acknowledged it had dry crusted food debris at the base of the wheelchair. Staff 2 stated night shift staff were to clean the wheelchairs. 3. On 6/28/23 at 10:20 AM Resident 13 was observed seated in a wheelchair in the living room area, under Resident 13 was approximately a two-inch hole in the concrete flooring. On 6/28/23 at 12:52 PM Staff 21 (Maintenance Director) confirmed there was a large hole in the concrete flooring in the living room area in need of repair.

Based on observation, interview and record review it was determined the facility failed to provide care and services to maintain good grooming and nail care for 2 of 5 sampled residents (#s 3 and 8) reviewed for ADLs and hospice. This placed residents at risk for lack of grooming and hygiene. Findings included: 1. Resident 3 admitted to the facility in 3/2023 with diagnoses including chronic heart failure. A 4/4/23 Care Plan indicated Resident 3 was to have diabetic nail care by the night shift nursing staff and nails trimmed weekly. Resident 3 had an ADL care deficit related to stroke, was on hospice, required one or two staff for bathing and referred to the ADL care CNA task for bathing. The 5/2023 and 6/2023 TARs indicated weekly checks and nail care were completed by nursing staff. Resident 3 refused nail care on 5/17/23 and 5/31/23. The ADL care CNA task for bathing had no information regarding if Resident 3 was scheduled or received any type of bathing. A review of hospice notes revealed from 5/8/23 through 6/27/23 Resident 3 only received four bed baths by the hospice CNA aide. Random observations from 6/26/23 through 6/28/23 revealed Resident 3 was in bed, hair unkempt and her/his right hand rested on top of her/his blanket. Resident 3's nails were thick, yellowish and beyond her/his nail bed. On 6/26/23 at 12:28 PM Resident 3 indicated staff were supposed to trim her/his nails and provide a bed bath or shower. On 6/27/23 at 2:20 PM Staff 14 (NA) stated Resident 3 was on hospice and she/he stayed in bed most of the time. Staff 14 stated she thought hospice was responsible for bathing and trimming Resident 3's nails. On 6/28/23 at 9:06 AM Staff 15 (CNA) entered the room and confirmed Resident 3's nails were long, yellowish and her/his hair was unkempt. Staff 15 stated Resident 3 was on hospice and hospice was responsible for showers and nail care. Staff 15 stated they provided showers or bed baths only PRN. On 6/28/23 at 12:00 PM Staff 19 (Hospice Nurse) stated the facility was responsible for nail care and showering the resident. Staff 19 stated hospice provided a bed bath for Resident 3 once a week. On 6/28/23 at 12:53 PM Staff 2 (DNS) stated hospice provided Resident 3's bed baths and CNAs at the facility were only responsible to provide a bed bath or shower PRN. Staff 2 acknowledged Resident 3's nails were long, thick and had a nail fungus and staff were expected to address her/his nail care and request an anti-fungal cream to address her/his nail fungus. On 6/30/23 at 10:17 AM Staff 1 (Administrator) and Staff 4 (Regional Director of Operations) stated staff were expected to provide showers or a bed bath two times a week and showers were not just provided by hospice. Staff 1 and Staff 4 acknowledged Resident 3's nail care and showers were not provided appropriately. 47005 2. Resident 8 admitted to the facility in 2022 with diagnoses including respiratory failure. A 1/11/23 Care Plan indicated Resident 8 recieved hospice services, was dependent on staff to provide weekly and as necessary bathing and shower care. A review of the facility 30-day shower log indicated Resident 8 did not receive a shower in the past 30 days. A review of Resident 8's clinical record revealed she/he was not provided nail care from facility staff. A review of the hospice notes revealed from 5/5/23 to 6/23/23 Resident 8 received seven showers and one nail care by the hospice CNA. On 6/26/23 at 1:17 PM Resident 8 stated she/he had long, thick toenails that needed to be cut and was not sure when her/his last shower or bed bath was completed. On 6/27/23 at 1:51 PM Staff 22 (CNA) stated she had not given Resident 8 a shower, bed bath or provide any nail care. Staff 22 stated she believed hospice was responsible for showers and nail care and hospice was in one or two times a week. On 6/28/23 at 9:19 AM Staff 23 (CNA) stated hospice was responsible for Resident 8's showers and nail care. On 6/28/23 at 12:12 PM Staff 19 (Hospice RN) stated hospice was not primarily responsible for providing all showers or nail care but was an additional support for ADL care. On 6/28/23 at 12:53 PM Staff 2 (DNS) stated hospice provided Resident 8's bed baths and CNAs at the facility were only responsible to provide a bed bath or shower PRN. On 6/30/23 at 10:17 AM Staff 1 (Administrator) and Staff 4 (Regional Director of Operations) stated staff were expected to provide showers or a bed bath two times a week and showers were not just provided by hospice. Staff 1 and Staff 4 acknowledged Resident 3's nail care and showers were not provided appropriately.

Based on interview and record review it was determined the facility failed to ensure physician orders were followed and implemented for 3 of 5 sampled residents (#s 4, 12 and 23) reviewed for medications. This placed residents at risk for adverse side effects of medications. Findings include: 1. Resident 4 admitted to the facility on [DATE] with diagnoses including osteoporosis. a. The admission order dated 4/26/23 indicated Resident 4 was to receive alendronate (medication used to treat osteoporosis) 35 mg once weekly. Progress notes and 5/2023 MARs indicated alendronate was not administered as ordered on the following dates: -5/7/23 -5/14/23 -5/21/23 -5/28/23 The 6/2/23 Medication Report indicated Resident 4 missed four doses of alendronate. On 6/28/23 at 11:15 AM Staff 13 (RN) stated Resident 4 missed four weekly doses of alendronate due to a miscommunication and the nurse did not follow through with ordering medications. On 6/29/23 at 1:17 PM Staff 2 (DNS) acknowledged Resident 4 missed alendronate on the identified dates. b. The 5/2023 MAR indicated Resident 4 did not receive levothyroxine (thryroid medication) on the following dates: -5/4/23 -5/10/23 -5/23/23 On 6/29/23 at 1:17 PM Staff 2 (DNS) acknowledged Resident 4 missed levothyroxine on the identified dates. 36494 2. Resident 23 admitted to the facility in 2022 with diagnoses including diabetes and dialysis (removing excess water solutes and toxins from the blood when the kidneys no longer perform). A 8/15/22 Care plan indicated Resident 23 was to be provided and administered medications as ordered. A review of Resident 23's MARs for 8/2022 and 9/2022 revealed the following: 8/2022 MARs: -20 times nephrocaps (treats vitamin deficiency), lokelam (treats high levels of potassium), culturelle (a probiotic), norvasc (a calcium channel blocker) medications were not administered due to waiting on the medication from pharmacy or Resident 23 was out of the facility or was noted as don't have. 9/2022 MARs: -13 times nephrocaps, lokelam, culturelle, norvasc medications were not administered due to waiting on the medication from the pharmacy. -21 times Resident 23 was noted as being out of the facility. -Eight times calcium acetate (phosphate binder) was not administered due to waiting on the pharmacy or unsure if medication was given or Resident 23 was at dialysis. On 6/26/23 at 2:51 PM Witness 6 (Complainant) stated there was an ongoing concern with Resident 23's not getting medications timely or at all. On 6/28/23 at 1:47 PM Staff 3 (LPN/Unit Manager) stated she did not recall specifics regarding Resident 23's medication administration during 8/2022 and 9/2022 but the facility struggled to receive medication requests back from the pharmacy and physicians timely. On 6/30/23 at 9:27 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 4 (Regional Director of Operations) acknowledged Resident 23 was not administered her/his medications per physician orders and staff were expected to follow up if medications were unavailable. 3. Resident 12 admitted to the facility in 7/2021 with diagnoses including diabetes. A physician order dated 6/17/23 directed staff to obtain Resident 12's CBG one time a day in the AM. A review of the 6/2023 MARs and TARs revealed from 6/18/23 through 6/30/23 (13 days) no CBGs were obtained for Resident 12. On 6/29/23 at 1:29 PM Staff 2 (DNS) stated she expected staff to update and implement physician orders. Staff 2 acknowledged staff were not monitoring CBGs appropriately for Resident 12's CBGs.

Based on interview and record review it was determined the facility failed to ensure physician orders were followed and implemented for 1 of 1 sampled resident (#21) reviewed for ostomy care. This placed residents at risk for skin breakdown. Findings include: Resident 21 readmitted to the facility in 1/2023 with diagnoses including malnutrition. The 3/1/23 physician order indicated the following: -Ileoostomy (a procedure in which part of the small bowel, is brought through the abdominal wall via a surgically-created opening called a stoma. The purpose of an ileostomy is to evacuate stool from the body via the ileum) care: change bag in the evening every three days and PRN leaking; -Cleanse skin with water only and allow to completely dry. The 3/17/23 8:14 PM Administration Note indicated there were no supplies to do proper change of the ostomy bag. The 3/18/23 at 8:20 PM Administration Note indicated proper supplies not available, replaced with similar situation. The 3/18/23 9:04 PM Administration Note indicated 0 supplies available that would work, had been changed 3 times in 3 hours. Sent to emergency room for ileostomy change. The 3/18/23 at 11:19 PM Progress Note indicated Resident 21 returned from the emergency room with a regular ostomy bag intact. On 6/28/23 at 11:05 AM Staff 13 (RN) stated Resident 21 had a specific ostomy that required specific supplies. Staff 13 stated the facility did not have the ordered ostomy care supplies and staff had to use the regular supplies that were on hand which resulted in the ostomy site leaking and caused skin issues. On 6/28/23 at 11:30 AM Witness 7 (Wound/Ostomy RN) stated the ostomy and wound clinic sent supplies and specific instructions for ostomy care. Witness 7 stated Resident 21 was seen three times weekly at the wound/ostomy clinic. Witness 7 further stated on multiple occasions Resident 21 arrived at the clinic with incorrect ostomy supplies and/or incorrectly applied supplies resulting in leaking around the ostomy site. Witness 7 stated the ostomy care instructions were often not followed. On 6/28/23 at 12:10 PM Staff 20 (RN) stated a lot of times the facility did not have the correct ostomy supplies for Resident 21 and the ostomy site leaked. Staff 20 stated the facility had regular ostomy supplies that had to be used since the ordered supplies were not available. Staff 20 further stated she had to send the resident to the emergency room because the facility did not have the proper supplies for the ostomy. On 6/29/23 at 1:24 PM Staff 2 (DNS) acknowledged the facility often did not have the ordered ostomy supplies for Resident 21.

Based on observation, interview and record review it was determined the facility failed to ensure resident respiratory orders were accurate and equipment was maintained for 1 of 1 sampled resident (#3) reviewed for respiratory care. This placed residents at risk for respiratory issues. Findings include: Resident 3 admitted to the facility in 3/2023 with diagnoses including chronic heart failure. Random observations from 6/26/23 through 6/28/23 revealed Resident 3 utilized oxygen and wore a nasal cannula. The concentrator had two gray filters on the sides of the concentrator and had a white dusting/particle build-up on the outsides of the filter and dust particles were on the front of the concentrator. No documentation was found in the clinical records indicating Resident 3's oxygen concentrator machine and filters were cleaned on a regular basis. On 6/27/23 at 2:20 PM Staff 14 (NA) stated Resident 3 was on hospice, utilized oxygen and she/he stayed in bed most of the time. Staff 14 stated she thought the CNAs were responsible for cleaning the oxygen concentrator. On 6/28/23 at 9:06 AM Staff 15 (CNA) entered the room and confirmed the oxygen concentrator was not clean; both filters were dusty with particles and dust was visible on the top of the oxygen concentrator. Staff 15 stated Resident 3 was on hospice, utilized oxygen and wore her/his nasal cannula in bed all the time. Staff 3 stated she thought hospice was responsible for cleaning the oxygen concentrator. On 6/28/23 at 11:52 AM Staff 13 (RN) stated Resident 3 received hospice care and her/his oxygen concentrator cleaning was provided by hospice. On 6/28/23 at 12:00 PM Staff 19 (Hospice Nurse) stated the facility was responsible for cleaning the oxygen concentrator. On 6/28/23 at 12:53 PM Staff 2 (DNS) stated facility staff were responsible for cleaning the oxygen concentrator. Staff 2 verified there was no evidence in the clinical record to ensure Resident 3's oxygen concentrator was cleaned regularly. b. A 5/6/23 hospice order directed staff to administer oxygen at two liters per minute. The order did not indicate if Resident 3 was to wear the oxygen continuously or PRN. No documentation was found in the clinical records indicating if Resident 3's oxygen was worn continuously or PRN. Random observations from 6/26/23 through 6/28/23 revealed Resident 3 utilized oxygen and wore a nasal cannula. The oxygen concentrator was set at two liters per minute. On 6/27/23 at 2:20 PM Staff 14 (NA) stated Resident 3 was on hospice, utilized oxygen and the concentrator was used 24 hours a day seven days a week. Staff 14 stated she was not sure if Resident 3 was to use oxygen all the time. On 6/28/23 at 11:52 AM Staff 13 (RN) stated Resident 3 received hospice care and utilized oxygen at all times but was not sure how many liters per minute Resident 3 received. On 6/28/23 at 12:00 PM Staff 19 (Hospice Nurse) stated Resident 3 utilized oxygen but could not recall if she/he had continuous or PRN use only. On 6/28/23 at 7:06 PM Staff 4 (Regional Director of Operations) reviewed and acknowledged the orders were not clarified or accurate regarding the use of Resident 3's oxygen and facility staff were expected to clarify oxygen orders if there were discrepancies.

Based on interview and record review it was determined the facility failed to ensure accurate staffing information was posted for 7 of 30 days reviewed for staffing reports. This placed residents and the public at risk for lack of staffing information. Findings include: a. The Direct Care Daily Staff Reports indicated the following dates when two different forms were completed for the same date and signed by different staff. There were discrepancies between the two forms regarding the number of staff worked on the following dates: -9/2/22 -9/3/22 -9/6/22 -9/7/22 b. The Direct Care Daily Staff Reports were missing information on the following dates: -9/9/22 no census was noted for night shift. -9/11/22 no census was noted for evening or night shift. -9/18/22 no census was noted for night shift. On 6/28/23 at 2:37 PM Staff 1 (Administrator) and Staff 4 (Regional Director of Operations) confirmed the identified Direct Care Daily Staff Reports discrepancies and acknowledged the incomplete forms.

Based on interview and record review it was determined the facility failed to ensure pharmacy recommendations were addressed by the physician for 2 of 5 sampled residents (#s 5 and 15) reviewed for medications. This placed residents at risk for medication complications. Findings include: 1. Resident 5 admitted to the facility in 2/2022 with diagnoses including anxiety and depression. The 3/28/23 pharmacy recommendation indicated the following: -Resident 5 had an order for diclofenac (topical pain cream) with no specific dose, and stated, Please clarify the amount of grams are to be applied to the affected areas or joint. For the upper extremities it should be two grams per area and lower extremities four grams per area with a maximum of 32 grams per day. Please clarify and update the MAR. The pharmacy recommendation regarding the diclofenac was not signed or updated until 4/26/23. On 6/29/23 at 1:29 PM Staff 2 (DNS) confirmed the facility did not act upon the pharmacist recommendation timely. 47005 2. Resident 15 admitted to the facility in 2021 with diagnoses including anxiety and depressive disorder. a. The 1/24/23 pharmacy recommendation indicated the following: -Resident 15 was taking trazodone routinely for insomnia and was due for a gradual dose reduction (GDR) assessment. On 2/10/23 Resident 15's provider signed the pharmacy recommendation and wrote will discuss with patient at an upcoming appointment. A physician visit dated 5/9/23 revealed no mention of a reduction or GDR for trazodone. A review of the 2/2023 to 6/2023 MAR and the clinical record revealed no changes to the trazodone dosage. On 6/28/23 at 3:02 PM Staff 2 (DNS) confirmed the facility did not act upon the pharmacist recommendation timely. b. The 5/22/23 pharmacy recommendation indicated the following: -Resident 15 received several psychotropic agents since October 2022, buspirone 5 mg daily for anxiety and depression and duloxetine 60 mg for depression and was due for a GDR assessment. On 6/28/23 the clinical record was reviewed and there was no indication a response was received from the physician. On 6/28/23 at 3:02 PM Staff 2 (DNS) confirmed the facility did not act upon the pharmacist recommendation timely.

Based on interview and record review it was determined the facility failed to provide adequate behavior monitoring for 1 of 5 sampled residents (#5) reviewed for medications. This placed residents at risk for increased behaviors and adverse side effects. Findings include: 1. Resident 5 admitted to the facility in 2/2022 with diagnoses including anxiety and depression. A 3/12/22 Care Plan indicated Resident 5 received buspirone (antianxiety) medication related to the diagnosis of anxiety disorder. Interventions included to monitor side effects and effectiveness of the medication. A revision dated 9/3/22 indicated staff were to monitor/record occurrence of target behavior symptoms (pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/other.) and document per facility protocol. Resident 5 was resistive to care and staff were to negotiate a time to lay her/him down and if Resident 5 resisted to return within five to 10 minutes. A review of progress notes and behavior monitoring from 4/29/23 through 6/27/23 revealed multiple behaviors including: -Accusing of others, expressed frustration/anger at others and made disruptive sounds. -Repetitive motion, threatening and screaming at others. -Yelled help help after turning off her/his call light and staff was hardly out of the room. -Caught using her/his vape pen in inappropriate areas and stated she/he did not know where she/he was on multiple occasions. -Hitting her/his hairbrush on the bedside table, cursed and argued with staff. -Entered other resident rooms and screamed at the CNAs while they were assisting other residents. -Pacing back and forth continuously in her/his electric wheelchair asking when her/his smoke break was. -Resident 5 screamed for help instead of using the call light. Staff reminded Resident 5 to utilize her/his call light because she/he scared other residents. -Resident 5's roommate was very tired and lost her/his temper because of no sleep due to Resident 5's disruptive behaviors in their room. The progress notes, care plan and behavior monitoring logs did not indicate non-pharmacological interventions for Resident 5, if they were successful and how the facility staff attempted to address Resident 5's disruptive behaviors. On 6/27/23 the 4/2023, 5/2023 and 6/2023 Psychotropic reviews were requested and none were received. On 6/27/23 at 2:00 PM Staff 14 (NA) stated Resident 5 was very anxious with behaviors, very hard to redirect and was fixated on her/his vape pen. Resident 5 was disruptive to other residents and at times barged into other residents rooms when the door was closed while staff provided ADL cares to other residents. Staff 14 stated the facility did not have specific interventions in place to address Resident 5's ongoing behaviors. On 6/28/23 at 2:09 PM Staff 3 (LPN/Unit Manager) stated Resident 5 had behaviors due to anxiety and staff attempted to redirect or re-assure her/him but they were not always successful. Staff 3 indicated she was not involved in the psychotropic reviews/meetings and were completed by Staff 2 (DNS) and Staff 16 (Pharmacy Consultant). On 6/29/23 at 9:52 AM Staff 12 (RN) stated Resident 5 had severe anxiety and short-term memory loss. Staff 12 stated Resident 5 was passive aggressive, hard to redirect and the facility did not have true interventions in place to address Resident 5's ongoing behaviors. Staff 12 stated her/his behaviors were disruptive to other residents. On 6/29/23 at 1:29 PM Staff 2 (DNS) stated she was not sure how psychotropic meetings were conducted and if any psychotropic documentation kept prior to her starting at the end of 5/2023. On 6/29/23 at 1:44 PM Staff 16 (Pharmacist) stated she completed pharmacy reviews off site but at times was in the building to meet with Staff 2 regarding all residents. Staff 16 stated the facility did not complete psychotropic meetings and she only interacted with Staff 2. Staff 16 stated she encouraged the facility to create an IDT (Interdisciplinary Team) related to psychotropic meetings to review all medications, discuss behaviors and ensure a thorough overview was completed for each resident. On 6/29/23 at 3:26 PM Staff 5 (Social Service Director) stated she was supposed to address behaviors and interventions for Resident 5 but was not involved or included in the psychotropic meetings. On 6/30/23 at 9:51 AM Staff 1 (Administrator) stated the psychotropic drug meetings were completed monthly along with the pharmacy reviews, however it was mainly Staff 2 and Staff 16 and did not involve Staff 3 or Staff 5 in the meetings. Staff 1 acknowledged they did not have appropriate behavior monitoring in place, including interventions or if they were effective for Resident 5 on a consistent basis.

Based on interview and record review it was determined the facility failed to honor residents religious food preferences for 1 of 7 sampled residents (#23) reviewed for food and religious choices. This placed residents at risk for not honoring religious choices. Findings include: Resident 23 admitted to the facility in 2022 with diagnoses including renal dialysis (removing excess water solutes and toxins from the blood when the kidneys no longer perform). A 8/15/22 care plan indicated Resident 23 was to be provided and served a diet as ordered. The care plan indicated double portions for all meals and no pork. A diet order on 9/22/22 revealed CCHS (Controlled Carbohydrate Diet) regular, low potassium and sodium, double proteins for all meals. The new diet order indicated no pork. A diet order updated on 10/13/22 revealed Resident 23 was to not be served any ham, bacon or sausage. On 6/26/23 at 2:51 PM Witness 6 (Complainant) stated Resident 23's religious preferences were not honored. Witness 6 indicated when he visited Resident 23 during mealtimes she/he was served pork products often which was against her/his religious beliefs. On 6/28/23 at 10:45 AM Staff 10 (Former Registered Dietician) stated there were concerns regarding Resident 23's religious preferences not being implemented and she/he was served pork products on a regular basis. Staff 10 stated she updated the 10/13/22 diet order to ensure staff did not serve Resident 23 any pork products at any meal. On 6/29/23 at 10:24 AM Staff 9 (Former Dietary Manager) stated she recalled Resident 23 and her/him being served pork products which was against her/his religious beliefs and took a awhile to sort out. On 6/30/23 at 9:27 AM Staff 1 (Administrator) and Staff 4 (Regional Director of Operations) indicated they expected dietary and kitchen staff to implement and honor religious preferences regarding food.

Based on interview and record review it was determined the facility failed to follow therapeutic diet recommendations for 1 of 7 sampled residents (#23) reviewed for food and therapeutic diet. This placed residents at risk for weight loss. Findings include: Resident 23 admitted to the facility in 2022 with diagnoses including renal dialysis (removing excess water solutes and toxins from the blood when the kidneys no longer perform). An 8/11/22 progress note indicated labs and recommendations were received from dialysis, a diet change including double portions was to be implemented. An 8/11/22 dietary order indicated Resident 23 was to receive double protein for all meals. The 8/15/22 care plan indicated Resident 23 was to be provided and served a diet as ordered. The resident's ordered diet included double portions for all meals. The care plan also indicated the dietician was to evaluate and make recommended diet changes as needed. The care plan indicated Resident 23 received dialysis three times a week on Monday, Wednesday, and Friday. An 8/15/22 progress note indicated Resident 23 requested to get up earlier than normal to have time to eat before she/he went to dialysis. Review of the dialysis lab report indicated the following: - 8/2022- double protein at meals. The albumin level (protein in blood) was 3.6, with a goal of 4 or higher. - 9/2022- double protein, do not skip meals on dialysis days. The albumin level remained 3.6. A diet order dated 9/22/22 indicated changes to Resident 23's diet and included, patient needs double protein portions with meals. On 6/28/23 at 10:45 AM Staff 10 (Former Registered Dietician) stated dialysis was very specific about Resident 23's diet recommendations, including implementing the double portions for all meals. Staff 10 stated the facility did not send the resident with a morning meal to dialysis or ensure the resident was up earlier to eat a meal prior to dialysis. Staff 10 stated Resident 23 did not receive a morning meal for two to three weeks on dialysis days. On 6/29/23 at 10:24 AM Staff 9 (Former Dietary Manager) stated Resident 23 was to receive double protein portions for all meals. Staff 11 stated there was confusion related to Resident 23's dialysis days. Staff 11 acknowledged there were times when staff did not wake up Resident 23 for a meal to be offered prior to dialysis. On 6/30/23 at 9:23 AM Staff 1 (Administrator) and Staff 4 (Regional Director of Operations) acknowledged Resident 22 did not receive an appropriate therapeutic diet as ordered.

Based on observation, interview and record review it was determined the facility failed to ensure a resident received pressure ulcer treatments for 2 of 2 sampled residents (#s 4 and 8) reviewed for pressure ulcers. This resulted in multiple avoidable Stage 2 pressure ulcers for Resident 8. This placed other residents at risk for worsening pressure ulcers. Findings include: 1. Resident 8 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 2/25/22 Admission MDS Pressure Ulcer CAA indicated Resident 8 had a pressure relief mattress, had no current skin breakdown and was to be care planned for risk of skin breakdown. Resident 8's Care Plan did not identify any pressure ulcers or interventions prior to 5/4/22. The 4/23/22 Skin Assessment indicated Resident 8 had a new pressure ulcer on the buttocks. The 4/25/22 Skin/Wound Note indicated a new skin issue, pressure sore to buttocks. The 4/26/22 Fax Communication to the physician indicated please advise on skin care per pressure sores. The physician responded by fax on 4/28/22 with please consult RN for bed sore management. Resident 8's Skin/Wound Notes indicated the following: -4/27/22 at 5:54 AM two pressure spots on the right hip, the physician was faxed. -4/27/22 at 7:40 PM two pea size purple areas on right hip, no skin is broken, appears to be bruising, per DNS barrier cream was to be applied. The 4/28/22 Progress Note indicated a CNA called the nurse into the room to observe the resident's coccyx and found residents cheeks to have multiple lateral skin [CONDITION(S)] ranging in length from 1 cm to 3 cm. The area was cleaned and dried and then a 7 x 7 sacrum [MEDICATION(S)] dressing was applied. The resident was put on a turning schedule which she refunded [refused] in the past. The resident agreed to get out of her/his wheelchair after each meal and had been spending most of the day in her/his power chair recently. The 4/29/22 Skin Assessment indicated Resident 8 had broken skin on the right and left buttocks and lateral [CONDITION(S)] along the inside of her/his buttock. The 4/30/22 Fax Communication to the physician indicated the resident had multiple lateral skin [CONDITION(S)] ranging 1 cm to 3 cm to the cheeks and a 7 x 7 [MEDICATION(S)] dressing was applied to the sacral area. Staff will monitor and change every 72 hours or sooner if soiled. Resident put on a turning schedule which she/he had refused in the past and she/he also agreed to get out of the wheelchair after meal and had been spending most of the day in the power chair. Do you want me to keep this treatment plan or modify it? The physician responded by fax on 5/2/22 with continue as planned, recommend air cushion on power wheelchair. The 5/1/22 Skin/Wound Note indicated the resident refused to change positions in bed to relieve pressure to the right side. Staff explained the risk associated with not being repositioned and the resident still refused, writer attempted x3. On 5/4/22 at 11:18 AM Staff 10 (RN) was observed to remove a foam dressing dated 5/3 from Resident 8's coccyx area. The area was observed to be open and additional open areas were observed and were not covered with dressings. On 5/4/22 at 11:31 AM Staff 2 (DNS) entered the room to complete a skin assessment. Staff 2 stated she looked at this area a week ago and the wound was a bruise. Staff 2 measured and staged the areas and identified them as Staff 10 (RN) documented the measurements. Staff 2 measured and verbalized the identified areas as: -Stage 2 pressure ulcer on right buttock 1 cm x 6 cm; -Stage 2 right hip 1.5 cm x 1 cm; -Stage 2 right coccyx 4.5 cm x 1.2 cm; -Stage 2 left coccyx 3.2 cm x 6 cm; -Right gluteal fold 0.3 cm x 0.6 cm; -Right buttock deep tissue injury 0.8 cm x 0.4 cm; -Right gluteal fold-coccyx 0.7 cm x 0.4 cm. On 5/4/22 at 12:54 PM Staff 2 stated there were no skin assessments with measurements prior to 5/4/22. On 5/4/22 at 1:53 PM Staff 10 (RN) stated she had not contacted the physician regarding Resident 8's identified pressure ulcers on 5/4/22 because she hasn't had time. On 5/5/22 at 3:19 PM Staff 2 was asked about physician notification and orders regarding the identified pressure ulcers. Staff 2 stated she asked Staff 10 to notify the physician and was unaware if the physician responded yet. The 5/5/22 fax to the physician indicated the resident had multiple Stage 2 wounds on coccyx and buttocks and please send wound orders. These are worsening since prior [MEDICATION(S)] orders. On 5/6/22 the physician responded by fax please consult wound care nurse. On 5/6/22 at 6:08 AM Staff 13 (LPN) stated Resident 8 had multiple pressure ulcers and she/he had a large dressing covering the area on her/his hip. Staff 13 stated she completed dressing changes but could not stage pressure ulcers. She stated the physician indicated to follow nursing orders for the pressure areas. Staff 13 stated Resident 8 was up in her/his power chair during the day and would usually only lay down in bed for 30 minutes or an hour before she/he wanted to get up again. Staff 13 stated therapy was looking at getting the resident a different cushion as she/he did not like one they provided. On 5/6/22 at 11:45 AM Staff 2 stated Resident 8's pressure ulcer to the coccyx was first identified on 4/23/22, a fax was not sent to the physician until 4/26/22 and a response was not received until 4/28/22. Staff 2 acknowledged the multiple delays for notification of the physician, lack of wound monitoring, lack of wound care orders and the multiple additional Stage 2 pressure ulcers identified on 5/4/22. Staff 2 stated she followed up with the physician and the plan was to send Resident 8 to the wound clinic. Staff 2 stated the expectation was for staff to report any open skin areas and complete an incident report. Staff 2 stated she was out of the facility from 4/26/22 until 5/1/22 and the facility did not have a resident care manager or staff delegated to complete skin and wound assessments. Staff 2 further acknowledged there was no update to the residents care plan regarding the pressure ulcers until 5/4/22. 2. Resident 4 admitted to the facility in 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 2/9/22 physician order [MEDICAL RECORD OR PHYSICIAN ORDER] -clean with soap and water, pat dry. -apply thin layer of extra protective cream around wound. -apply a piece of purple foam in the shape of the wound to the wound bed. -cover with foam dressing. -change every 2-3 days. The 3/31/22 physician notes indicated Resident 4 had a 2 cm ulcer on the right ankle that was healing well. The note indicated to continue wound care and the wound was healing well. Non-pressure chronic ulcer of right ankle with fat layer exposed. On 5/2/22 a copy was made of Resident 4's skin sheets and wound measurements. The 4/20/22 skin sheet indicated Resident 4 had a Stage 4 pressure ulcer to the right ankle that measured 12 mm x 15 mm x 1 mm (1.2 cm x 1.5 cm x 0.1 cm). There were no additional skin and wound measurements after 4/20/22. On 5/2/22 at 2:59 PM Staff 10 (RN) stated Resident 4 had a pressure ulcer on the right ankle and the evening shift nurse or Staff 2 (DNS) was responsible for changing the dressing. Staff 10 stated the MARs/TARs indicated the resident received a dressing change on 5/1/22 at 9:43 PM by Staff 11 (LPN). An observation was made with Staff 10 of Resident 4's dressing on the right ankle. The dressing was observed to have dark brown drainage visible through the top of the bandage and it was dated 4/28[2022]. Staff 10 confirmed the dressing was dated 4/28 [2022]. On 5/2/22 at 3:16 PM Staff 2 stated Resident 4's pressure ulcer was last measured on 4/20/22 and the expectation was for measurements to be completed weekly. On 5/2/22 at 3:39 PM the surveyor asked Staff 2 (DNS) to complete a dressing change for Resident 4. Staff 2 removed the old dressing and acknowledged it was dated 4/28. Staff 2 stated there was a scant amount of serosanguineous drainage (discharge that contains blood and serum) when she removed the bandage, there was no foam pad observed under the dressing. Staff 2 stated the wound was a Stage 4 pressure ulcer and the resident admitted with it. Staff 2 measured the area and stated it measured 1.4 cm x 1 cm x 0.4 cm. Staff 2 completed the dressing change per the order. On 5/2/22 at 3:58 PM Staff 11 (LPN) stated she documented she completed a dressing change for Resident 4 on 5/1/22 but did not complete the dressing change and must have overlooked it. On 5/3/22 at 12:07 PM Witness 4 (Clinic Wound Nurse) stated Resident 4 was being seen at the wound clinic and her/his last visit was 2/9/22. Witness 4 stated the resident had subsequent appointments scheduled but did not show up. Witness 4 further stated the facility did not bring Resident 4 back for the scheduled appointments and did not schedule future appointments. Witness 4 stated the wound measurements on 2/9/22 were 1.9 cm x 1.9 cm x 0.3 cm. On 5/3/22 at 3:09 PM Staff 2 (DNS) acknowledged Resident 4 did not have the foam pad in place when she changed the dressing on 5/2/22. On 5/3/22 at 5:02 PM Staff 2 (DNS) stated Resident 4 was not seen by the wound clinic after 2/9/22 even though the resident had future appointments set up. Staff 2 stated there was a system breakdown. On 5/6/22 at 11:48 AM Staff 2 stated the MAR/TAR indicated Resident 4 refused dressing changes on 4/10/22 and 4/16/22 and there was no indication in the clinical record to indicate the resident was reapproached for a dressing change. Staff 2 acknowledged the resident received a scheduled dressing change on 4/7/22 then refused 4/10/22 and an additional dressing change was not completed until 4/13/22. Staff 2 further acknowledged the resident did not receive the scheduled dressing change on 4/16/22 and an additional dressing change was not completed until 4/19/22. Staff 2 acknowledged staff should have reapproached the resident for a dressing change after her/his refusals on 4/10/22 and 4/16/22. Refer to F692.

Based on observation, interview, and record review it was determined the facility failed to provide care and services to maintain acceptable parameters of nutritional status and ensure residents received a therapeutic diet and nutritional supplements as ordered for 2 of 4 sampled residents (#s 4 and 14) reviewed for nutrition. This resulted in Resident 14 and Resident 4 experiencing a severe weight loss. This placed other residents at risk for weight loss. Findings include: The 2001 Facility Nutrition Program Policy indicated: 1. Direct care staff, assisted by the facility's Clinical Dietitian, will evaluate each individual's physical, functional, and psychosocial factors that affect eating and nutritional intake and utilization. 2. Physician and related Health Care Practitioners (NP, PA, etc.) would help the staff identify specific factors in individual residents (medical conditions, medications, etc.) that may be affecting a resident's appetite, nutritional needs, nutrition utilization, and hydration status. 3. A facility Dietitian would help assess the nutritional needs and risks of all residents and patients in the facility, and help the facility assure that it provided appropriate meals and other nutritional interventions. 6. As part of the facility's quality improvement program, the staff, Administrator, and Medical Director would review nutrition-related outcomes and address related problems. The 12/1/20 Weight Policy indicated: 4. If there was a +/- three-pound variance from the prior weight, a re-weight would be completed within 24 hours. 6. Any residents with a +\- three-pound variance would be noted in the 24-hour report and in the care notes for further RN review. 7. The RN or designee would review monthly weights to further evaluate for any significant weight loss or gain. Significant weight loss or gain would be defined as: 5% in 30 days, 7.4% in 90 days, and 10% in 180 days. 8. Any resident with a significant weight loss or gain would be further assessed by the RN for the cause of the weight change and the physician and family would be notified as needed. 9. The service plan would be updated to reflect any changes in care and further interventions. 1. Resident 14 admitted to the facility in 12/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 14 had a 12/16/21 Nutrition Order for a regular diet, minced, moist, and thin liquids. The 12/23/21 Admission MDS indicated Resident 14 was moderately cognitively impaired, had no difficulty with swallowing but reported difficulty or pain with swallowing, and the resident weighed 177 pounds. The 12/23/21 Nutrition CAA indicated Resident 14 was currently prescribed a mechanical soft diet and consumed an average of 51-70% of meals with meal substitutions and/or replacement shakes offered when the resident consumed less than 50% of any given meal. Weight, meal intakes, labs, and nutritional needs would be followed by the interdisciplinary team and the RD via NAR (Nutrition At Risk). The 3/13/22 Quarterly MDS indicated Resident 14 weighed 168 pounds with no significant weight loss noted. The Weight Summary indicated Resident 14's weights in pounds: *12/16/21: 174.6 *12/17/21: 172.8 *12/18/21: 177 *12/19/21: 176.4 *12/22/21: 177.4 *1/10/22: 171.2 *2/3/22: 168.2 *3/30/22: 154 *4/6/22: 162.8 *5/4/22: 161.8 The resident was 177.4 pounds on 12/22/21 and 154 pounds on 3/30/22. This was a 23.4-pound weight loss (8.79%) in 99 days, indicating a severe weight loss. Resident 14 weighed 161.8 pounds on 5/4/22. This was a 15.6-pound weight loss (8.79%) in 134 days from 12/22/21, indicating a significant weight loss. There were no re-weights of Resident 14 in the medical record. There was no evidence in the medical record to indicate RD or NAR assessments were completed for Resident 14 from 1/2022 until 4/25/22. There was no evidence in the medical record the RD or physician were notified of Resident 14's weight loss. The Admission Dietary assessment dated [DATE] was noted as in progress in Resident 14's medical record as of 5/4/22. The assessment information included: no bacon per resident, mechanical soft texture and needs food soft and moist to chew due to no bottom teeth. The 4/25/22 Nutrition/Dietary Note indicated Resident 14 experienced a significant weight loss and was observed to be thin with sunken eyes and slow skin turgor. The resident reported the food was cold and she/he had difficulty biting off sandwiches and chewing raw/vegetables and fruits. The notes indicated Resident 14 had mild PCM (protein-calorie malnutrition) related to dysphagia, dissatisfaction with the food, and chewing difficulty related to missing lower teeth and having top dentures. Intake was estimated as 75% of estimated energy needs for calories with a 10% weight loss in three months. The plan indicated Resident 14 was to receive oatmeal and scrambled eggs for breakfast and cottage cheese with lunch and dinner. The resident was noted to accept nutritional supplements 118ml TID with meals. The resident's diet was to be regular with mechanical soft textures with all foods finely chopped/ground, gravy/sauce on all foods, no raw veggies, no raw fruits, and no bread/buns/rolls/crusts. The 4/26/22 Change of Diet Slip indicated Resident 14 was to receive a regular diet, mechanical soft with all food finely chopped/ground, gravy sauce on all foods, no raw veggies or fruits, and no breads. Meal Monitoring Sheets were reviewed from 2/1/22 through 5/4/22 and indicated the amount of times Resident 14 consumed less than 50% of her/his meal or the meal was undocumented: *2/1/22 through 2/28/22: 24 out of 84 meals. *3/1/22 through 3/31/22: 19 out of 60 meals (Resident 14 was hospitalized [DATE] until 3/14/22). *4/1/22 through 4/30/22: 49 out of 90 meals. *5/1/22 through 5/4/22: 12 out of 19 meals. There was no evidence in the medical record the resident was offered a nutritional shake when Resident 14 consumed less than 50% of any given meal. On 5/1/22 at 2:13 PM Resident 14 stated she/he did not like the food, and she/he wanted oatmeal for breakfast and did not receive it. The following observations and interviews occurred on 5/3/22: *12:37 PM Resident 14's lunch tray was observed, and the resident was eating ice cream independently in her/his bed. The tray was observed to contain a full sandwich that was not cut up, no gravy or sauce, and no cottage cheese. Resident 14 stated she/he wanted cottage cheese with her/his lunch and was unable to eat the sandwich. Resident 14 did not have a meal/diet card on her/his tray. Resident 14 was observed in bed with the head of the bed at approximately a 60-degree angle. *12:43 PM Staff 2 (DNS) stated the RD had just made the recommendation for a mechanical soft diet and the diet had not been implemented. Staff 2 stated Staff 15 (Dietary Manager) was expected to have updated the meal card. Staff 15 stated when the RD made recommendations, Staff 2 would get the order from the nursing staff and update the meal card. Staff 15 confirmed Resident 14 did not receive a mechanical soft diet and should not have gotten a sandwich and should have received cottage cheese. Staff 15 stated she had implemented the order on the meal card, but she was training new kitchen staff and it was not implemented. Staff 2 was asked if the resident was at risk for aspiration and left the room to obtain Resident 14's last speech evaluation. *12:54 PM Resident 14 received cottage cheese and began consuming independently. *12:57 PM Staff 2 read Resident 14's 12/2021 speech evaluation which indicated the resident's self-reported swallowing difficulties were related to sitting up and eating preferences and per RD required a mechanical soft diet with gravy. The Speech Therapist recommended the resident be up in bed at 90 degrees for all meals. Staff 2 confirmed Resident 14's bed was not 90 degrees and raised the head of the resident's bed. *1:26 PM Resident 14's meal card was reviewed and indicated the resident was to receive a regular diet with mechanical soft texture. All foods finely chopped/ground, gravy/sauce on all food. No raw veggies, raw fruits, or breads, milk with every meal, and no bacon per resident. On 5/3/22 at 3:28 PM Staff 14 (RD) stated she had not worked in the facility for three months due to contractual issues and there were no NAR meetings for those months. Staff 14 confirmed the facility had been without a dietitian from 1/2022 until 4/2022. Staff 14 stated for her nutritional recommendations she would inform the Administrator, DNS, Resident Care Managers (RCMs), and dietary managers of her recommendations and they would implement them. Staff 14 stated the expectation for implementing dietary recommendations was 24 hours. Staff 14 stated Resident 14 had mechanical soft dietary orders since admission and had not been receiving those orders and this put the resident at risk for weight loss. Staff 14 stated Resident 14 did not have any problem with swallowing or choking issues per her assessments. Staff 14 stated there were issues with the facility obtaining weights and the plan had always been to reweigh residents if there was a three-pound increase or decrease from the previous weight. Staff 14 stated based on Resident 14's weights the facility would be expected to weigh the resident weekly due to the resident's significant weight loss. Staff 14 further stated she expected the head of bed to be at 90 degrees unless a more recent speech evaluation concluded the intervention was no longer needed for Resident 14. On 5/4/22 at 8:18 AM Resident 14's breakfast tray was observed to have cottage cheese and an over-easy egg cut up. Resident 14 stated she/he did not like eggs like that and never will. Resident 14 did not have oatmeal on her/his meal tray. A CNA was observed to remove the tray stating they would get the resident scrambled eggs, but the resident replied she/he wanted to go back to bed and did not have an appetite. On 5/4/22 at 8:59 AM Staff 15 (Dietary Manager) acknowledged Resident 14 did not receive oatmeal for breakfast and eggs were not scrambled. Staff 15 stated she would update the dietary card per the RD assessment and resident preferences. On 5/4/22 at 11:41 AM Staff 15 (Dietary Manager) confirmed the Dietary Assessment was noted as in progress but stated it had been completed with Staff 14 (RD) on 4/25/22. Staff 15 confirmed the assessment was expected to be completed at admission, but she had only started working at the facility a few weeks prior and the RD had not been in the facility for three months prior to 4/2022. On 5/5/22 at 11:35 AM Staff 7 (CNA) stated if a resident consumed less than 50% intake of meals staff would offer the resident an alternative or a high protein shake if ordered. Staff 7 stated staff documented the nutritional shakes or alternatives under a prn tab in the Tasks section of the medical record. Staff 7 stated Resident 14 had ongoing issues with intake and the resident liked oatmeal so she would bring the resident oatmeal and other soft foods. Staff 7 stated Resident 14 was not offered a protein shake as it was not on the resident's care plan. On 5/6/22 at 11:33 AM Staff 2 (DNS) and Staff 1 (Administrator) stated any residents who experienced a significant weight loss or gain would be discussed with Staff 14 and interventions would be put in place like a nutritional supplement. Staff 2 stated the policy was for residents who triggered for a 5% weight loss or gain would be re-weighed. Staff 1 and Staff 2 acknowledged Resident 14 experienced a severe weight loss from 12/2021 through 3/2022 of over 13% in three months. Staff 2 confirmed there were no assessments or interventions implemented for Resident 14's weight loss and the medical provider was not notified. Staff 1 confirmed there was no dietitian in the building from 1/2022 until 4/2022 to assess residents for nutrition status. Refer to F657, F710, F803, and F825. 2. Resident 4 admitted to the facility 11/8/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 11/21/21 Admission MDS indicated Resident 4 was rarely/never understood, had no swallowing issues, and weighed 138 pounds with no weight loss. The 11/21/21 Nutrition CAA indicated Resident 4 received protein powder in drinks and consumed meals independently with 1:1 mealtime assist to encourage increased PO intake of meals and fluids. The assessment indicated the RD was to review/recommend quarterly and prn. The assessment further indicated the resident had an extensive history of refusing meals and the resident was offered meal alternatives, supplements, and snacks as needed. The Weight Summary indicated Resident 4's weights in pounds: 11/19/21: 138 12/8/21: 121.8 12/18/21: 123 12/19/21: 118.8 12/27/21: 119 1/3/22: 124.6 1/10/22: 123.4 1/13/22: 124.8 2/6/22: 118.8 3/30/22: 128.6 4/6/22: 121 5/3/22: 120.4 Resident 4 weighed 138 pounds on 11/19/21 and weighed 120.4 pounds on 5/3/22. This was a 16.6 pound weight loss (12.4%) in less than six months, indicating a severe weight loss. There were no re-weights of Resident 4 in the Weight Summary, except on 12/18/21 the resident weighed 123 pounds and on 12/19/21 the resident weighed 118.8 pounds. An 11/15/21 Nutrition/Dietary Note indicated Resident 4 had a regular diet with regular textures and nutrition needs were met. Facility weights were pending, and staff were to alert the RD as weights became available for further assessment of nutrition/hydration needs. A 12/16/21 Nutrition/Dietary Note indicated Resident 4's admission weight was 138 and the resident currently weighed 121.8 pounds. A re-weight was requested. The note indicated if the weights were accurate then Resident 4 sustained a severe loss since admission in the past month of 16.2 pounds (11.7%). The assessment indicated due to Resident 4's significant dementia, oral intakes being impacted and were diminished to suboptimal amounts of 50-75% since admission. The plan included to provide Resident 4 with a nutritionally enhanced regular diet with a large high protein nutritional supplement TID with meals and 2cal (nutritional shake) 80cc TID between meals. The note indicated staff were to document supplement intakes and the NAR (Nutrition at Risk) IDT (Interdisciplinary Team) were to monitor skin and weight. There was no evidence in the medical record to indicate RD or NAR assessments were completed for Resident 14 from 1/2022 until 4/28/22. There was no evidence in the medical record the RD or physician were notified of Resident 14's weight loss. The 2/16/22 Care Plan indicated Resident 4 was to receive a protein shake with lunch to promote adequate nutrition for wound healing. The 2/21/22 Quarterly MDS indicated Resident 4 had no swallowing issues and weighed 119 pounds and had a loss of 5% or more in the last month or a loss of 10% or more in the last 6 months and was not on a prescribed weight loss regimen. A 3/1/22 Nutrition/Dietary Note indicated Resident 4's diet order was clarified with the dietician, including regular diet and a protein shake with meals and 4 oz of 2Cal between meals. A 4/28/22 Nutrition/Dietary Note indicated Resident 4 had a current weight of 121 pounds and a loss of 17 pounds (12%) in the past five months and a seven-pound (6%) weight loss in one month. The RD questioned the accuracy of the 128-pound weight on 3/30/22 as the resident did not have [CONDITION(S)] and was not on a diuretic. Resident 4's diet was noted as regular with an added high protein nutrition supplement 118ml TID with meals and a 2-Cal (nutrition shake) between meals. Intakes of food were noted as variable between 25-100% of meals. The note further indicated NAR (Nutrition at Risk) IDT (Interdisciplinary Team) to monitor the resident for wound healing and until weight was at goal. Meal Monitoring Sheets were reviewed from 1/1/22 through 5/4/22 and indicated the amount of times Resident 4 consumed less than 50% of her/his meal or the meal was undocumented: *1/1/22 through 1/31/22: 54 out of 96 meals. *2/1/22 through 2/28/22: 35 out of 84 meals *3/1/22 through 3/31/22: 36 out of 96 meals. *4/1/22 through 4/30/22: 42 out of 90 meals. *5/1/22 through 5/5/22: 5 out of 15 meals. There was no evidence a health shake or 2Cal shake were ordered or documented in Resident 4's medical record. The following observations and interviews were conducted regarding Resident 4 on 5/3/22: *12:39 PM Staff 8 (CNA) was observed passing meal trays to the dining room. *12:42 PM Resident 4 was observed eating a sandwich independently alone at a table in the corner of the dining room. Resident 4 attempted to get up and Staff 8 asked the resident if she/he wanted to drink her/his juice. The sandwich was observed as untouched, and it appeared as though the resident had consumed some of the soup. Resident 4 did not consume her/his juice. Staff 8 asked Resident 4 if she/he wanted more and the resident stated no. There was no health shake observed at Resident 4's table and no shake was offered by staff. *12:48 PM Staff 8 (CNA) was asked if Resident 4 received a health shake with meals. Staff 8 stated he had seen the resident receive one before but was unsure if the resident received them with meals. Staff 8 stated the resident liked the health shakes and would consume them. Staff 8 further stated if a resident received a health shake staff would document the shake as liquids in Resident 4's medical record and not as a health shake. *1:10 PM Staff 7 (CNA) stated Resident 4 received health shakes in the morning and would consume the shake. *1:13 PM Staff 15 (Dietary Manager) stated Resident 4 received a health shake at every meal and it was put on the meal tray. Staff 15 stated she did not see Resident 4's health shakes come back so she assumed the resident drank the health shake. *5:28 PM Staff 9 (CNA) stated she had seen Resident 4 receive health shakes but was unsure if the shakes were on Resident 4's care plan. Staff 9 further stated there was no section in the medical record to document supplements so there was no way to document if Resident 4 received/consumed the health shake. On 5/3/22 at 3:28 PM and 3:43 PM Staff 14 (RD) stated she had not worked in the facility for three months due to contractual issues and there were no NAR meetings for those months. Staff 14 confirmed the facility had been without a dietitian from 1/2022 until 4/2022. Staff 14 stated per the facility weights, Resident 4 experienced a significant weight loss, and her expectation was if a resident's weights were fluctuating the facility would reweigh the resident to ensure weights were correct. Staff 14 stated there were issues with the facility obtaining weights and the plan had always been to reweigh residents if there was a three-pound increase or decrease from the previous weight. Staff 14 stated she would expect the facility to provide the health shakes at the meals as part of the diet order and to specify to how much was consumed and then the documentation was to be entered as a task and documented by the CNAs. Staff 14 further stated if a supplement was provided between meals like 2Cal then the supplement would be entered as a specific order and documented on the MAR by nursing staff. On 5/5/22 at 11:35 AM Staff 7 (CNA) stated if a resident consumed less than 50% intake of meals staff would offer the resident an alternative or a high protein shake if ordered. Staff 7 stated staff documented the nutritional shakes or alternatives under a prn tab in the Tasks section of the medical record. Staff 7 stated staff offered Resident 4 ice cream and or shakes if the resident ate less than 50% of her/his meal. On 5/6/22 at 11:33 AM Staff 2 (DNS) and Staff 1 (Administrator) stated any residents who experienced a significant weight loss or gain would be discussed with Staff 14 and interventions would be put in place like a nutritional supplement. Staff 2 stated the policy was for residents who triggered for a 5% weight loss or gain would be reweighed. Staff 1 and Staff 2 acknowledged Resident 4 experienced a severe weight loss of 16.6 pounds (12.4%) in less than six months. Staff 2 confirmed there were no assessments or interventions implemented for Resident 4's weight loss and the medical provider was not notified. Staff 1 confirmed there was no RD in the building from 1/2022 until 4/2022 to assess residents for nutrition related concerns. Refer to F657, F710, and F803.

Based on observation, interview, and record review it was determined the facility failed to ensure a resident was free from abuse for 3 of 4 sampled residents (#s 2, 4, and 7) reviewed for resident to resident altercations. This placed residents at risk for abuse. Findings include: Resident 6 admitted to the facility in 2017 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 8/2/21 Annual MDS indicated Resident 6 had a BIMS of 2 (severe cognitive impairment). The 10/22/17 Care Plan indicated Resident 6 had the potential for physically aggression (hitting) related to frustration and poor impulse control. The resident was identified to become frustrated and agitated easily and quickly for unexpected and minor things. Two resident to resident incidents were indicated on 2/6/21 and 2/10/21. Interventions included to monitor every shift, for staff to be aware of possible aggression or contact with others and for staff to be alert when Resident 6 is approaching another resident to be close by to ensure no aggressive contact occurred (initiated 2/14/22). Interventions also included for Resident 6 to be at least six feet away from Resident 7 at all times (initiated 2/11/21) and to also be six feet apart from Resident 4 at all times (initiated 12/16/21). a. Resident 7 admitted to the facility in 2016 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 10/4/16 Care Plan indicated Resident 7 had impaired cognitive function relate to [CONDITION(S)] and a stroke. On 12/4/21 a FRI was received that indicated Resident 6 went to get coffee in the dining room. Resident 6's wheelchair was not able to get by Resident 7's wheelchair and Resident 6 began hitting Resident 7. Resident 7 suffered a scratch to her/his right forehead. Both residents were separated by staff (Environmental Services) who witnessed the incident and residents were placed on 15 minute checks. There was no further altercations between the residents. The investigation noted that both residents had another incident in the past. Resident 6 was noted to have diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility investigation concluded that abuse was not ruled out and it was determined Resident 6 assaulted Resident 7. The staff who witnessed the incident was unable to be interviewed due to being out on medical leave. On 5/4/22 at 10:57 AM Staff 2 (DNS) confirmed the statement taken from the staff who witnessed the incident was accurate to her knowledge. Staff 2 confirmed resident to resident abuse occurred between Resident 6 and Resident 7 as indicated. b. Resident 4 admitted to the facility in 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] An 11/9/21 Wandering Assessment indicated the resident was at risk for wandering. The 11/27/21 Care Plan indicated Resident 4 had cognitive impairments. A 4/5/21 FRI was received that indicated Staff 11 (LPN) heard Resident 4 screaming from the nurses station. Staff 11 responded and observed Resident 6 behind Resident 4's wheelchair with her/his hands near Resident 4's neck. Both residents were unable to state what took place. Resident 4 indicated her/his neck hurt and scratches were observed on the right side of the her/his neck. Both resident's were separated without further incident. The investigation concluded that abuse was not ruled out. On 5/3/22 at 4:22 PM Staff 11 stated she was present during the incident between Resident 6 and Resident 4. Staff 11 stated she heard screaming from the nurses station and down the hall she observed both Resident 6 and Resident 4 in their wheelchairs. Staff 11 stated she was not able to tell if Resident 6's arms were on Resident 4 but observed her/his arms raised. Staff 11 stated both residents were not able to tell her what happened. She stated Resident 4 indicated her/his neck hurt and was observed to have scratches. Staff 11 stated she was the only staff around at the time of the incident as the other two CNAs were in a resident room. Staff 11 stated she was unaware if Resident 6 and Resident 4 were supposed to be apart from each other. On 5/4/22 at 10:57 AM Staff 2 (DNS) confirmed the allegation of resident to resident abuse occurred between Resident 6 and Resident 4 as indicated. 3. Resident 4 admitted to the facility in 11/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The 11/21/21 Admission MDS indicated Resident 4 was rarely/never understood and Resident 4 hallucinated and rejected care during the look-back period. The 11/21/21 Behavior CAA indicated Resident 4 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Since admission, staff reported the following behavioral symptoms: confusion, hallucinations, combativeness, and refusal of care. Resident 4's reported mood symptoms were most likely to be attributed to her/his diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's 2/14/22 Care Plan indicated Resident 4 wandered aimlessly. Interventions included: distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, or a book. The care plan indicated Resident prefers: (left blank). The Care Plan was updated 4/15/22 (prior to the incident) and noted Resident 4 had been involved in a resident-to-resident altercation. The Care Plan indicated Resident 4 sometimes attempted to take other residents belongings as she/he did not understand they are not hers/his and noted Resident 4 kicked another resident. Interventions to prevent further altercations included: If Resident 4 was seen approaching others' personal space or attempting to take their personal items, re-direct Resident 4 in a different direction. Use distraction techniques such as engaging in conversation, offering cares, and snacks. A 4/19/22 Incident Note indicated on 4/18/22 the business office manager (Staff 21) witnessed Resident 4 in the main television area sitting in her/his wheelchair facing a second resident (Resident 2) who was also sitting in her/his wheelchair. Resident 4 was observed to kick (Resident 2) in the shin. The two were separated without further incident. Both parties' care plans were updated to include keeping them at a distance from one another when in common areas. Observations of Resident 4 and Resident 2 from 5/1/22 through 5/2/22 revealed the following: * 5/1/22 at 1:37 PM Resident 4 came out of Resident 2's room. Resident 2 was not in the room. There were no staff present. *5/1/22 at 1:43 PM Resident 2 was observed sitting in front of the television as Resident 4 self-propelled right next to Resident 2 in the main area with their wheelchairs pressed up against each other. There were no staff present. Resident 2 yelled to be moved out of the way of Resident 4. Staff came and moved the residents away from each other. *5/1/22 at 4:05 PM: Resident 4 attempted to go into Resident 2's room. Staff 7 (CNA) stated the room used to also be Resident 4's until the residents had an altercation. Staff 7 redirected Resident 4 away from the room. *5/2/22 at 3:17 PM Resident 4 attempted to go into another resident's room and was redirected by staff. On 5/3/22 at 11:32 AM Staff 21 (Business Office Manager) stated she observed the incident between Resident 2 and Resident 4 on 4/18/22. Staff 21 stated she was walking to the printer and observed Resident 4 in the main room next to Resident 2. Both residents were in their wheelchairs. Staff 21 stated she observed Resident 4 kick Resident 2 in the shin. Staff 21 stated she said, stop that! to Resident 4 and the resident kept intentionally kicking, so Staff 21 moved Resident 4 away from Resident 2 to the other side of the room. Staff 21 stated she could not recall if staff were in the room with the residents. Staff 21 further stated she retrieved her copies from the printer and when she was walking back to her office, she saw Resident 4 close by Resident 2 attempting to kick her/him again. Staff 21 stated she intervened and moved Resident 4 further across the room and went and told the DNS. Staff 21 stated she had heard about other incidents between Resident 4 and Resident 2 but had not witnessed other incidents. On 5/3/22 at 5:28 PM Staff 9 (CNA) stated she was a traveling CNA and had worked in the facility since 4/2022. Staff 9 stated she had been advised to keep Resident 4 away from Resident 6 but was not aware to distance Resident 4 from any other residents, including Resident 2. On 5/4/22 at 10:57 AM Staff 2 (DNS) acknowledged the resident-to-resident altercation involving Resident 4 and Resident 2 on 4/18/22 and the facility investigation substantiated the allegation of abuse. Staff 2 stated staff were to try to keep Resident 4 away from other residents, like Resident 2. Staff 2 acknowledged Resident 4 wandering unsupervised and wandering into other resident's rooms and personal spaces put residents (including Resident 4) at risk for abuse. Refer to F679, F689, and F725.

Based on interview and record review it was determined the facility failed to ensure residents were free from neglect related to a failure to provide necessary goods and services to prevent accidents for 1 of 3 residents (#1) reviewed for accidents. This failure resulted in Resident 1 sustaining a right femur fracture, experiencing increased pain, and placed the resident at risk for further accidents. Findings include: A public complaint was received on 9/24/20, which indicated Resident 1 slipped out of her/his shower chair due to the facility placing garbage bags on the chair and the resident hit her/his head and right knee sustaining fractures. The complaint indicated Resident 1 still had not seen a doctor and was waiting for a call from the surgeon. Resident 1 admitted to the facility in 2015 with [DIAGNOSES REDACTED]. The 8/11/20 Pain Tool indicated Resident 1 reported no pain and if she/he received scheduled pain medications the resident was relatively pain free. The 9/5/20 Quarterly MDS indicated the resident was cognitively intact and was totally dependent on staff for transfers and bathing. Resident 1's care plan for bathing, last updated 4/29/16, indicated the resident was independent with washing her/himself, but required one staff person to physically assist with washing the resident's back and bottom and the resident showered in a bariatric shower chair. The 9/9/20 physician orders [REDACTED]. There was also an order [REDACTED].>A 9/10/20 incident report indicated on 9/9/20 Resident 1 slid out of a chair while in the shower due to slippery surface and ill-fitting chair for shower. The investigation further indicated Resident 1 sustained a skin tear to the left forearm and left thigh and hit her/his right stump on the way down. The investigation indicated the resident needed a a proper fitting shower chair to prevent falls. A review of resident 1's progress notes from 8/2020 through 10/2020 revealed: *On 9/9/20 Resident 1 was found on the floor in a seated position in the shower. The resident stated she/he was showering and felt like she/he was sliding out of the chair and could not stop it. The note indicated Resident 1 had a shower chair the resident fit in very nicely but the chair recently broke and the resident used her/his manual wheelchair to shower as the resident did not fit in any of the other facility shower chairs. The note indicated the manual wheelchair was not necessarily safe or ideal but was the only option for providing a shower. The note further indicated Resident 1 was assessed for injuries and Resident 1 reported she/he hit her/his right stump on the wall and reported 6/10 on the pain scale. Resident 1 was placed on alert charting, the doctor was notified, and significant bruising was expected due to Resident 1 taking [MEDICATION NAME]. *On 9/10/20 12:46 AM Resident 1's leg/stump was very painful that night and the resident requested more pain medication. *On 9/10/20 7:44 PM Resident 1 stated the only pain she/he still experienced was her/his right stump. The noted indicated no apparent injury or bruising. *On 9/10/20 7:46 PM Resident 1 was brought into the shower room and left to do her/his own bathing for privacy per resident request. The note indicated no staff abuse suspected as Resident 1 could verbalize what happened. The note indicated Resident 1 needed a proper fitting shower chair as the resident was bariatric. The resident was noted to have increased pain in her/his right stump, and it was most likely from this incident. The note further indicated a new shower chair would be ordered and until the new shower chair arrived the resident was able to shower in her/his manual wheelchair. *On 9/11/20 4:44 AM Resident 1 continued to be sore related to the 9/9/20 fall and had prn pain medication. Resident 1 was able to move her/his leg, but it was noted as painful. *On 9/14/20 Resident 1 was just sore all over and had leg soreness. *On 9/17/20 5:20 AM Resident 1 was very painful while CNAs helped the resident back to bed and during attempts to move the resident yelled out in pain. *On 9/17/20 1:27 PM Resident 1 complained of 10/10 pain with movement of the right leg following the fall on 9/9/20 and a request was made for an x-ray and ultrasound of the right lower extremity. The 9/11/20 Pain Tool indicated Resident 1 had 7/10 pain on the pain scale. Resident 1 complained of increased pain since the 9/9/20 incident. The resident reported moving her/his right lower extremity made the pain worse (8/10 on the pain scale). Pain was noted to affect sleep, physical activity, mobility, and emotions. The 9/17/20 right femur x-ray indicated Resident 1 sustained a [MEDICAL CONDITION] to distal femur. The 9/17/20 hospital notes indicated Resident 1 fell in the shower and her/his head and arm were improved but the resident's right knee was still painful any time she/he moved it. The 10/1/20 orthopedic clinic notes indicated Resident 1 had pain to the proximal right thigh and the pain was described as a sharp, burning ache. Resident 1 rated her/his pain 5/10 on the pain scale, improving over time. On 3/8/21 at 3:18 PM Resident 1 stated she/he did not wish to further discuss the incident on 9/9/20. On 3/8/21 at 4:13 PM Staff 9 (LPN) stated she was the nurse on duty the night of Resident 1's incident on 9/9/20, she assessed the resident and the resident had no significant injuries and did not want to go to the hospital. Staff 9 stated a few days later Resident 1 really complained of pain and was sent out for an x-ray. Staff 3 stated Resident 1 insisted on putting the plastic bag over the cushion of her/his wheelchair for showering on 9/9/20. Staff 3 stated the facility did not have a shower chair to fit Resident 1 as the bariatric shower chair was broken. Staff 3 stated the shower chair had been broken for two months prior to the 9/9/20 incident and at that time it was common for management not to replace broken resident equipment. On 3/9/21 at 11:16 AM Staff 12 (CNA) stated the bariatric shower chair was broken at the time of the incident and multiple staff told administrative staff for awhile and they kept attempting to fix the chair but it was never fixed. Staff 12 stated the shower chair was broken for at least a month prior to the incident and she reported the incident to maintenance, but the chair was never fixed. On 3/9/21 at 12:41 PM Staff 13 (Maintenance) stated he started working as the maintenance person for the facility in 10/2020 and the prior maintenance person no longer worked in the facility. Staff 13 was unaware of any maintenance logs regarding a bariatric shower chair. On 3/9/21 at 1:42 PM Staff 14 (CNA) stated she was aware of the incident with Resident 1 on 9/9/20 but was not working on that date. Staff 14 stated Resident 1's prior shower chair was inoperable and facility administrative staff dragged their feet about ordering a new bariatric shower chair when it was repeatedly brought up by staff. Staff 14 stated the shower chair was broken for a couple weeks to a month. Staff 14 stated Resident 1 only received a new shower chair after the resident threatened to report the facility to the news. Staff 14 stated Resident 1 continued to use her/his manual wheelchair after the incident for showers, but without the garbage bags on the seat. Staff 14 stated after the 9/9/20 incident, Resident 1 had a lot of pain, more staff had to assist Resident 1 to roll over in bed, and the resident had a hard time lifting her/his legs up. On 3/10/21 at 9:11 AM Staff 15 (LPN) stated a week prior to the incident she assisted a CNA with transporting Resident 1 to the shower. Staff 15 stated it took three staff members to move the bariatric shower chair as the wheel was broken and she had to help physically pick up the bottom of the chair to move it. Staff 15 stated she told the staff to stop using the broken shower chair and put a request in the maintenance log. On 3/10/21 at 9:56 AM Staff 6 (CNA) stated she worked the night of 9/9/20 after the incident with Resident 1 occurred. Staff 6 stated she recalled Resident 1 was in pain and staff had to be gentle. Staff 6 stated Resident 1's prior bariatric shower chair was terrible, the chair was not functional at all, and a wheel was broken. Staff 6 stated since June 2020 staff had issues with the bariatric shower chair not working. Staff 6 stated she could not recall when the facility received the new bariatric shower chair but it took a long time and it took a long time for them to even order it. Staff 6 stated maintenance attempted to fix the shower chair, but it was never really fixed. Staff 6 stated nursing staff really had to complain for administrative staff to order a new bariatric shower chair. The facility was requested to provide maintenance logs from June 2020-October 2020. The facility was unable to provide the maintenance logs. The 9/2020 Bathing Sheets indicated Resident 1 received showers on 9/13/20 by Staff 14 and 9/23/20 by Staff 17 (CNA). Resident 1 refused bathing on 9/16/20 and 9/20/20. A medical supply invoice indicated Resident 1's new bariatric shower chair was ordered on [DATE], 13 days after Resident 1's incident. On 3/10/21 at 10:37 AM Staff 2 (DNS) acknowledged the facility was unable to find maintenance logs in regards to the bariatric shower chair and Resident 1 sustained a fracture due to using a manual wheelchair covered by a plastic bag instead of a bariatric shower chair.

Based on interview and record review it was determined the facility failed to operationalize policy and procedures regarding fall investigations and pressure ulcers for 3 of 5 residents (#s 22, 25 and 30) who were reviewed for accidents and pressure ulcers. The facilities failure to investigate resulted in missed opportunities to identify risk factors and appropropriate interventions to protect residents from fall injuries and the development of pressure ulcers. Findings include 1. Resident 22 was admitted to the facility in 2013 with [DIAGNOSES REDACTED]. Resident 22's Wound/Skin Record dated 9/4/13 revealed the resident had developed three Stage II pressure ulcers. The Wound/Skin Record documented the presence of Stage II pressure ulcers on the resident's right heel, coccyx and right buttock. A review of the resident's record revealed no investigation related to the presence of three facility acquired Stage II pressure ulcers was completed to rule out abuse or neglect. On 4/10/14 at 10:40 am, Staff 4, DNS, acknowledged there was no investigation regarding the cause of Resident 22's pressure ulcers. Failure to conduct an investigation into the cause of three facility acquired Stage II pressure ulcers resulted in a missed opportunity to identify not only abuse and neglect but risk factors and appropriate interventions to protect Resident 22's skin. Refer to F314 2. Resident 30 was admitted to the facility in 2014, with [DIAGNOSES REDACTED]. A nurse's note dated 3/11/14 documented the resident was found at 2:30 am lying on the floor next to the bed with a bleeding abrasion on her/his left knee. The facility's incident investigation policy dated 1/14/13 included the directive all incidents require a thorough investigation to determine what occurred and to implement measures as needed to prevent recurrence. The facility policy also included the procedure to follow for investigation, including collecting complete information before coming to a conclusion, preserving physical evidence and witness statements, determining causal factors and reporting resident abouse. Nurse's notes did not include any documentation of investigation, causal factors, or interview with the witness who had found the resident. No statement ruled out abuse or neglect, or documented the need for further investigation. The incident report dated 3/11/14 documented Resident 30 was not able to say how the injury had been acquired. On 4/9/14 at 2:00 PM, Staff 4 DNS, confirmed no investigation existed other than what was documented in the 3/11/14 incident report and nurse's note and the facility policy was not followed for injuries of unknown origin. 3. Resident 25 was admitted to the facility in 2013 with [DIAGNOSES REDACTED]. The facility's Reporting Resident Abuse policy and procedure dated 1/14/13 indicated all incidents required a thorough investigation to determine what occurred and to implement measures to prevent recurrence and to determine if abuse occurred. To determine if the incident was foreseeable and preventable and determine causal factors to prevent recurrence. The investigation was to answer who, what, where, when, why and how, through interviews, documentation review, and observation. Each investigation was to be documented. An Accident/Incident Report dated 12/15/13 indicated a CNA reported the resident was found on the floor next to her/his bed holding the tab alarm which had not sounded. The resident's bed was saturated with urine. An Accident/Incident Report dated 12/20/13 indicated a CNA reported the resident was sitting on the floor. (The report provided no additional information as to the where the incident occurred or what preceded it.) An Accident/Incident Report dated 3/10/14 indicated Resident 25 was being pushed in a wheelchair by Staff 3, RN, when the resident's feet went under the wheelchair and the resident fell forward onto her/his knees and forehead. The resident had an abrasion on the forehead but an assessment revealed no other injuries. The section of the report for "Recommended steps to prevent recurrence:" was blank. The incident reports of 12/15/13, 12/20/13 and 3/10/14 did not include an investigation of the falls to rule out abuse or neglect. On 4/9/14 at 10:16 am, Staff 1, RN, stated when a resident had a fall involving a head injury staff were to notify the nurse and not to move the resident until the nurse had assessed the resident's neurological status. The resident would be placed on alert charting for a minimum of three days. The alert charting was to be done in the nurse's progress notes. An incident report was filled out and the Administrator, the DNS, family, and the physician were to be notified. A review of the resident's record revealed one progress note on 12/16/13 which referred to Resident 25's fall on 12/15/13 and indicated the resident was found on the floor, the resident's bed was saturated with urine, and the resident was holding the tab alarm which had not sounded. No injuries were identified. The resident was laughing and was assisted back to bed. Resident 25's record revealed no other documentation of the falls on 12/15/13, 12/20/13 and 3/10/14. No investigation to rule out abuse or neglect, no neurological assessments, no progress notes or on-going monitoring or assessments for latent injuries and no revisions of the care plan. On 4/9/14 at 1:54 pm, Staff 4, DNS, stated the expectation was for the nurse to assess a resident who had a fall, including neurological status, and document the assessments. A resident who had a head injury was to be sent to the hospital for further evaluation. Staff 4 acknowledged there were no documented investigations to rule out abuse or neglect related to Resident 25's falls, no neurological assessments and no revision of the resident's care plan. Refer to F-323

Based on interview and record review it was determined the facility failed to comprehensively and accurately assess residents for 9 of 16 sampled residents (#s 3,8, 25, 12, 15, 18, 21, 22, and 31) for whom assessments were reviewed. The facility's failure to comprehensively and accurately assess a resident's skin resulted in missed opportunities to identify risk factors and appropriate interventions to protect residents skin which led to the development of three stage II pressure ulcers. Finding include: 1 (a). Resident 22 was admitted to the facility in 2013 with [DIAGNOSES REDACTED]. Resident 22's admission orders [REDACTED]. Resident 22's Admission MDS and CAA dated 8/5/13 indicated the resident was always incontinent of urine, however, did not note the resident's Foley catheter. Resident 22's Care Plan dated 8/9/13 failed to indicate the resident had a Foley catheter. On 4/10/14 at 10:46 am, Staff 4, DNS, acknowledged the resident's Foley catheter had not been comprehensively assessed. (b). Resident 22 was admitted to the facility in 2013 with [DIAGNOSES REDACTED]. Resident 22's Admission MDS dated [DATE] indicated the resident was not at risk for developing pressure ulcers despite having limited mobility and being incontinent of bowel and bladder. The resident's CAA dated 8/5/13 revealed the resident triggered for being at risk of developing pressure ulcers but this risk would not be care planned. On 4/10/14 at 10:40 am, Staff 4, DNS, acknowledged Resident 22's risk factors for developing a pressure ulcer was not been comprehensively assessed. Failure to complete comprehensive assessments resulted in missed opportunities to identify risk factors and appropriate interventions to protect Resident 22's skin, which led to the development of three Stage II pressure ulcers. Refer to F314. 2. (a) Resident 25 was admitted to the facility in 2013 with [DIAGNOSES REDACTED]. Resident 25's Falls CAA dated 11/24/13 indicated the resident had triggered for falls but the assessment was blank. The question "Will Falls be addressed in the care plan?" was checked no. On 4/9/14 at 1:54 PM Staff 4, DNS, acknowledged the Falls CAA was not comprehensive or accurate. Refer to F-323 (b) . Resident 25 was admitted to the facility in 2013 with [DIAGNOSES REDACTED]. Resident 25's [MEDICAL CONDITION] Drug Use CAA indicated the resident was administered [MEDICAL CONDITION] medications while in the hospital and would be reviewed at the next pharmacy review. The assessment did not indicate what medications the resident was taking, what the resident was taking them for, how the resident's behaviors manifested, what non-pharmacological interventions were used or what the adverse side effects of the medications were. The assessment indicated the resident's care plan would address [MEDICAL CONDITION] drug use. A review of Resident 25's record revealed no care plan related to the use of [MEDICAL CONDITION] medication use. Resident 25's December 2013 physician's orders [REDACTED]. Resident 25's April 2014 MAR indicated [REDACTED]. On 4/8/14 at 3:17 PM, Staff 4, DNS, acknowledged Resident 25's [MEDICAL CONDITION] Drug Use CAA was not a comprehensive or accurate assessment. 3. Resident 18 was admitted to the facility in 2013 with [DIAGNOSES REDACTED]. Resident 18's [MEDICAL CONDITION] Drug Use CAA indicated the resident received [MEDICAL CONDITION] medications with [DIAGNOSES REDACTED]. The assessment indicated the resident's care plan would address [MEDICAL CONDITION] drug use. Resident 18's record revealed no care plan related to the resident's use of [MEDICAL CONDITION] medications. Resident 18's April 2014 MAR indicated [REDACTED]. On 4/9/14 at 1:54 pm, Staff 4, DNS, acknowledged Resident 18's [MEDICAL CONDITION] Drug Use CAA was not a comprehensive or accurate assessment. 4. Resident 31 was admitted to the facility in 2014 with [DIAGNOSES REDACTED]. The admission nurse's note dated 2/1/14 documented a Foley catheter in place. The MDS dated [DATE] failed to include a comprehensive assessment of the Foley catheter. On 4/7/14 at 1:20 PM, Staff 4, DNS, acknowledged the failure to complete a comprehensive assessment of the Foley catheter. 5. Resident 3 was admitted to the facility in 2013 with [DIAGNOSES REDACTED]. Resident 3's comprehensive admission MDS dated [DATE] identified the resident with limited of range of motion of all extremities. The ADL CAA dated 2/27/13 was blank and there was no explanation provided to explain the decision not to care plan. On 4/10/14 at 9:52 am, Staff 4, DNS, acknowledged a comprehensive assessment of Resident 3's contractures was not completed. 6 (a) . Resident 12 was admitted to the facility in 2004 with [DIAGNOSES REDACTED]. Resident 12's Significant Change of Condition MDS dated [DATE] identified the resident had an intravenous feeding which required a CAA in the area of nutrition. The Nutrition CAA dated 12/9/13 had no assessment was found in the CAA. On 4/10/14 at 9:52 am, Staff 4, DNS, acknowledged a comprehensive assessment of Resident 12's tube feeding was not completed for the 11/9/13 MDS. (b) Resident 12 was admitted to the facility in 2004 with [DIAGNOSES REDACTED]. Resident 12's Significant Change of Condition MDS dated [DATE] indicated the resident had a feeding tube which required a CAA in the area of nutrition. The Nutrition CAA dated 5/9/13 contained no assessment. On 4/10/14 at 9:52 am, Staff 4, DNS, acknowledged a comprehensive assessment of Resident 12's tube feeding was not completed for 5/9/13 MDS. 7 (a). Resident 15 was admitted to the facility in 2009 with [MEDICAL CONDITION], anxiety disorder, and hypertension. Resident 15's significant change MDS assessment dated [DATE] identified the resident had no natural teeth and dental care was identified as an area which required a CAA. The Dental CAA dated 12/4/12 was blank and there was no explanation provided to explain the decision not to care plan in this area. On 4/10/14 at 9:52 am, Staff 4, DNS, acknowledged a comprehensive assessment of Resident 15's dental status was not completed on 12/4/12. (b) Resident 15 was admitted to the facility in 2009 with [MEDICAL CONDITION], anxiety disorder, and hypertension. Resident 15's Annual assessment dated [DATE] identified the resident had no obvious or likely cavity or broken natural teeth as an area which required a CAA. The Dental CAA dated 12/7/13 indicated the resident had poor dentition and did not want to go to the dentist. No assessment was found on the CAA. On 4/10/14 at 9:52 am, Staff 4, DNS, acknowledged a comprehensive assessment of Resident 21's dental status was not completed on 12/7/13. 8. Resident 21 was admitted to the facility in 2013 and placed on hospice in December of 2013. Resident 21's significant change MDS assessment dated [DATE] indicated the resident and no natural teeth and dental care was identified as an area requiring a CAA. The CAA was blank and there was no explanation provided to explain the decision not to care plan in this area. On 4/9/14 at 12:32 pm, Staff 4, DNS, acknowledged a comprehensive assessment of Resident 21's dental status was not completed. 9 (a). Resident 8 was admitted to the facility in 2012 with [DIAGNOSES REDACTED]. Resident 8's Annual MDS dated [DATE] identified the resident as requiring a CAA in the area of mood. The Mood CAA dated 12/12/13 failed to identify and assess the impact of other factors, such as Resident 8's [DIAGNOSES REDACTED]. On 4/10/14 at 1:18 pm, Staff 4, DNS, acknowledged the mood assessment was not comprehensive and did not accurately reflect Resident 8's condition. (b). Resident 8 was admitted to the facility in 2012 with [DIAGNOSES REDACTED]. Resident 8's Annual MDS dated [DATE] identified the resident as requiring a CAA in the areas of [MEDICAL CONDITION] drug use. The [MEDICAL CONDITION] Drug Use CAA dated 12/12/13 failed to identify factors, such as Resident 8's [DIAGNOSES REDACTED]. The CAA also identified Resident 8 as experiencing side effects from anti-psychotic and anti-anxiety medications, when Resident 8 was not receiving either category of medication. On 4/10/14 at 1:18 pm, Staff 4, DNS, acknowledged the [MEDICAL CONDITION] medication assessment was not comprehensive and did not accurately reflect Resident 8's condition. (c) . Resident 8 was admitted to the facility in 2012 with [DIAGNOSES REDACTED]. Resident 8's Annual MDS dated [DATE] identified the resident as requiring a CAA in the area of pain. The Pain CAA dated 12/12/13 stated Resident 8 "complains of continuous pain." It failed to identify and assess the impact of other factors contributing to Resident 8's pain concerns, such as Resident 8's [DIAGNOSES REDACTED]. On 4/10/14 at 1:18 pm, Staff 4, DNS, acknowledged the pain assessment was not comprehensive and did not accurately reflect Resident 8's condition.

Based on interview and record review it was determined the facility failed to provide care and services to prevent the development of three Stage 2 pressure ulcers for 1 of 3 sampled residents (#22) who were reviewed for pressure ulcers. This placed residents at increased risk for the development of pressure ulcers. Findings include: Resident 22 was admitted to the facility in 2013 with [DIAGNOSES REDACTED]. Resident 22's Admission MDS dated [DATE] documented the resident had limited bed mobility and was always incontinent of bladder and bowel (potential risk factors for skin breakdown). The assessment indicated the resident was not at risk for developing pressure ulcers. Resident 22's Pressure Ulcer CAA dated 8/5/13 identified multiple risk factors including limited mobility and bowel and bladder incontinence which placed the resident at risk for developing pressure ulcers. However, the assessment stated, "Pressure ulcer will not be addressed in the care plan." No care plan was developed with interventions to prevent pressure ulcers for Resident 22. A Braden Scale (a tool for assessing pressure ulcer risks) dated 7/26/13 indicated the resident was at moderate risk for developing a pressure ulcer due to limited mobility, limited activity level and slightly limited sensory perception. A significant change MDS dated [DATE] indicated the resident was at risk for developing pressure ulcers and currently had one unhealed Stage II pressure ulcer. A significant change Pressure Ulcer CAA dated 8/27/13 indicated the resident had developed a pressure ulcer the size of a dime on her/his buttock. The assessment stated pressure ulcers would be addressed in the resident's care plan. Resident 22's Care Plan indicated no revisions had been made for pressure ulcer prevention and care after the completion of the significant change MDS and CAA on 8/27/13. Resident 22's Wound/Skin Record dated 9/4/2013 revealed the resident had developed three Stage II pressure ulcers. The Wound/Skin Record documented the presence of Stage II pressure ulcers on the resident's right heel, coccyx and right buttock. A review of the resident's record revealed no documentation related to prevention or interventions related to pressure ulcers prior to 9/4/13. On 4/10/14 at 10:40 am, Staff 4, DNS, acknowledged the resident's MDS, CAA and Care Plan did not include the resident's risk factors for developing a pressure ulcer nor did it include any preventative measures. Staff 4 could not provide any documentation showing preventive care had been provided by staff. Failure to comprehensively assess and care plan any efforts to stabilize, reduce or remove underlying risk factors, monitor the impact of interventions and to modify the interventions as appropriate for Resident 22's skin resulted in the development of three Stage II pressure ulcers.