**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure one (#1) of one resident was free from mental anguish out of three sample residents. Resident #1 was admitted to the facility on [DATE] for long term care with a diagnosis of diagnoses included developmental disabilities, dementia, depression, anxiety, schizophrenia (mental illness), myocardial infarction (heart attack), nicotine dependence, hypertension (high blood pressure), coronary heart disease and chronic obstructive pulmonary (lung) disease (COPD). On 12/7/24, the facility staff noticed Resident #1 had a pipe used to smoke methamphetamines. The nursing home administrator (NHA) approached Resident #1 in order to find out where the resident was purchasing the drugs. The NHA asked Resident #1 if he could observe the resident purchase drugs to determine who was selling the drugs within the facility. Resident #1 told the NHA that he did not have any money. The NHA provided Resident #1 with $20 to purchase methamphetamines, so he could determine who was selling the drugs. The NHA watched Resident #1 approach Resident #2 and purchase methamphetamines. The NHA confiscated the drugs and the pipe from Resident #1. The NHA notified the police of the incident. Resident #1 suffered mental anguish from the drug buying incident the NHA arranged. Resident #1 reported he felt he needed to purchase the drugs to prove to the NHA that he was not a drug dealer. Resident #1 said he was afraid and the incident made him feel uncomfortable. Resident #1 said he was staying in his room longer as he was afraid he was going to get kicked out of the facility or arrested. Findings include: I. Facility policy and procedure The Abuse Prevention and Reporting policy, revised August 2024, was provided by the director of nursing (DON) on 4/3/25 at 4:57 p.m. It read in pertinent part, Residents will be free from verbal abuse, physical abuse, mental abuse, neglect, and exploitation. Residents will not be subjected to abuse by anyone, including but not limited to, facility staff, other residents, or other individuals. All allegations of abuse are investigated. All reported incidents of alleged abuse are immediately investigated and reported per state law and in accordance with the Elder Justice Act. Any staff member who has reasonable cause to believe or reason to suspect abuse will immediately report to the charge nurse. The staff member will intervene to ensure the resident is safe during the investigation. The staff member will notify the administrator or designee immediately. The staff member will report suspicion of a crime against a resident. Social services will provide ongoing support and counseling to the resident and other residents as needed. The administrator will complete the investigation and implement corrective action based on the investigation findings. II. Resident #1 A. Resident status Resident #1, age less than 65, was admitted on [DATE]. According to the April 2025 computerized physician's orders (CPO), diagnoses included developmental disabilities, dementia, depression, anxiety, schizophrenia , myocardial infarction , nicotine dependence, hypertension , coronary heart disease and COPD. The 1/3/25 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview for mental status (BIMS) score of 12 out of 15. The resident was independent with activities of daily living. B. Resident interview Resident #1 was interviewed on 4/3/25 at 2:15 p.m. Resident #1 said the nursing home administrator (NHA) approached him and said a staff member saw him outside the facility with a pipe used for drugs. Resident #1 said he told the NHA the pipe was not his. Resident #1 said he told the NHA that another resident, Resident #2, sold drugs from inside the facility. Resident #1 said the NHA wanted to know which resident sold the drugs. Resident #1 said when he told the NHA, the NHA asked him if he would return and buy drugs from Resident #2. Resident #1 said he told the NHA that he did not have any money to buy drugs. Resident #1 said the NHA called him a drug user and drug dealer. Resident #1 said the NHA said he would provide him with money to purchase the drugs from Resident #2. Resident #1 said the NHA wanted to watch Resident #2 purchase drugs. Resident #1 said he agreed to the deal to prove to the NHA he was not a drug dealer. Resident #1 said the NHA gave him two ten-dollar bills and they went to Resident 2's room. Resident #1 said he entered Resident #2's room and purchased the drugs. Resident #1 said he was unaware when the NHA entered the room and said the NHA took the drugs. Resident #1 said he told the NHA he had used drugs and was a drug runner for Resident #2. Resident #1 said after the drug incident the NHA and the DON told him he could not enter the unit where Resident #2 resided. Resident #1 said that it upset him because he had friends who were residents there, and he enjoyed visiting and participating in bingo and other activities with those friends. Resident #1 said he felt bad because he considered Resident #2 a friend and was scared about her being arrested. Resident #1 said before the drug purchase, no staff member reviewed with him what could happen during and after the drug purchase. He repeated that he participated in the set-up just to prove to the NHA he was not the drug dealer. Resident #1 said he cooperated with the police investigation because he thought he did not do anything wrong. Resident #1 said he thought he would not get into trouble because he bought the drugs for the NHA and not for another resident. Resident #1 said the officer told him if Resident #2 was arrested, he and the NHA would also be charged because they participated in the drug-buying set-up. Resident #1 said he was scared and fearful of the police because he would be charged. Resident #1 said he was afraid that the NHA would discharge him from the facility Resident #1 said he had since talked with the NHA to see if things were good because he felt scared. Resident #1 said none of the facility staff helped him determine if he was at risk with the police, so he reported the investigation to his sister. Resident #1 said he told her he wanted to resume counseling services with his preferred provider. Resident #1 said that he felt bad and afraid after the incident. He said that he stayed in bed longer because he was scared of the police and felt bad for what happened to Resident #2. Resident #1 said he had received counseling at the facility. He said he was unhappy with the service because the provider talked to him about breaking the facility rules with drugs. He said the meetings were held in common areas instead of in a private location. Resident #1 said he wanted to return to a prior counselor because he wanted to talk in a different environment. Resident #1 said he still felt upset that he was used in a drug set-up. He said he still had some fear he would be arrested and discharged from the facility. He said he still heard nursing and therapy staff refer to him as a drug dealer. He said he enjoyed living in the facility. C. Resident #1's family interview Resident #1's sister was interviewed by telephone on 4/3/25 at 5:32 p.m. She said she was not informed on 12/7/25 that her brother had been involved in a drug investigation and that he had reported he used methamphetamine. The sister said she was notified of the drug purchase in mid-January 2025, when Resident #1 spoke to her about being afraid of a nurse and said he was upset that the staff called him a drug dealer. The sister said Resident #1 told her he wanted to change mental health providers because he was uncomfortable talking about his concerns in the facility. The sister said Resident #1 was still upset that he was used to buy drugs and told her he was still afraid of having to discharge from the facility. The sister said the resident was still upset that the staff called him a drug dealer. D. Facility investigation The facility investigation regarding Resident #1 was requested from the DON on 4/3/25. The DON said there was no documentation for the investigation related to the drug purchase incident. E. Care plan review The cognitive impairment care plan, revised 2/16/24, revealed the resident was at risk for cognitive function or impaired thought process related to intellectual disability and schizophrenia. Pertinent interventions included administering medications as ordered, communicating with the family/caregivers regarding the residents capacity as needed, giving step-by-step instructions to support cognitive function, monitoring for changes in cognitive function and reporting to the physician as needed and to provide psychosocial support through social services as needed. F. Record review An undated notification that was sent to the police by the NHA was provided by the DON on 4/3/25 at 11:15 a.m. It read in pertinent part, Earlier today, Resident #1 was found with a methamphetamine pipe in his room. The NHA immediately notified the police, who came to investigate (However, the police came to investigate two days after the incident on 2/9/24). During the conversation with Resident #1 he disclosed he had been receiving drugs from another resident (Resident #2). To address this issue, the NHA and the DON accompanied Resident #1 the next time he attempted to purchase drugs. This led to the identification of the resident involved in selling, who was caught in the act. The police confiscated the drugs and the ombudsman was notified. Resident #1 cooperated with law enforcement. Resident #1 was no longer able to visit the unit where Resident #2 resided. At this time, no further issues had been noted, but the facility would continue to monitor closely. The note was signed by the NHA. The local police department investigation report, dated 12/9/24, was provided by the police department. It read in pertinent part, The report documented on 12/9/24 at approximately 12:53 p.m., the officer was dispatched to the facility on a narcotics violation (two days after the incident). Upon arrival, the NHA was contacted and said there was a drug problem inside the facility. The NHA said he found out who he believed was supplying the drugs. The NHA said he observed a male (Resident #1) who had a pipe used for drugs in his possession. The NHA had Resident #1 tell him where he got the drugs. The NHA reported to the officer he conducted a sting operation with Resident #1 and went to where Resident #1 said he got the drugs from. The NHA identified another resident (Resident #2) as the one who was supplying the drugs. The NHA reported to the officer he gave Resident #1 $20 to buy methamphetamine from Resident #2. The NHA said that he stood outside of the room in a spot where Resident #2 could not see him, when Resident #1 bought methamphetamine from Resident #2. The police report read the NHA gave what appeared to be methamphetamine and a pipe used to smoke methamphetamine to the officer. The officer took pictures of the items and the items were confiscated. The police report read the NHA told the officer he believed Resident #2's son was a drug dealer and he brought the drugs to the resident to sell. The police report read the NHA reported Resident #2 used Resident #1 as a runner to deliver drugs to another resident, and the NHA reported he believed that resident had $40 worth of methamphetamine from the suspected resident/supplier and had attempted to locate the drugs but had not found the drugs. The police report revealed the police officer contacted Resident #1, who was developmentally delayed. Resident #1 told the officer he had received drugs from Resident #2 at least 12 times and that he also brought the drugs to another resident. The police report revealed Resident #1 told the officer that Resident #2 gave him methamphetamine for delivering the drugs to the other resident. The police report revealed Resident #1 reported he was the go-between man for the suspected supplier. Resident #1 told the officer he suspected Resident #2 kept the drugs in a drawer. The clinical record review did not reveal progress notes, assessments, or physician notifications related to Resident #1's involvement in a drug investigation. III. Staff interviews The DON was interviewed on 4/3/25 at 11:06 a.m. The DON said she was aware of the drug set-up investigation completed by the NHA. The DON said the staff had suspected Resident #2 had been dealing drugs but had been unable to catch the resident in the act. The DON said she was aware that the NHA met with Resident #2 after he completed the drug purchase set-up. The DON said the NHA issued Resident #2 a 30-day discharge notice because the NHA observed her provide methamphetamine to Resident #1. The social services director (SSD) was interviewed on 4/3/25 at 1:40 p.m. She said she coordinated the change in mental health counselors for Resident #1. She said she was unaware of why Resident #1 wanted to change providers. The SSD said she was aware Resident #1 had bought illegal substances and was found with a drug pipe. She said she checked on Resident #1 occasionally and he had not reported concerns to her. The NHA was interviewed on 4/3/25 at 2:15 p.m. He said he wrote and sent the message on 12/7/24, the day of the occurrence, to the police and the ombudsman. The NHA said this document was sent by email and was used to report the occurrence (see staff notification above). The NHA was interviewed again on 4/3/25 at 3:15 p.m. The NHA said he had suspected there was a drug problem in the facility. The NHA said the staff had been talking about drugs being used in the facility but had not heard that from any residents. The NHA said after an employee reported she saw Resident #1 with a drug pipe, he responded by investigating the situation. The NHA said he went to Resident #1's room and found a drug pipe. The NHA said he spoke with Resident #1, who told him that he got drugs from Resident #2. The NHA said Resident #1 said he also delivered drugs to another resident in the facility. The NHA said he asked Resident #1, if he could go with him the next time he went to get drugs. The NHA said Resident #1 told him he could go to Resident #2 to get drugs but needed money. The NHA said he provided Resident #1 with $20 and he went with Resident #1 to buy the drugs. The NHA said he confiscated the drugs during the purchase and notified the police. The NHA said he kept the drugs in his office to give to the police. The NHA said he knew Resident #1 was developmentally delayed, but did not abuse Resident #1 in any way. -However, Resident #1 suffered mental anguish and fear from the drug buying incident that was set up by the NHA. The NHA said Resident #1 agreed to help and participate in the drug purchase and said he felt it was the opposite of abuse. The NHA said he successfully identified the drug dealer and stopped drugs from reaching residents. He said by doing that, he prevented drug overdoses and deaths. The NHA said that after the investigation, he notified the facility's legal department about the situation. The NHA said the legal department's feedback was that they approved and told him he did a great job. The NHA said he did not have investigation documents because there was nothing to investigate. The NHA said after discovering and confirming that illegal drugs were in the facility, he did not interview other residents or staff members. He said he interviewed Resident #1 and Resident #2 and identified the parties that were involved. The NHA said there was no reason to go further with interviewing other residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure the resident environment remained as free from accident hazards as possible for one (#20) of four residents reviewed for accident hazards out of 29 sample residents. Resident #20, who had severely impaired daily decision-making skills, was admitted on [DATE]. The facility determined the resident to be at risk for falls upon her admission and implemented a care plan with generalized fall risk interventions that were not individualized for Resident #20. Resident #20 sustained falls with minor injuries on 5/3/24, 5/10/24 and 5/16/24. Per interviews during the survey (from 7/12/24 to 7/16/24), the facility added fall interventions following each of the falls, however, the facility failed to update the interventions on the resident's care plan or ensure staff were consistently implementing the identified fall interventions for the resident. The facility additionally did not evaluate the fall interventions to determine if the interventions were effective. On 7/8/24, Resident #20 sustained another fall, which resulted in the resident being transferred to the hospital for further evaluation, where it was discovered that she had sustained a fractured nose from the fall. Observations during the survey revealed the resident was not always wearing appropriate footwear (non-skid socks or shoes), as had been identified as a fall intervention. Additionally, the resident did not have a call light in her room, despite one of the fall interventions instructing staff to ensure the call light was within reach of the resident. Due to the facility's failures to identify and consistently implement individualized person-centered fall interventions, and update the resident's care plan with new fall interventions that were identified, Resident #20 sustained four falls within a three month period between 4/25/24 and 7/8/24, with the last fall on 7/8/24 resulting in a fracture to the resident's nose. Findings include: I. Facility Policy The Falls Monitoring and Management policy, undated, was provided by the director of nursing (DON) on 7/10/24 at 5:28 p.m. The policy read in pertinent part, Residents are assessed and evaluated to identify risks for injury due to falls. Residents receive necessary treatment and monitoring after a fall and interventions are implemented to minimize risks for injury due to falls. II. Resident status Resident #20, age greater than 65, was admitted on [DATE]. According to the July 2024 computerized physician orders (CPO), diagnoses included neurocognitive disorder with Lewy bodies, cognitive communication deficit and diabetes. The 5/1/24 minimum data set (MDS) assessment revealed the resident was rarely/never understood and had short-term and long-term memory problems and her daily decision-making was severely impaired. She was dependent on staff for personal hygiene, dressing, bathing, toileting and oral hygiene. She also needed setup and clean-up for meals. She was dependent on staff for bed mobility, and needed supervision or touching assistance for walking and sitting to standing, while needing substantial assistance with transferring from chair to bed and bed to chair. She was frequently incontinent of bladder and always incontinent of bowel. III. Observations On 7/10/24 at 11:00 a.m., Resident #20 was observed getting up from her chair and beginning to walk. The brakes on the resident's wheelchair were not locked. The resident's representative was in the room and asked for the resident to sit down. The resident did not sit back down until she was encouraged to sit back down. She did have non-slip socks on. On 7/11/24 at 11:35 a.m., the resident was sitting in her wheelchair. She was self propelling with her feet. -Resident #20 had socks on her feet, however they were not non-slip socks. Certified nurse aide (CNA) #3 said the resident was at risk for falls and staff needed to ensure she had proper footwear on, which would be non-slip socks or shoes. On 7/11/24 at 2:00 p.m. Resident #20's room was observed. -There was no call light in the resident's room, however, ensuring the call light was within reach was one of the resident's care planned fall interventions (see record review below). On 7/12/24 at approximately 5:00 p.m. the resident was sitting in her wheelchair. -Resident #20 had socks on her feet, however, they were not non-slip socks. CNA #2 was interviewed on 7/12/24 at approximately 5:00 p.m. CNA #2 said the resident was at risk for falls and staff needed to ensure she had proper footwear on, which would be non-slip socks or shoes. IV. Resident representative interview Resident #20's representative was interviewed on 7/10/24 at 11:41 a.m. The representative said Resident #20 had resided at the facility since April 2024. She said since the resident had resided at the facility, she had fallen four times. She said Resident #20 fractured her nose during her most recent fall on 7/8/24. The representative said the resident had been at risk for falling prior to her admission to the facility and the facility was aware of the resident's fall history. She said the resident was not always toileted timely and that could be a contributing factor to the falls. The representative said the facility had just placed a lipped mattress on the resident's bed after the fall on 7/8/24. The representative said the Resident #20 was not on a walking program, but she frequently would stand up and try to walk on her own. -The lipped mattress was not added to Resident #20's care plan. V. Record review The fall care plan, initiated on 4/29/24, identified Resident #20 was at risk for falls related to the resident's confusion and impaired safety awareness. Pertinent interventions included to ensure the call light was within reach, resident to wear proper footwear when ambulating or wheeling in wheelchair and to maintain a clear pathway. -There were no interventions added to the resident's care plan following the resident's falls on 5/3/24, 5/10/24, 5/16/24 or 7/8/24. The [NAME] (a tool utilized for providing consistent care for residents), dated 7/12/24, documented the safety interventions which in place for Resident #20 were to provide frequent checks and ensure the resident was wearing appropriate footwear when walking or wheeling her wheelchair. Review of Resident #20's fall risk assessments revealed the following: -On 4/25/24, Resident #20's fall risk score was documented as an eight, which indicated she was a medium fall risk; -On 5/3/24 Resident #20's fall risk score was documented as a 13, which indicted she was a high fall risk; -On 5/11/24 Resident #20's fall risk score was documented as a 13, which indicted she was a high fall risk; -On 5/16/24 Resident #20's fall risk score was documented as a nine, which indicted she was a medium fall risk; and, -On 7/8/24 Resident #20's fall risk score was documented as a 13, which indicted she was a high fall risk. -Resident #20 was incorrectly assessed as a medium hall risk on 5/16/24 despite the resident sustaining falls on 5/3/24, 5/10/24 and 5/16/24. A. Fall #1 The 5/3/24 fall investigation documented Resident #20 fell on 5/3/24 and was found laying on her right side in the hall. The resident sustained a large hematoma (an injury which causes blood to pool under the skin) forming on the back right side of her head. The investigation documented the resident was confused, drowsy, incontinent and ambulating without assistance. The investigation further documented the predisposing psychological factors were confusion, drowsy, incontinence and impaired memory. The predisposing situation factors were ambulating without assistance and being a wanderer. -The investigation failed to document if the resident was wearing appropriate footwear (no-slip socks or shoes) at the time of the fall. A nurse progress note dated 5/3/24 at 5:18 a.m. documented the registered nurse (RN) heard a loud thud and noted the resident laying on the floor on her right side. The resident had been walking in the hallway. A CNA was walking toward the resident with the resident's wheelchair when the fall occurred.The RN assessed the resident and found a large hematoma forming on the back right side of her head. The resident was assisted up into a waiting wheelchair and brought to the nurses station. Neurological checks were started on the resident. The 5/3/24 post fall interdisciplinary team (IDT) note documented the resident was found on the floor. She could not explain what happened. The note documented more frequent checks were to be provided when the resident was in her room. -However, the intervention for more frequent checks was not added to the resident's care plan. B. Fall #2 The 5/10/24 fall investigation documented the resident was refusing to sit down and Resident #20 was found laying on the floor on her right side in the common area living room. She had a small one millimeter (mm) by two mm bruise to her eye and a bruise on her leg. The investigation documented the resident was ambulating without assistance. The investigation further documented the predisposing psychological factors were confusion, gait imbalance, recent change in medication and impaired memory The predisposing situation factor was ambulating without assistance. -The investigation failed to document if the resident was wearing appropriate footwear (no-slip socks or shoes) at the time of the fall. A nurse progress note dated 5/11/24 at 1:03 a.m. documented the resident fell on 5/10/24. The resident had been refusing to go to her room or sit in her wheelchair and was wide awake. The resident was on the other side of a wall. A RN who was nearby heard a noise and went to assess. Resident #20 was found laying in front of her wheelchair on her right side on the floor. The RN assessed the resident and found bruises on the resident's right lateral eye orbit, left side of her face near the temple area and her right lower leg. The resident was alert and able to follow simple directions. The resident was assisted to stand by a CNA and the RN, placed into her wheelchair and positioned within view of the nurses station. Neurological checks were started on the resident. -Review of Resident #20's electronic medical record (EMR) revealed there was no documentation to indicate the IDT reviewed the resident's 5/10/24 fall or that new fall interventions were implemented. C. Fall #3 The 5/16/24 fall investigation documented the resident slid to the floor from her wheelchair. The resident did not sustain any injuries. The investigation documented the predisposing psychological factor was confusion. The predisposing situation factor was she was a wanderer. -The investigation failed to document if the resident was wearing appropriate footwear (no-slip socks or shoes) at the time of the fall. A nurse progress note dated 5/16/24 at 8:25 p.m. documented Resident #20 was in the front entrance hallway of the facility and was observed sliding from her wheelchair to the floor in a seated position and then laying herself flat on her back. There were no injuries observed and neurological checks and vital signs were initiated. The 5/17/24 post fall IDT note documented the resident slid from her chair near the front door. Frequent checks and an occupational therapy wheelchair evaluation were documented as prior fall interventions. The new fall intervention added was for the occupational therapist to screen for adding dycem (a non-slip material used under wheelchair cushions) to the resident's wheelchair. -However, the interventions for frequent checks and dycem to the wheelchair were not added to the resident's care plan. D. Fall #4 The 7/8/24 fall investigation documented Resident #20 was face down on the floor bleeding from her nose and the right side of her head. The resident was sent to the emergency department. The resident had facial grimacing. The fall happened in the hallway. The investigation documented the predisposing psychological factors were gait imbalance, impaired memory and confusion. The predisposing situation factor was she was a wanderer. -The investigation failed to document if the resident was wearing appropriate footwear (no-slip socks or shoes) at the time of the fall. A nurse progress note dated 7/8/24 at 11:33 p.m. documented the resident was observed on the floor face down bleeding from the bridge of her nose and the right side of her head. She had bruising and swelling noted to her face and her pupils were unequal. The resident was sent to the hospital for further evaluation and treatment. A nurse progress note dated 7/9/24 at 3:33 a.m. documented the resident had returned from the hospital. A nurse progress note dated 7/9/24 at 3:48 a.m. documented the resident had a fractured nose with swelling and bruising noted. The 7/8/24 post fall IDT note documented the resident had been found in her room laying on the floor with a fractured nose. The prior interventions listed were for occupational therapy to screen for wheelchair safety and dycem and frequent checks. The current new intervention was to lay the resident down when she appeared fatigued. -However, none of the interventions were added to the resident's care plan. VI. Staff interviews RN #1 was interviewed on 7/12/24 at 11:30 a.m. RN #1 said the resident had memory impairments and dementia. He said the resident could walk with assistance but she was not on a walking program. RN #1 said the resident's dementia was worse later in the day and the interventions the facility used to keep her safe were keeping an eye on her and ensuring she was wearing proper footwear. -However, observations during the survey revealed the resident was not consistently wearing non-slip socks or shoes (see observations above). The DON was interviewed on 7/12/24 at 3:42 p.m. The DON said residents were assessed for fall interventions upon admission, quarterly and after each fall. She said the falls were to be analyzed the day of or the day after a fall in the facility's morning meetings and as a IDT they talked about what interventions had worked to prevent falls and which ones had not. The DON said the IDT came up with new interventions and implemented them after the falls. The DON said Resident #20 was found laying on her right side on 5/3/24 and that she had a hematoma on her head. She said they implemented frequent checks. -However, the intervention was not added to the resident's care plan. The DON said the resident fell on 5/10/24 in front of her wheelchair. She said she received a laceration on her eye. She said that the resident's representative did not want to move her room. She said the occupational therapist screened for a new wheelchair. However, she said the resident's family did not wish to change the chair. -However, the intervention was not added to the resident's care plan and there was no documentation the resident's family had declined a room move or a new wheelchair for the resident. The DON said Resident #20 fell on 5/16/24 when she slid to the floor onto her back. She said dycem was placed in the wheelchair under the cushion. -However, the intervention was not added to the resident's care plan. The DON said the resident fell on 7/8/24 and was sent to the emergency department for evaluation and treatment. She said Resident #20 had a fractured nose. The MDS coordinator (MDSC) was interviewed on 7/12/24 at approximately 6:00 p.m. The MDSC said she completed the MDS assessments and also the residents' care plans. She said the fall intervention for Resident #20 to have her call light within reach was not an appropriate intervention for the resident because she did not have a call light in her room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure two (#23 and #1) of nine residents reviewed for weight loss out of 29 sample residents received the care and services necessary to meet their nutrition and hydration needs and to maintain their highest level of physical well-being Resident #23, admitted at nutritional risk and lost 14 pounds in six weeks. While nutritional interventions were initiated on admission (supplements three times a day) and again when a significant weight loss was identified on 6/20/24 (fortified foods), observations revealed the facility failed to promote the resident's nutritional status by encouraging, cueing and assisting the resident at mealtime, documenting his intake of snack and supplement, and addressing his agitation in the dining room at mealtime. No new interventions were considered when the resident continued to lose weight. Additionally, the facility failed to weigh Resident #1 upon admission to create a baseline to assess the resident's weight and nutritional status. Findings include: I. Facility policy and procedure The Weights policy, revised May 2017, was provided by registered dietitian consultant (RDC) #1 on 7/12/24 at 12:20 p.m. It read in pertinent part, It is the policy of this facility to obtain an accurate weight as part of the resident's assessment upon admission and at least monthly thereafter. Nursing will be responsible for the initial determination of each individual's weight. admission weights will be obtained. This will be included in the admission process and documented in the medical record. If hospital weight is entered, it should be listed as'type of scale used. ' The facility is responsible for obtaining correct weights on a regular basis, and for keeping accurate records. This includes having adequate weight scales, lift scales and/or wheelchair scales as needed. Erroneous (incorrect) weights may be struck out when determined inaccurate. Reweighs may be requested if a discrepancy is presumed or if a significant weight change is noted to assure accuracy of the weight. Individuals with unplanned significant or severe weight loss may receive nutrition interventions to prevent further weight loss, stabilize weight and/or assist to regain weight as appropriate. II. Resident #23 A. Resident status Resident #23, age [AGE], was admitted on [DATE]. According to the July 2024 computerized physician orders (CPO), diagnoses included senile degeneration of the brain, anxiety, hyperglycemia (high blood sugar), protein-calorie malnutrition, dysphagia oropharyngeal phase (difficulty swallowing), muscle weakness, muscle wasting and atrophy multiple sites (partial or complete wasting of the muscles). The 5/28/24 minimum data set (MDS) assessment revealed the resident was rarely or never understood through staff assessment. The resident had short-term and long-term memory deficits and was severely impaired in daily decision-making through staff assessment. The resident required set up and clean up assistance for meals and was dependent for all other activities of daily living (ADL). The assessment revealed the resident had complaints of difficulty or pain of swallowing, was on a mechanically altered diet and showed none or had unknown weight loss or weight gain. B. Observations On 7/9/24 at approximately 5:06 p.m., an unidentified staff member served Resident #23 dinner. Resident #23 was able to eat approximately 25% of his dinner and drink 100% of his beverages. -Resident #23 was not encouraged, cued or assisted by staff. -No alternates, refills or seconds were offered to Resident #23 before he was assisted out of the dining room. On 7/10/24 at approximately 12:05 p.m. Resident #23 was served his lunch meal. He was eating his lunch with no issues. -Resident #23 was not encouraged, cued or assisted by staff. At approximately 12:15 p.m. Resident #23 accidentally knocked his plate over the side of the table which spilled his plate of food down the front of himself and onto the floor. Resident #23 had consumed less than 25% of his meal. The resident was assisted out of the dining room and into the common area. -The resident was not offered a new meal after his lunch spilled on the ground. C. Record Review The nutrition care plan, dated 5/23/24, revealed the resident had a nutritional problem related to the diagnoses of dementia and hyperglycemia. The care plan documented the resident was malnourished and had a history of weight loss based on hospitalizations prior to admission to the skilled nursing facility. Pertinent interventions included honoring his right to make dietary choices, monitoring and reporting signs and symptoms of decreased appetite and unexpected weight loss to the physician, monitoring weekly weights for four weeks, monitoring intake and the registered dietitian (RD) would monitor the resident's ongoing nutritional status. -Resident #23's care plan did not identify weight loss was expected for the resident and there were no updates made to the care plan when significant weight loss was identified (see record review below). The July 2024 CPO revealed the resident had a physician's order to receive MedPass 2.0 (nutritional supplement) 120 ml (millileters) three times a day, ordered 5/24/24. The June 2024 and July 2024 medication administration records (MAR) revealed that MedPass 2.0 120 ml was being given to the resident three times a day and the resident was consistently consuming 100% of the supplement. -However, the amount of the supplement was not increased or another nutritional supplement added when the resident continued to lose weight until 6/25/24 when the RD added fortified foods. Resident #23's weights were documented in the resident's electronic medical record (EMR) as follows: -On 5/22/24, the resident weighed 153.5 lbs; -On 6/5/24, the resident weighed 150 lbs; -On 6/13/24, the resident weighed 147.5 lbs; -On 6/20/24, the resident weighed 142 lbs; -On 6/24/24, the resident weighed 140.5 lbs; and, -On 7/1/24, the resident weighed 139.0 lbs. -The resident lost 14.5 lbs (9.5%) from 5/22/24 to 7/1/24, in 40 days, which was considered significant. The 5/23/24 mini nutritional assessment (MNA) score was a six, which indicated that he was malnourished upon admission. The 5/24/24 admission nutritional assessment documented the resident's weight was 153.5 lbs upon admission. It documented his mini nutritional assessment risk score was a six, which indicated the resident was malnourished. The RD documented the resident was consuming 75-100% of most meals. The RD recommended starting 120 ml MedPass 2.0 three times a day, which would provide 720 calories and 30 grams protein per day. The assessment documented the RD would continue to monitor and follow up as needed. The 6/25/24 RD progress note documented the RD spoke to the resident's representative about the resident's weight loss and recommended fortified meals to help reduce further weight loss. The resident's representative agreed with the intervention. The 6/25/24 nutrition at risk committee documented the resident's current weight was 140.5 lbs. The committee reviewed the resident's weight loss, which was down 13 lbs from the admission weight. The committee determined the resident's weight loss might have been related to fluctuating intake at meals and the disease progression. The resident's representative said the resident enjoyed peanut butter and honey. The note documented the recommendation was to assist the resident at meals to help reduce further weight loss. The physician was notified of the weight loss and was requested to evaluate for a possible appetite stimulant. The 7/1/24 progress note revealed the resident was placed on hospice with the diagnosis of senile degeneration of the brain. A review of Resident #23's intake meal record on 7/11/24 at 11:37 a.m., revealed the amount the resident had consumed of his meals from 6/12/24 to 7/11/24 was as follows: -25% of meals on 23 occasions; -50% of meals on 21 occasions; -75% of meals on 12 occasions; -100% of meals on 28 occasions; - refusal noted one time; and, - no documentation on two occasions. A decline in the resident's meal intakes was noted between 7/5/24 and 7/11/24, following the resident's admission to hospice. D. Staff interviews Registered nurse (RN) #1 was interviewed on 7/11/24 at 4:00 p.m. RN #1 said Resident #23 should have been given another meal when he had spilled his first one. He said the resident was able to feed himself. RN #1 said Resident #23 required encouragement and oversight with eating. RN #1 said the certified nurse aides (CNA) were responsible for documenting the amount each resident consumed at meals. CNA #3 was interviewed on 7/12/24 at 11:45 a.m. CNA #3 said snacks were offered to the residents throughout the day. She said if a resident did not like something (snacks or meals), the staff would go and get them what they wanted. CNA #3 said the CNAs would chart how much each resident ate after the resident was finished eating. The dietary manager (DM) was interviewed on 7/12/24 at approximately 10:00 a.m. The DM said the satellite kitchen in the secured area had extra pureed food. The DM said the staff should have offered Resident #23 a new meal after he spilled his food. RDC #2 was interviewed on 7/12/24 at approximately 2:00 p.m. RDC #2 said Resident #23 had first experienced a three pound weight loss. She said because the resident did not have a significant weight loss, the facility did not implement a new intervention since he was already on the prescribed health shake upon admission. She said, on 6/20/24, the resident had experienced a significant weight loss. She said after the resident triggered for significant weight loss, the interdisciplinary team (IDT) began reviewing the resident in the nutrition at risk meetings. RDC #2 said the RD assessed the resident's nutritional status, spoke with the resident's family and observed the resident at lunch on 6/25/24. She said the RD spoke with the resident's representative about the fortified meal program and recommended fortified foods to help combat the resident's weight loss. RDC #2 said the resident often had increased agitation at meal times. She said the noise and amount of activity may have contributed to the agitation. She said the resident began hospice services on 7/1/24 with the diagnosis of senile degeneration of the brain. III. Resident #1 A. Resident status Resident #1, age less than 65, was admitted on [DATE] and discharged on 5/1/24. According to the July 2024 computerized physician order (CPO), diagnoses included hemiplegia (paralysis on one half of the body), hemiparesis (muscle weakness on one half of the body) following a cerebral infarction (stroke) affecting right non-dominant side, quadriplegia (paralysis of all four limbs), tracheostomy status (opening from the outside of the windpipe to help oxygen reach the lungs), dysphagia oropharyngeal phase (inability to swallow food or fluids) and gastrostomy status (artificial opening to the stomach). The 5/2/24 minimum data set (MDS) assessment revealed the resident was unable to be understood and unable to participate in the brief interview for mental status (BIMS). The MDS assessment indicated the resident had no memory problems through staff assessment. The assessment documented Resident #1 had lost five percent or more of his body weight in the previous month or 10% or more of his body weight in the previous six months and he was not on a prescribed weight loss regimen. The assessment documented Resident #1 had a feeding tube and 100% of his nutrients were received through the feeding tube. B. Record review Resident #1's weights were documented in the resident's EMR as follows: On 2/22/24, Resident #1 weighed 103 lbs, this was struck out as an incorrect weight on 2/23/24. On 2/23/24, it was documented that Resident #1 weighed 152 lbs, which was obtained during his hospital stay. On 3/13/24, Resident #1's weight was 152 lbs, via the Hoyer scale (mechanical lift). On 3/28/24, Resident #1's weight was 104.5 lbs, via the Hoyer scale. Resident #1's nutritional care plan, revised 3/4/24, documented the resident had a nutritional problem or potential for a nutritional problem referring to his diagnoses. Interventions implemented were to provide the resident with Nutren 2.0 (tube feeding formula) at 35 milliliters (ml) an hour for 24 hours a day, enteral support regimen as ordered by the physician, staff monitoring for signs of intolerance to the tube feedings, staff monitoring for muscle wasting and significant weight loss and staff providing the resident his diet as ordered of nothing by mouth. Resident #1's tube feeding care plan, revised 3/6/24, documented the resident was dependent on tube feedings and water flushes and needed the RD to evaluate his needs quarterly and as needed to provide recommendations for changes to the tube feeding regimen. Review of nutritional assessments and IDT notes revealed the facility continued to use the resident's hospital weight and failed to weigh the resident to create a baseline for nutritional assessment until 3/28/24, 36 days after he was admitted to the facility, even though the RD requested the facility to obtain a weight on 2/23/24, in order to determine the correct amount of tube feeding the resident should be receiving (see RD nutritional summary below). The 2/23/24 nutritional summary documented Resident #1's hospital weight was entered into the facility's EMR. The RD requested for the facility to obtain a weight because the resident's weight history was undetermined. The 3/27/24 nutrition at risk meeting note documented the reason the resident was reviewed by the IDT was to adjust the resident's enteral feeding. The note documented Resident #1 weighed 152 lbs and often requested to have his feeding turned off because the resident felt full. The RD followed up with the resident and Resident #1 said the feedings caused the resident to feel full and made the resident nauseous. The resident said he had thrown up and the RD confirmed this in his chart. The RD spoke with the resident's family that the current feeding regimen was not enough to meet Resident #1's nutritional needs. The RD requested a follow-up weight and anticipated a weight decline because of a decrease in calories and a potential erroneous weight at the facility. The RD recalculated Resident #1's nutritional needs based on the resident's weight at home and adjusted the feeding regimen to match the weight of 103 lbs. C. Staff interviews The RD was interviewed on 7/11/24 at 10:14 a.m. The RD said the nursing staff weighed the residents upon admission. He said the facility preferred not to use the hospital weight because the facility was unsure if the weight was accurate. He said if a resident who received nutrition via a feeding tube experienced weight loss, he asked the nursing staff to re-weigh the resident to ensure the weight was accurate. The RD said when he noticed Resident #1 had lost weight he called the resident's family and the family said the resident typically weighed around 105 lbs and the family said the resident did not weigh 152 lbs. The RD said he questioned Resident #1's initial weight entered into the EMR, but the resident's weight was never confirmed. Registered dietitian consultant (RDC) #1 and RDC #2 were interviewed together on 7/12/24 at 10:19 a.m. RDC #1 said she and RDC #2 were dietary resources for the facility when help was needed. She said the hospital weight was not supposed to be entered into the resident's chart and the resident needed to be weighed on the facility's scale. RDC #1 said it was important to have an accurate weight because the facility needed to be able to provide the resident with the correct amount of calories he needed since he had a feeding tube. She said she and RDC #2 investigated any resident who experienced any type of weight loss. RDC #1 said the facility had documentation that Resident #1's family said the resident never weighed over 120 lbs and the facility knew the weight was incorrect. RDC #1 said the 152 lbs weight needed to be struck out as it was incorrect. She said the weight had not been struck out. She said when the resident was admitted to the facility, the hospital weight of 152 lbs was entered into Resident #1's EMR. RDC #1 said the resident's weight was documented as 103 lbs. She said the following day, on 2/23/24, the former RD struck out the 103 lbs and re-entered the 152 lbs as the resident's current weight. She said the current RD documented in the resident EMR that Resident #1's admitting weight was incorrect. She said the RD entered a progress note that indicated the weight of 152 lbs was incorrect should have been disregarded. The director of nursing (DON) was interviewed on 7/12/24 at 3:17 p.m. The DON said she had spoken to the staff member who documented Resident #1's admitting weight at 152 lbs. She said the staff member informed the DON she did not physically weigh the resident. The DON said the staff member who entered Resident #1's weight did not normally weigh residents The DON said the facility planned to have one staff member responsible for documenting the weights so someone was keeping track of any weight changes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure that the resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for for one (#1) of three residents reviewed for dental care out of five sample residents. The facility failed to provide emergency dental services for Resident #1. Resident #1's family was visiting on 4/16/23. The family notified the licensed nurse on duty of a broken, dark tooth, pain, discoloration and swelling to the resident's right lower jaw and neck.The family member said it was weeks before he was seen by a dentist, and the facility just kept giving him antibiotics. The resident received oral and intravenous (IV) antibiotics between 4/18/23 and 5/25/23 for repeat swelling and pain to the jaw. He was not seen by a dentist until 5/3/23, more than two weeks after he was observed with pain and swelling to his right jaw and neck. The dentist documented on 5/3/23, Resident #1 needed a root canal (dental procedure needed when the soft tissue or pulp inside the tooth becomes infected leading to severe toothache, tooth becomes darker, swollen painful gums and abscess if not treated). The resident was discharged to the hospital on 6/5/23, he had not had a root canal or been scheduled for one. Additionally, antibiotics were not initially started until two days after the resident developed signs of infection. Findings include: I. Facility policy and procedure The Dental Services policy, dated January 2020, was provided by the director of nursing (DON) on 9/11/23 at 4:57 p.m. It revealed, in pertinent part, It is the policy of this facility, in accordance with residents' needs, to promptly assist residents in obtaining routine (to the extent covered under the State plan) and emergency dental care. Emergency dental services include services needed to treat an episode of acute pain in teeth, gums, or palate; broken, or otherwise damaged teeth, or any other problem of the oral cavity that required immediate attention by a dentist. The Social Services Director maintains contact information for providers of dental services that are available to facility residents at a nominal cost. II. Resident status Resident #1, age [AGE], was admitted on [DATE], readmitted on [DATE] and discharged from the facility to the hospital on 6/5/23. According to the August 2023 computerized physician orders (CPO), diagnoses included hypothermia (dangerously low body temperature) with shock, acute respiratory failure and metabolic encephalopathy (problem of the brain due to chemical imbalance in blood). The 5/17/23 minimum data set (MDS) assessment revealed the resident had minimal cognitive impairment with a brief interview for mental status (BIMS) with a score of 14 out of 15. He was totally dependent on two staff to assist with bed mobility, transfers, dressing, toileting and personal hygiene. He had a tracheostomy and was on a mechanical ventilator with oxygen. The assessment documented the resident had mouth or facial pain and discomfort. He had received intravenous medications while at the facility. III. Interviews Resident #1's family was visiting the resident on 4/16/23 and observed discoloration and swelling to the resident's right lower jaw extending down his neck. The family member said the entire right lower jaw and neck were swollen and the resident complained of pain when the family member lightly touched his neck. The family said she could see a broken dark tooth in his lower right jaw. The family member notified the nurse on duty. The family said the nurse became angry and abruptly said she would call the physician for an x-ray. The x-ray showed no bone abnormality and there were no new orders on 4/16/23. The family member said it would be weeks before Resident #1 was actually seen by a dentist, and in the meantime the facility had just kept giving him antibiotics. Social worker (SW) #1 was interviewed on 9/11/23 at 9:39 a.m. She said social services handled ancillary services such as dental services. SW #1 said she was assigned to Resident #1. She said she was not notified of the resident's dental issue on 4/16/23. SW #1 said she discovered the resident had pain and swelling in his jaw and neck when she was reviewing progress notes on 4/19/23. She said the facility had no formal process for notifying her of emergent dental needs. SW #1 said emergency dental services could probably be provided within a week through the visiting dentist, but not 24 hours. She asked if it was a requirement that the resident receive dental services in 24 hours. She said she would have to send them to the emergency room (ER) because the visiting dentist probably would not come out in 24 hours. SW #1 acknowledged there were no dentists in the ER. She said she scheduled an appointment for Resident #1 with the visiting dentist for 4/26/23. However, the dentist had a scheduling problem and did not come on 4/26/23 (see below). The resident was treated with oral and IV medications for repeated swelling, redness and pain to his right jaw and neck. SW #1 provided a note from a dentist dated 5/3/23, more than two weeks after he developed pain and swelling to his jaw and neck. The dentist note recommended a root canal. -The resident was discharged to the hospital on 6/5/23. He had not had a root canal. SW #1 said she had not been able to schedule the procedure due to insurance issues. IV. Record review On 4/16/23 at 10:13 a change of condition report documented the resident had swelling along the right mandible (lower jaw). The report documented the family was at bedside, the physician was notified and ordered an x-ray of the face and jaw. -There was no further description of the jaw or neck by the nurse, or of the broken tooth the family observed. On 4/16/23 at 5:59 p.m. the nurse notes documented the x-ray was normal and there were no new orders. On 4/17/23 the nurse practitioner (NP) documented the resident's face had developed redness and swelling. She documented the area was hot to touch and hard. The NP documented the area probably had an abscess or was an odontogenic (infection of teeth and or tissues). -There was no description of his mouth or broken tooth. The NP ordered two antibiotics, Linezolid Oral Tablet, 600 mg (milligrams) via PEG (percutaneous endoscopic gastrostomy) feeding tube two times a day for skin infection for 10 Days. The NP documented this antibiotic was given in case the infection was MRSA (methicillin resistant staphylococcus aureus). Additionally, she ordered Augmentin antibiotic 875-125 MG, one tablet via PEG tube two times per day for odontogenic infection for 10 days. The April 2023 medication administration record (MAR) documented the antibiotics were not started until the following day 4/18/23, two days after the family notified the facility of the signs of infection to Resident #1's tooth, jaw, and neck. On 4/19/23 at 10:27 a.m. SW #1 documented the resident was referred to the dental provider for swelling in his lower jaw, three days after his facial and neck swelling was observed. On 4/19/23 at 3:43 p.m. the nurse's notes documented the dentist would come for an emergency visit on 4/26/23 (10 days after the resident developed emergent dental concerns). Additionally, the Augmentin was increased to four times per day. On 4/26/23 at 10:50 a.m. the resident's physician documented the jaw and neck had improved, and the dentist would be out to evaluate the resident that day. On 4/26/23 at 2:07 p.m. the nurse notes documented the dentist would be here today for possible tooth extractions, and the resident and the resident's niece were notified. On 4/27/23 at 10:46 a.m. the nurse documented the social worker said the dentist would see the resident on 5/3/23. SW #1 provided an email she sent to the dentist on 4/27/23 at 9:49 a.m., when the dentist did not show up to see the resident on 4/26/23. The dentist said she had not added the emergency to her phone and therefore missed it. She said would come to see Resident #1 on 5/3/23. On 5/10/23 at 11:38 a.m. the NP documented the redness and swelling had returned to the residents face and neck on the right side. The NP ordered IV antibiotics, Unasyn IV every six hours for seven days total. On 5/10/23 at 1:00 p.m. the nursing notes documented the resident's face on the right side and jaw were swollen again and tender to touch. At 3:00 p.m. the nurse documented the resident and his medical power of attorney would like to do antibiotics through the PEG tube. The Augmentin was restarted twice per day via the PEG tube. On 5/15/23 at 11:23 the resident's swelling was worse. The Augmentin was discontinued and the Unasyn 3 g (grams) IV every 6 hours for 7 days until seen by a dental surgeon was ordered. On 5/17/23 3:51 a.m. the nursing note documented the swelling was better but the resident was having pain. He was medicated for pain. On 5/18/23 4:19 a.m. the nursing note documented the swelling was diminished to the resident's right jaw, but the resident was having pain. He was medicated for pain. On 5/22/23 at 8:04 a.m. the NP documented the resident was supposed to come off IV antibiotics today but due to significant swelling the IV antibiotics would be continued for three more days. 5/25/23 at 11:15 a.m. the NP documented the the resident would complete the IV antibiotic today, and the jaw swelling was better. -There were no further progress notes related to the resident's jaw or follow up appointment with the oral surgeon. On 6/1/23 at 9:23 a.m. SW #1 documented she had spoken to the resident's insurance company and the insurance would be transferred from the office in the city the resident previously resided in to the office of his current address at the nursing home. -This was the first social service follow up note since the initial note on 4/19/23 at 10:27 a.m. On 6/5/23 at 7:34 a.m. the nursing progress notes documented the resident was transferred to the hospital with altered mental status and a low blood pressure. V. Facility follow-up The facility provided a note from the medical director (MD) on 9/12/23, after the survey. The note, undated, documented in pertinent part, The dental delay did not have any impact on the resident health as the infection resolved with interventions in place. This had no impact on the resident eating as he was NPO (nothing by mouth) and meeting nutritional needs through enteral feeds. There was no harm related to dental appointments being rescheduled and the provider was monitoring the situation closely with resolution of the infection obtained in house. -However, emergency dental services were required to be provided. Placing the resident on antibiotics repeatedly by the primary physician did not meet this requirement. Additionally, the resident was not initially started on antibiotics for two days after his symptoms began, a dentist recommended increasing the amount of antibiotics three days later via telephone, but he was not seen by a dentist for two weeks after he developed symptoms. He suffered repeated swelling and pain and needed repeat treatments with antibiotics. Furthermore, the facility never followed up and scheduled the resident with an oral surgeon.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure residents received care consistent with professional standards of practice to prevent worsening and infection of a pressure injury for two (#1 and #3) of four residents with pressure injuries out of five sample residents. Resident #1 admitted to the facility on [DATE] with intact skin. Resident #1 developed pressure injuries at the facility to his sacrum, left shoulder and right buttock. He had multiple comorbidities including a history of cardiogenic shock (heart not pumping enough blood to organs) and chronic respiratory failure, rhabdomyolysis (muscle tissue breakdown) and diabetes mellitus. He was at high risk for pressure injuries. The facility failed to initiate treatment when the sacral wound was first found on [DATE] for three days until [DATE]. The treatment administration records from [DATE] to [DATE] documented the wound care to his sacral, shoulder and right buttock wounds was held on multiple dates. The facility discussed the sacral wound with the wound doctor and documented the sacral wound was probably a Kennedy ulcer (terminal ulcer that may develop possibly indicating impending death) on [DATE]. However, there was no documentation that was discussed with the resident or the resident's representative to determine if aggressive treatment was desired. The decision to aggressively treat the wounds or seek acute care, regardless of risk factors or rationale for developing or worsening should have been discussed with the resident and/or his representative. His sacral wound became almost three times larger between [DATE] and [DATE] with a large amount of drainage. His wound was described by the facility as having a foul odor on [DATE]. There was no documentation the resident or his family were notified. He was sent to the hospital on [DATE] with altered mental status and hypotension. The resident's wounds were diagnosed as infected and he was septic. He underwent surgical treatment of the wounds, intravenous (IV) antibiotics and extensive wound care. He passed away 10 days later. His hospital death discharge summary listed his infected wounds and pneumonia as his final diagnoses. Resident #3 was admitted with a stage three pressure injury to his sacrum on [DATE]. On [DATE] at 4:03 p.m. the nursing note documented the resident fell out of bed, face down and hit his head causing a laceration. At 11:22 p.m. the nursing notes documented the resident began jerking, was less responsive with sluggish pupils and a high blood pressure (BP) of 165/137 (normal 130s/80s). The resident was sent to the hospital. He was admitted for sepsis infection to his sacral wound. The hospital notes documented the wound had pus coming from it, his temperature was 101 (normal for this resident 97.3 to 98.3). degrees fahrenheit and the resident had severe sepsis of his chronic sacral wound. His head computed tomography (CT, x-ray with cross sections) was normal. The resident was readmitted to the facility on [DATE], however there was no assessment of the wound until [DATE] or treatment of the sacral wound documented until [DATE]. Additionally, the resident was observed on an air mattress during the survey which was set for someone weighing 320 lbs (pounds). The resident weighed 233 lbs as of [DATE]. The air mattress was overinflated. Findings include: I. Professional reference According to the National Pressure Injury Advisory Panel, European Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Injuries: Clinical Practice Guideline, third edition, [NAME] Haesler (Ed.), EPUAP/NPIAP/PPPIA: 2019, retrieved from https://www.internationalguideline.com/guideline on [DATE], Pressure ulcer classification is as follows: Category/Stage 1: Nonblanchable Erythema (discoloration of the skin that does not turn white when pressed, early sign of tissue damage) Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate 'at risk' individuals (a heralding sign of risk). Category/Stage 2: Partial Thickness Skin Loss Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising.This Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. Category/Stage 3: Full Thickness Skin Loss Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/ Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/ Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage 4: Full Thickness Tissue Loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/ Stage 4 ulcers can extend into muscle and/ or supporting structures ( fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable Unstageable: Depth Unknown Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/ Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed. Suspected Deep Tissue Injury: Depth Unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. II. Facility policy and procedure The Skin and Wound Monitoring and Management policy, revised [DATE], was received from the director of nursing (DON) on [DATE] at 4:57 p.m. The policy documented in pertinent part, A resident who enters the facility without pressure injury does not develop pressure injury unless the individual's clinical condition or other factors demonstrate that a developed pressure injury was unavoidable; and a resident having pressure injury(s) receives necessary treatment and services to promote healing, prevent infection, and prevent new, avoidable pressure injuries from developing. Current evidence documents that, in certain circumstances, the development of pressure injury is an unavoidable occurrence. In accordance with the guidance issued by the National Pressure Ulcer Advisory Panel ([DATE]), the facility recognizes that an 'unavoidable' pressure injury is one that developed even though the provider evaluated the individual's clinical condition and pressure injury risk factors; defined and implemented interventions that are consistent with individual needs goals and recognized standards of practice; monitored and evaluated the impact of the interventions; and revised the approaches as appropriate. Facility nursing staff will identify and document in the resident's clinical records, the condition and pressure injury risk factors related to the development of unavoidable pressure injury. This identification and implementation of a plan of care will begin at admission with the initial care plan and be completed throughout the assessment process for developing a comprehensive plan of care. A licensed nurse must assess/evaluate a resident's skin on admission. All areas of breakdown, excoriation, or discoloration, or other unusual findings, will be documented on the Initial admission Record. A licensed nurse will assess/evaluate each pressure injury and/or non-pressure injury that exists on the resident. This assessment/evaluation should align with the scope of practice and include but not be limited to: measuring the skin injury, staging the skin injury when the cause is pressure, describing the nature of the injury, describing the location of the skin alteration, describing the characteristics of the skin alteration. Once an area of alteration in skin integrity has been identified, assessed, and documented, nursing shall administer treatment to each affected area as per the physician's order. Any changes in the condition of the resident's skin as identified daily, weekly, monthly, or otherwise, must be communicated to the resident and or responsible party. Monitoring, daily via medication administration (MAR) and treatment administration records (TAR), weekly via the Skin Weekly Committee, inspection on showering, weekly skin check by a licensed nurse. III. Resident #1 A. Resident status Resident #1, age [AGE], was admitted on [DATE], readmitted on [DATE] and discharged from the facility to the hospital on [DATE]. According to the [DATE] computerized physician orders (CPO), diagnoses included hypothermia (dangerously low body temperature) with respiratory failure and shock, and metabolic encephalopathy (problem of the brain due to chemical imbalance in blood). The [DATE] minimum data set (MDS) assessment revealed the resident had minimal cognitive impairment with a brief interview for mental status (BIMS) with a score of 14 out of 15. He was totally dependent on two staff to assist with bed mobility, transfers, dressing, toileting and personal hygiene. He had a tracheostomy and was on a mechanical ventilator with oxygen. The assessment documented the resident had two stage 3 pressure injuries. He was on a pressure reducing device in bed and he was not on a turning or repositioning program. The assessment documented the resident did not have application of wound dressing. B. Resident representative interview The resident's representative was interviewed on [DATE] at 2:19 p.m. She said she had not been aware of the resident's deteriorating wound until she got a panicked call from the nurse on [DATE], and the nurse said they were sending Resident #1 to the hospital. The representative reviewed the calls on her phone. The representative had no record of a call from the facility on [DATE]. She said she spoke to nurse, she thought it was licensed practical nurse (LPN) #1, on [DATE] and [DATE]. LPN #1 said each time the wounds were looking good. She was not notified of the deterioration of the wounds. The representative said Resident #1 was not on hospice or comfort care and was not dying. She said she was familiar with the term Kennedy ulcer. The representative said the facility should have notified her so a decision could have been made on treatment options. C. Record review The resident had a medical orders for scope of treatment (MOST) form dated [DATE], signed by the resident [DATE] and the physician [DATE], documenting he wanted full CPR (cardiopulmonary resuscitation) if needed and full treatment to prolong life by all means, including transfer to the hospital and intensive care unit (ICU). The resident was not on comfort care, palliative care or hospice. On [DATE] at 5:21 p.m. the nursing admission assessment documented the resident admitted with intact skin. The only note was regarding a healed surgical incision to the back of his neck. He was placed on a pressure redistributing overlay. On [DATE] at 3:30 p.m. the nursing notes documented the resident was sent to the hospital with altered mental status. On [DATE] at 1:25 p.m. the nursing admission assessment documented the resident's skin was intact except for being dry with three small scabs to the right ankle. On [DATE] at 10:57 a.m. the nurse practitioner (NP) documented the resident had been admitted to the hospital [DATE] with septic shock due to lung infection. On [DATE] at 7:14 p.m. the resident was sent to the hospital with abdominal distension and vomiting. On [DATE] at 1:15 p.m. the facility nursing admission documented the resident had an open area 7.0 centimeter (cm) in length by 0.5 cm width to his left inner thigh and an 0.5 cm by 0.5 cm red area to his scrotum. On [DATE] a non pressure wound report documented the resident had an abrasion to the back of the left thigh, with an onset of [DATE]. The wound was 0.3 cm by 0.15 cm. On [DATE] the nursing notes documented the resident had altered mental status and was sent to the hospital. On [DATE] at 11:34 a.m. the nursing admission note documented the resident had a 1.0 cm by 2.0 cm red area on the back of his right thigh. -There were no pressure injuries or wounds documented. There were no treatment orders until [DATE] (see below). On [DATE] at 3:11 a.m. the weekly skin evaluation documented monitor red area back of leg. -There was no further description of which leg or the size of the red area. On [DATE] at 5:26 a.m. (the same day) the weekly skin evaluation documented the resident's skin was intact. On [DATE] at 2:39 a.m. the weekly skin evaluation documented the resident had three pressure injuries. One to the rear left thigh 0.4 cm by 0.6 cm, stage 2. One to the sacrum 5 cm by 1 cm, stage 3. One to the right gluteal fold 4 cm by 3.5 cm stage 3. The evaluation said the resident would see the wound doctor on [DATE]. -There was no documentation the physician or family were notified. The [DATE] CPO was reviewed and revealed there were no treatment orders until [DATE], three days after the wounds were discovered (see below). On [DATE] at 10:27 a.m. the weekly pressure ulcer assessment documented: -Left rear thigh was 0.4 cm by 0.6 cm, no depth, no drainage or odor, 100% epithelialization (new epidermis outer skin layer), stage 2. -The sacrum was 5 cm by 1 cm, no depth, no drainage or odor, wound bed pink, 50% epithelialization, 50% granulation (new connective tissue), stage 3. -The right buttock was 4 cm by 3.5 cm, no depth with scant serosanguineous (contains blood and serum) drainage, the wound bed had slough (dead cells in wound, white or yellow material in wound bed) stage 3. The wound physician notes on [DATE] documented the above measurements and ordered to clean the wounds with normal saline and apply barrier cream twice daily and as needed for all wounds. On [DATE] at 10:22 p.m. a change of condition evaluation documented the resident had moisture associated skin damage (MASD) to the right and left buttock. On [DATE] at 4:53 a.m. the weekly skin evaluation documented the wounds to the sacrum and back of right thigh were intact (the wound on [DATE] as the left thigh). -There was no further documentation. On [DATE] at 3:45 p.m. the weekly pressure ulcer assessment documented: -Left rear thigh was resolved. -The sacrum was larger, 8.5 cm by 6.5 cm, no depth, with a small amount of serosanguinous drainage, no odor, the wound bed had granulation and the wound edges were macerated (softening and breaking down of skin related to moisture), stage 3. -The right buttock was smaller, 3.5 cm by 2 cm, no depth, with a small amount of serosanguinous drainage, no odor, the wound bed had granulation and the wound edges were macerated, stage 3. All necessary notifications have been made. -It was unclear if the resident or family were updated at this time. The wound physician notes on [DATE] documented the above measurements and ordered to clean the wounds with normal saline and apply barrier cream twice daily and as needed for both wounds. On [DATE] at 10:53 a.m. the weekly pressure ulcer assessment documented, -The sacrum was 7.5 cm by 6.5 cm, by 0.2 cm depth, with a small amount of serosanguinous drainage, no odor, the wound bed had non granulating tissue and the wound edges were macerated, stage 3. The treatment changed to Medihoney and foam dressing daily and as needed. -The right buttock was smaller, 2.1 cm by 4.2 cm, no depth, with a small amount of serosanguinous drainage, no odor, the wound bed was black and brown eschar (necrotic tissue) and the treatment was changed to Medihoney and foam dressing daily and as needed.The wound was a stage 3. All necessary notifications have been made. -It was unclear if the resident or family were updated at this time. On [DATE] the wound MD documented the same measurements and ordered to clean the wounds with normal saline and apply honey and cover with foam dressing daily and as needed for both wounds. On [DATE] at 10:37 a.m. the weekly pressure ulcer assessment documented: The sacrum was 9.5 cm by 10.5 cm, by no depth, with a moderate amount of serosanguinous drainage, no odor, the wound bed had black and brown eschar and the wound edges were macerated, the surrounding skin was red, stage 3. The treatment changed to barrier cream to wound edges, Medihoney and abdominal dressing daily and as needed. -The right buttock was larger, 4.4 cm by 2.7 cm, no depth, with a moderate amount of serosanguinous drainage, no odor, the wound bed was black and brown eschar and the treatment was changed to barrier cream to wound edge, Medihoney and foam dressing daily and as needed. The wound was stage 3. All necessary notifications have been made. -It was unclear if the resident or family were updated at this time. On [DATE] the wound physician documented the above measurements and ordered to clean the wounds with normal saline, protect the wound edge with barrier cream, and apply honey and cover with abdominal dressing, twice daily and as needed for both wounds. On [DATE] at 1:18 p.m. the weekly pressure ulcer assessment documented: The sacrum wound had improved and was 4.5 cm by 5 cm, by no depth, with a small amount of serosanguinous drainage, no odor, the wound bed had black and brown eschar and the wound edges were macerated, the surrounding skin was red, stage 3. The treatment was unchanged. -The right buttock was improved, 4.1 cm by 2.5 cm, no depth, with a small amount of serous (clear to yellow fluid) drainage, no odor, the wound bed had granulation tissue and the treatment was unchanged. The wound was stage 3. All necessary notifications have been made. -It was unclear if the resident or family were updated at this time. On [DATE] the wound physician documented the above measurements and ordered to clean the wounds with normal saline, protect the wound edge with barrier cream, and apply honey and cover with abdominal dressing, daily and as needed for both wounds. On [DATE] at 2:04 p.m. the weekly pressure ulcer assessment documented: The sacrum wound had deteriorated and was 12 cm by 10 cm, by no depth, with large copious amounts of serosanguinous drainage, moderate odor, the wound bed had black and brown eschar, stage 3. The wound was debrided (removal of dead tissue with scalpel). The wound was packed with gauze soaked in Dakins (antiseptic). -The right buttock was improved, 3 cm by 2.7 cm, no depth, with a moderate amount of serosanguineous, no odor, the wound bed had granulation tissue and the treatment was unchanged. The wound was stage 3. The nurse documented the wound physician said the sacrum could be a Kennedy ulcer (pressure injury identified when a person is terminal). All necessary notifications have been made. -It was unclear if the resident or family were updated at this time. On [DATE] the wound physician documented the above measurements and ordered to clean the wounds with normal saline, protect the wound edge with barrier cream, and apply honey and cover with abdominal dressing, daily and as needed for both wounds. The wound physician documented the wounds were debrided, the length and width of each wound remained the same. The depth of the sacrum wound after debridement was 0.3 cm. The depth of the right buttock wound was 0.1 cm. On [DATE] at 2:49 p.m., the wound physician signed a Wound Tracker form documenting the sacral wound was probably a Kennedy ulcer. On [DATE] at 3:32 p.m. the nursing progress notes documented a late entry, that a call was placed to the resident's family about his wound deterioration and a return call was pending. -There was no further documentation of family or resident notification of the deteriorating wound. -The resident representative had no record of a call from the facility on [DATE] (see below). On [DATE] at 2:41 a.m. a change of condition assessment documented the resident had shearing to the back of the left shoulder. There was no further description. The MD was notified and the resident was notified. Wound care orders were obtained on [DATE] for bacitracin and an island dressing every shift and as needed. On [DATE] at 1:54 a.m. the weekly skin evaluation documented the sacrum wound was stage 4 and had a foul odor. -There was no documentation of the right buttock or left shoulder. On [DATE] at 7:38 a.m. a change of condition report documented the resident was unresponsive with a blank stare, labored breathing and a low blood pressure of 57/31. It further documented he had a new skin condition, changes to a wound and his skin color was jaundice (yellow due to build up of bilirubin with the liver not functioning). The treatment administration records (TAR) were reviewed for [DATE], [DATE] and [DATE] and revealed the following: [DATE] Wound care to sacrum and left posterior thigh, dated [DATE], clean with wound cleanser pat dry, apply skin prep to peri wound and apply barrier cream every shift. The facility had two shifts, day shift and night shift. The order was written three days after the wound was found on [DATE]. The wound care orders for the sacrum and posterior left thigh were documented as 2 hold on the night shift [DATE], [DATE] and [DATE]. A number 2 indicated the treatment was held, see progress notes. -However, there were no progress notes for the sacrum on those dates. Orders for wound care to the right thigh, dated [DATE], were documented as 2 hold on the night shift 4/13 to 4/15, 4/20 to 4/22, and 4/27 to [DATE]. The orders for barrier cream to the buttocks and peri area every shift, dated [DATE], were documented as 2 hold, see progress notes on the night shift on 4/13 to 4/15, 4/20 to 4/22, and 4/27 to [DATE]. [DATE] The wound care orders for the sacrum and right buttock were documented as 2 hold, see progress notes on the night shift on [DATE] to [DATE], [DATE], [DATE], [DATE] to [DATE], [DATE] to [DATE]. On [DATE] and [DATE] the TAR was blank for the night shift wound care. -There were no progress notes for the sacrum on those dates. The orders for barrier cream to the buttocks and peri area were documented as 2 hold, see progress notes on the night shift on [DATE] to [DATE], [DATE], [DATE], [DATE] to [DATE], [DATE] to [DATE]. On [DATE] and [DATE] the TAR was blank for the night shift barrier cream. [DATE] The orders for wound care to the left shoulder, right buttock and sacrum were documented as 2 hold, see progress notes on the night shift on [DATE] to [DATE]. The orders for barrier cream to the buttocks and peri area were documented as 2 hold, see progress notes on the night shift on [DATE] to [DATE]. -There were no progress notes for the dates documented that the wound care was held. The skin integrity, potential or actual skin impairment care plan initiated [DATE] was reviewed. The care plan had interventions: air mattress, keep skin clean and dry, use lotion and avoid scratching. The skin impairment, abrasion of the left thigh care plan initiated [DATE], documented to follow protocol: monitor the location and size, report abnormalities to the physician and avoid scratching. The pressure ulcer care plan actual or potential, initiated [DATE], documented administered treatment as ordered: air mattress, assess and monitor wounds, report decline to physician, call light in reach, daily body checks, monitor nutritional status. The pressure ulcer stage 3 to the sacrum care plan, initiated [DATE], documented administer treatment as ordered, assess wound for healing, encourage turning and repositioning, monitor and report changes to the physician, notify nurse of new area of skin breakdown, weekly head to toe skin assessment. The pressure ulcer stage 3 to the right buttock care plan, initiated [DATE], documented administer treatment as ordered, assess wound for healing, inform resident and family of new area of skin breakdown. The hospital records dated [DATE] documented the nursing facility staff said the resident's wounds were looking more infected and that the resident was usually able to communicate, but had been confused lately and was hypotensive (low blood pressure). The ER records documented the resident was hypotensive, hypoglycemic (low blood sugar), anemic (low red blood cells), hypothermic, with altered mental status and a large sacral wound. The ER notes documented the medical durable power of attorney (MDPOA) confirmed the resident's full code status and understood his condition was life threatening. On [DATE] a pelvic CT revealed a large sacral wound with evidence of early osteomyelitis. The notes documented the resident was in shock due to sepsis or hemorrhagic (due to blood loss). The blood loss was documented as most likely chronic blood loss due to the extensive sacral wound. On [DATE] the hospital measured the sacral wound at 8.1 cm by 18.9 cm by 4.6 cm. The left back wound was 7.1 cm by 6.4 cm by 2.1 cm. The right ischial wound was measured at 6.7 cm by 6.5 cm by 0.1 cm. The left ischial wound, not documented in the nursing facility record, was measured at 6.7 cm by 6.5 cm by 0.1 cm. The resident had MASD with draining open areas to the lower abdomen and front of the left thigh near his groin. The resident received IV antibiotics and was followed by the infectious disease physician. On [DATE] at 10:28 a.m. the hospital nursing notes documented the resident's representative provided photos of the coccyx (tailbone near sacrum) with what the nurse described as a skin tear for [DATE]. The resident representative expressed concern with the wound care at the nursing facility. Adult protective services (APS) was notified by the hospital. On [DATE] the surgical records documented the stage 4 wound to the sacrum and stage 3 wound to the left back were surgically debrided. The record documented the left back wound and sacral wound had extensive amounts of necrotic tissue with a foul odor. A wound vac (machine to pull out fluids, stimulate new tissue) was placed on the left back wound. On [DATE] the right ischial wound was smaller and was measured at 5 cm by 5 cm by 0.1 cm. The left ischial wound, not documented in the nursing facility record, was measured at 7.5 cm by 7 cm by 6.5 cm by 0.1 cm. On [DATE] the sacral wound was smaller at 7.8 cm by 16 cm by 7.6 cm depth (debrided [DATE]). The left back wound was 7.1 cm by 6.4 cm by 2.1 cm. On [DATE] the surgeon spoke with the family and recommended debride of the left back again per the advice of the infectious disease physician. The family declined further treatment. The resident's code status was changed, he was removed from the ventilator and passed away on [DATE]. On [DATE] the hospital discharge summary documented the resident was admitted with altered mental status and hypotension likely due to septic shock with pneumonia and bacteremia (bacteria in the blood). The shoulder and sacrum wound were considered the cause of the bacteremia. He had early signs of osteomyelitis. The final diagnoses in pertinent part: septic shock due pneumonia, infected sacral decubitus ulcer, osteomyelitis, hemorrhagic shock with anemia of blood loss. On [DATE] at 4:11 p.m. the DON provided a document titled QAPI (quality assurance and performance improvement), dated [DATE], related to hospital concern of wound management for Resident #1. The document reviewed the resident's wounds and interventions. The review documented the facility felt the wound was unavoidable and recommended talking to the rounding wound nurse about keeping the family updated. -There was no documentation or review of the left shoulder wound. There was no review of the missing treatments documented as a 2 on the TAR. The facility documented the wound was unavoidable, probably a Kennedy ulcer. The review did not include any information related to evaluating wound care technique. There were no names or signatures on the QAPI document. VI. Resident #3 A. Resident status Resident #3, under age [AGE], was admitted on [DATE]. According to the [DATE] CPO diagnoses included interstitial lung disease, fibrotic phenotype (fibrous changes in lungs affecting lung function), unstageable sacral pressure injury, anxiety and depression. The [DATE] MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of 11 of 15. He was totally dependent on extensive two person staff assistance for bed mobility, dressing, and personal hygiene. Transfers and toileting were documented as only having occurred one to two times, requiring extensive two person staff assistance. The assessment documented the resident had no behavioral concerns and did not refuse care. He had an unstageable wound and was not on a turning or repositioning program. B. Record review The nursing admission assessment dated [DATE] documented the resident had an unstageable wound to the sacrum measuring 3.6 cm by 3.4 cm. On [DATE] the weekly pressure ulcer assessment documented the wound was 6 cm by 10 cm by 0 cm. On [DATE] the weekly pressure ulcer assessment documented the wound was 8.5 cm by 10 cm by 0 cm. On [DATE] the weekly pressure ulcer assessment documented the wound was 6.5 cm by 9 cm by 0 cm. On [DATE] the weekly pressure ulcer assessment documented the wound was 7 cm by 8 cm by 0.5 cm. On [DATE] the weekly pressure ulcer assessment documented the wound was 8 cm by 8 cm by 0 cm. On [DATE] the weekly pressure ulcer assessment documented the wound was 7.5 cm by 7.6 cm by 2 cm. On [DATE] at 4:03 p.m. the nursing notes documented at the resident fell out of bed face down, and hit his head causing a laceration. At 11:22 p.m. the nursing notes documented the resident began jerking, was less responsive with sluggish pupils and a high blood pressure (BP) of 165/137. The resident was sent to the hospital. Hospital records dated [DATE] documented the resident was admitted for sepsis infection to his sacral wound. The hospital notes documented the wound had pus coming from it, his tempe[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure one (#5) of three residents reviewed out of five sample residents received respiratory care consistent with professional standards of practice. Resident #5 was admitted to the hospital from home on 6/28/23 with pneumonia. While at the hospital a tracheostomy was placed and the resident was placed on a mechanical ventilator (machine that breathes for you, ensures large enough breaths are taken). During the last week of the resident's hospitalization he was weaned from a ventilator down to a bi-level positive airway pressure (BIPAP, helps keep the airway open with positive pressure and gives more oxygen to the lungs, a person breathes on their own). The facility admitted the resident on 8/4/23. The facility placed him back on a mechanical ventilator. Facility records were requested that documented the resident was being weaned off the ventilator. The facility provided one respiratory note that was written during the survey and documented the resident was tolerating trach shield trials (a process of masking the tracheostomy and providing oxygen but no assistance with breathing) a few times per week for 20 minutes to four hours. However, the resident's hospital notes documented the resident was tolerating a BIPAP and trach shield trials up to five hours. The resident and his representative were interviewed which revealed the resident was not being weaned off the ventilator. The resident and resident representative expressed concern that since he had been on the ventilator at the facility for over a month, he would not be able to wean off successfully. Discharge orders from the hospital did not include mechanical ventilator orders. The facility admission orders did not include mechanical ventilator orders, tracheostomy care or suctioning orders until four days after the resident was admitted to the facility. Findings include: I. Facility policy and procedure The Mechanical Ventilator policy and procedure was requested on 9/11/23 at 4:30 p.m. and not received by the end of the survey 9/11/23 or within 24 hours after the survey exit. A protocol titled Mechanical Ventilation Weaning with Decrease of Settings, undated, was received from respiratory therapist (RT) #1 on 9/11/23 at 2:01 p.m. The protocol documented in pertinent part, daily evaluation, do not wean if systolic blood pressure is less than 90 mmhg (millimeters mercury), the pulse is less than 50 or greater than 130 sustained, BPM (beats per minute). Weaning, chart baseline on all parameters every two hours, weaning to continue 24 hours around the clock. II. Resident #5 A. Resident status Resident #5, under age [AGE], was admitted on [DATE]. According to the September 2023 computerized physician orders (CPO) diagnoses included amyotrophic lateral sclerosis (ALS, nervous system disease where nerve cells breakdown which reduces function of muscles). The 8/4/23 minimum data set (MDS) assessment revealed the resident had mild cognitive impairment with a brief interview for mental status score (BIMS) with a score of 14 of 15. He required extensive two person assistance with bed mobility. He required extensive two person assistance with transfers, dressing and personal hygiene. According to the assessment, the resident was only transferred and toileted one to two times and required extensive one person assistance with transfers and extensive one person assistance with toileting. The assessment documented the resident was on a mechanical ventilator with tracheostomy and oxygen and he had no shortness of breath. II. Interviews and record review The resident's representative was interviewed on 9/6/23 at 3:16 p.m. She said Resident #5 had initially been on a mechanical ventilator at the hospital. She said during the last two weeks the hospital had weaned the resident off the mechanical ventilator on to a BIPAP because he was able to breathe spontaneously on his own. She said when he was discharged from the hospital the resident's son was present. The emergency medical services (EMS) staff could not use the BIPAP in their vehicle, so they used an Ambu bag to provide supportive oxygen and positive pressure ventilation. However, when he arrived at the facility the respiratory staff placed him on a mechanical ventilator. The resident's representative said she had spoken to the director of respiratory therapy (DRT) several times including on 8/31/23 at the care conference without resolution (cross-reference F585 grievances). The DRT informed the resident representative that when he saw the resident at the hospital he was on a BIPAP with a back up. He told her this was the same as a ventilator. However, the resident representative said the facility's assessment was two weeks before Resident #5 was discharged from the hospital to the facility. She said the resident had been making progress at the hospital with just a BIPAP. The resident's representative said she and Resident #5 were aware that he had a progressive neurological disease. However, she said that did not excuse the facility's lack of care and treatment resulting in the resident becoming more dependent on a mechanical ventilator. He was up and walking in the hospital with just a BIPAP (see hospital notes). She said since admission to the facility he was in bed most of the time and on a mechanical ventilator full time. The resident's representative said the hospital records indicated he was weaned to just the BIPAP portion of the machine during the last week of hospitalization and breathing spontaneously on his own. The resident's representative expressed concern that Resident #5 was not able to get off the mechanical ventilator since the facility had placed it on him since his admission on [DATE]. She said the respiratory staff were supposed to be working with the resident on trach shields (a process of masking the tracheostomy and providing oxygen but no assistance with breathing). However, this was not occurring consistently. The DRT was interviewed via telephone on 9/11/23 at 1:52 p.m. He said if the resident came to the facility on a ventilator then that was continued at the facility. He said all residents come with orders for respiratory therapy (RT) to evaluate and treat. The DRT said residents were given more or less support based on their needs per the facility protocol. He said the facility was attempting to wean the resident off the full time ventilator. The DRT said the hospital BIPAP system also has a back up which functions as a ventilator and therefore it was the same as the facility ventilator. -However, the hospital records the last week before the resident discharged did not indicate the resident needed the backup ventilator. He was using the BIPAP and ambulating. The DRT said the facility was attempting to wean the resident using trach shields off the ventilator. The RT notes from admission to present related to weaning the resident off the ventilator were requested. Only one note related to weaning was received (see below). RT #1 was interviewed on 9/11/23 at 2:01 p.m. She said she reviewed the hospital notes and the notes did indicate the resident was only using the BIPAP. She said she did not know why he was put on a mechanical ventilator when he admitted . RT #1 said she had reviewed his physician orders, and did not find orders for the mechanical ventilator or orders regarding his tracheostomy until 8/8/23. III. Additional record review A record containing hospital notes labeled referral in the resident's facility medical record was reviewed. According to a hospital document History of Present Illness, Resident #5 had been living at home with his sister before admission. He was diagnosed with ALS in February 2023. He was on room air and ambulated with a walker at home. Resident #5 went to the hospital on 6/28/23 due to shortness of breath. He was diagnosed with pneumonia and sent to the intensive care unit (ICU). He had a tracheostomy placed and was on a mechanical ventilator as of 6/29/23. Hospital progress notes were reviewed and further documented: On 7/7/23 the hospital documented the resident was tolerating trach shields for three hours. On 7/10/23 the hospital notes documented the resident was tolerating trach shields for five hours and had participated in therapy five days per week for one to three hours. He was still on the ventilator. On 7/16/23 at 7:00 a.m. the nursing notes documented the resident was resting in bed with a ventilator via tracheostomy. At 7:20 a.m. the nursing notes documented the resident was placed on BIPAP per respiratory therapy. At 10:00 a.m. the nurses notes documented the physician was at bedside and said to plan to keep Resident #5 on BIPAP if he continues to tolerate it. On 7/17/23 at 11:11 a.m. the hospital nursing notes documented the nurse had placed a trach shield and taken the resident for a walk. The nursing note documented the resident tolerated the walk fine. On 7/20/23 at 7:09 p.m. the nursing notes documented the resident was on BIPAP and his vital signs were stable. On 7/25/23 at 10:05 a.m. the physician notes documented the resident was medically stable to leave the ICU and tolerating trach shield trials and was on a BIPAP. From 7/21/23 to 8/1/23 the nurse notes documented the resident remained on BIPAP and his vital signs were stable. The 8/3/23 at 6:30 a.m. the nurse notes documented the resident was maintaining oxygen saturation levels above 90% on BIPAP. The facility admission orders on 8/4/23 revealed there was an order for respiratory therapy to evaluate and treat as indicated. There were no orders for a mechanical ventilator, oxygen, tracheostomy care, tracheostomy size, monitoring or suctioning of the tracheostomy until 8/8/23, four days after the resident was admitted to the facility. The facility nursing admission note dated 8/4/23 at 11:15 p.m. documented the resident was alert and oriented to person, place and time. His lungs were clear, he had no cough. Oxygen was administered at 16 liters per minute via tracheostomy. The note documented the resident was on a mechanical ventilator. The resident had a tracheostomy and required suctioning. The RT records from admission to the facility 8/4/23 to 9/11/23 were received from RT #1 on 9/11/23 at 2:01 p.m. The RT notes for 8/4/23 to 8/8/23, 8/30 to 9/1/23 and 9/6/23 during the survey were received. No other notes were provided. The RT notes from 8/4/23 to 9/1/23 did not include any documentation regarding weaning the resident off the ventilator. The RT note on 9/6/23, during the survey, documented the resident has been able to tolerate TS (trach shield) trials roughly a few times per week for 20 minutes to four hours. -There was no information regarding what days the trials were done, how many times a trial was done, what the resident's vital signs were before or after the trials or why the trial ended at 20 minutes of the four hour mark. VI. Facility follow-up On 9/13/23, two days after the survey exit on 9/11/23, the facility provided an undated note from a pulmonologist. The note documented in pertinent part, patients have a standing order to maintain current ventilatory support at the time of discharge and to migrate them to management protocols in place at the facility.