**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 52 residents with 16 residents selected for review, which included one resident reviewed for accommodation of needs. Based on observation, interview and record review, the facility failed to ensure staff assessed one Resident (R) 4, for positioning devices in a timely manner. Findings included: - Review of Resident (R) 4's medical record revealed diagnoses that included chronic back pain, osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain) and left wrist abscess (cavity containing pus and surrounded by inflamed tissue). The Five Day admission Minimum Data Set (MDS) dated [DATE] assessed the resident with a Brief Interview for Mental Status (BIMS) score of 13, which indicated normal cognitive function. The ADL (Activity of Daily Living) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 04/12/24, assessed the resident had a diagnosis of osteoarthritis, R4 had impairment to one side of his lower extremity, and required supervision with touch assistance to total dependence with ADLs. R4 could voice his needs and wants. The Baseline Care Plan, dated 04/06/24, revealed bed rails were not indicated for the resident. The Care Plan, reviewed 05/13/24, instructed staff to know R4 had low back pain and to encourage different methods for pain relief that included positioning. The care plan instructed staff the resident required supervision of touch assistance with bed mobility. Review of a Skilled Nurse Note, dated 05/08/24 at 04:59 AM, documented staff noted the resident had increased back pain with rolling and raising and lowering the head of the bed, and the resident assisted more with turning, which helped with his back pain. Observation, on 05/22/24 at 08:30 AM, revealed R4 in bed feeding himself breakfast. The resident was alert to person, place, and time and responded to questions appropriately. The resident stated he would prefer to have positioning rails on the side of his bed to aide in movements as he had low back pain. R4 stated he mentioned this to multiple staff, and they stated the rails were available, but no one had placed them on his bed. Interview 05/28/24 at 08:45 AM with Licensed Nurse (LN) G revealed she did not know the resident requested positioning rails for his bed and would put a work order in for them. Observation, on 05/29/24 at 09:08 AM, revealed the resident positioned in bed eating breakfast. The resident stated the positioning rails were applied last evening, and he used them for positioning/turning himself in bed. Interview, on 05/29/24 at 09:10 AM, with Therapy Consultant GG revealed the use of positioning devices for R4 would be a nursing decision, and the device would assist the resident in positioning himself in bed. Interview, on 05/29/24 at 10:40 AM, with Administrative Nurse D, revealed residents were assessed by nursing staff for use of positioning rails and if a resident requested them to staff members, she would expect nursing staff to initiate the assessment for appropriateness and safety concerns. The facility policy Accidents, Bed Safety-Bed Rails, dated 09/2023, instructed staff to assess for appropriateness of positioning devices and the devices may be used at the resident's request to increase the resident's sense of security or if an assessment and consultation with the attending physician determined the need to help manage a medical symptom, help the resident reposition, move in bed and transfer. The facility failed to assess the R4's need for positioning devices to decrease pain when repositioning and to increase independence.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 52 residents with 16 sampled for review. Based on observation, interview, and record review, the facility failed to complete an accurate Minimum Data Set (MDS) for one Resident (R) 25, regarding opioid medications (a powerful pain-reducing medication). Findings included: - Review of Resident (R) 25's Electronic Medical Record (EMR) revealed a diagnosis of chronic pain (pain which persists for a long period). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. She received scheduled and as needed (PRN) medication and reported occasional pain which affected her sleep and day to day activities. She reported the worse pain in the past five days was a four on the one to ten pain scale. The MDS inaccurately documented the resident did not receive opioid medication (a powerful pain-reducing medication). The Pain Care Area Assessment (CAA), dated 12/22/23, documented the resident received Fentanyl (an opioid medication) every (Q) 72 hours. The Quarterly MDS, dated 03/23/24, documented the resident had a BIMS score of 15, indicating intact cognition. She received scheduled and PRN pain medications and reported occasional pain which rarely, if ever, affected her sleep or day to day activities. She reported the worse pain in the past five days was a five on the one to ten pain scale. The MDS inaccurately documented the resident did not receive opioid medication. The Care Plan for pain, revised 04/01/24, instructed staff the resident received a Fentanyl pain patch for chronic pain. Staff were to administer the patch and remove, per physician's orders. Review of the resident's EMR revealed the following physician's order: Fentanyl patch (a medication administered through a patch on the skin used in the management and treatment of chronic pain) 72 hour, 100 micrograms (mcg) per hour, transdermally (medication absorbed through the skin), every (Q) 72 hours, for pain, ordered 09/21/23. Review of the resident's Medication Administration Record (MAR) from, 12/01/23 through 05/28/24, revealed the resident received the medication, as ordered. On 05/29/24 at 06:49 AM, Administrative Nurse D confirmed the Annual MDS, dated [DATE] and the Quarterly MDS, dated [DATE], were inaccurately coded as the resident had received an opioid medication during the lookback period of the assessments. The facility utilized the Resident Assessment Instrument (RAI) for accurate completion of MDSs. The facility failed to complete two accurate MDSs for this dependent resident who received an opioid medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 52 residents with 16 sampled, including four residents reviewed for accident hazards. Based on observation, interview, and record review the facility failed to ensure fall interventions were maintained for Resident (R)13. This placed the resident at increased risk for further falls, injury, and pain. Findings included: - Review of Resident (R)13's Electronic Medical Record revealed diagnoses that included Huntington's disease (rare abnormal hereditary condition characterized by progressive mental deterioration; a disabling central nervous system movement disorder), major depressive disorder (major mood disorder), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of four, which indicated severe cognitive impairment. The resident had two or more nonmajor injury falls since the prior assessment. The Falls Care Area Assessment (CAA), dated 12/21/23, assessed the resident had repeated falls, weakness, lack of coordination, unsteadiness on his feet, and muscle weakness. The resident was independent for most activities of daily living and used a walker for mobility. The resident sustained two falls since the last assessment. The Quarterly MDS dated 03/22/24, assessed the resident with a BIMS score of four, and the resident sustained two noninjury falls, and one nonmajor injury fall since the last MDS. The Care Plan, reviewed 04/07/24, instructed staff the resident had a fall when he attempted to sit on the toilet in his bathroom. Due to the progression of the resident's Huntington's disease, the resident had increased fall incidents, did not use his walker, or call for staff assistance. The care plan instructed staff to ensure the nonskid strips in the bathroom in front of the toilet and by his recliner were in place; and ensure fall mats were in place. Observation on 05/22/24 and 05/23/24 revealed nonskid strips in front of R13's toilet. One of the strips contained a worn area approximately 10 inches in length by two inches in width. During an interview on 05/28/24 at 02:15 PM, Certified Nurse Aide (CNA) M revealed the resident often got up and ambulated without his walker or calling for staff assistance. CNA M stated the resident did have nonskid strips in front of his chair and in front of the toilet in the bathroom. During an interview and observation on 05/29/24 at 11:06 AM revealed one nonskid strip not adhered to the floor in the resident's bathroom. Housekeeping Staff V stated she cleaned the resident bathroom earlier as the resident soiled the floor. Housekeeping Staff V stated staff cleaned the bathroom frequently as the resident soiled the floor, and spits tobacco. During an observation on 05/29/24 at 01:30 PM, Maintenance Staff U confirmed the nonskid strip was not sticking to the floor, due to wetness. Maintenance Staff U stated at that time that he replaced the strip earlier and would apply a new one. During an interview on 05/29/24 at 02:15 PM, Administrative Nurse D revealed she expected staff to notify maintenance of the need for nonskid strip replacement and ensure the strips adhered to the floor. The facility lacked a policy for inspection of nonskid strips. The facility failed to ensure R13's bathroom contained nonskid strips in good working order to decrease the risk of falls as care planned.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 52 residents with 16 residents sampled, including five residents reviewed for unnecessary medications. Based on interview and record review, the facility failed to ensure one Resident (R) 25 remained free from unnecessary medications related to the failure to administer as needed (PRN) medications for lack of bowel movements (BM) for longer than three days. Findings included: - Review of Resident (R) 25's Electronic Medical Record (EMR) revealed a diagnosis of constipation (inability to pass stool). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. She was dependent on staff for toileting needs, had no behaviors, and rejected cares one to three days of the assessment period. She was occasionally incontinent of bowel and had no constipation. The Behavioral Symptoms Care Area Assessment (CAA), dated 12/22/23, documented the resident would frequently refuse bowel interventions for constipation and would hold her bowels for several days choosing not to use the bedpan to have a bowel movement (BM). The Quarterly MDS, dated 03/23/24, documented the resident had a BIMS score of 15, indicating intact cognition. She had no behaviors and refused cares one to three days of the assessment period. She was dependent on staff for toileting needs and was always incontinent of bowel. The Care Plan for constipation, revised 04/01/24, instructed staff the resident was at risk for constipation due to decreased mobility and medication side effects. Staff were instructed to follow the facility bowel protocol for bowel management and notify the nurse if the resident had difficulty with hard stools. The nurse was to monitor the electronic documentation system daily for no BM in three days and to follow-up as needed. Staff were to record all BMs, each day. Review of the resident's electronic medical record (EMR), from 05/01/24 through 05/27/24, revealed the resident had no behaviors. Review of the resident's EMR revealed the following physician's orders: Colace (a stool softener used to soften stool and ease the passing of stool) 100 milligrams (mg), by mouth (po), twice daily (BID), for constipation, ordered 06/30/21. Lactulose oral solution (a laxative used to treat constipation) 10 grams (gr)/15 milliliters (ml), 15 ml po, every day (QD), for constipation, ordered 10/11/23. Milk of Magnesia (MOM-a laxative) 30 cubic centimeters (cc), po, QD as needed (PRN), for constipation, ordered 06/30/21. Bisacodyl suppository (a laxative), 10 mg rectally, QD PRN, for constipation, ordered 11/17/23. Fleets disposable enema (a laxative), rectally, one every (Q) 24 hours PRN, for constipation, ordered 03/08/21. Review of the resident's EMR, from 04/24/24 through 05/27/24, revealed the following concerns: The resident did not have a BM from 04/28/24 through 05/04/24, for a total of six days with staff failing to administer a PRN BM medication or enter a nurse's note documenting the resident's refusal for a bowel management intervention. The resident did not have a BM from 05/06/24 through 05/13/24, for a total of six days with staff failing to administer a PRN BM medication or enter a nurse's note documenting the resident's refusal for a bowel management intervention. The resident did not have a BM from 05/19/24 through 05/23/24, for a total of four days with staff failing to administer a PRN BM medication or enter a nurse's note documenting the resident's refusal for a bowel management intervention. On 05/28/24 at 07:51 AM, Licensed Nurse (LN) G stated the resident had constipation from time to time but would refuse the ordered PRN medications. On 05/29/24 at 12:05 PM, Administrative Nurse D communicated Administrative Nurse E would review the bowels on the electronic documentation system Monday through Fridays for any resident who may require a PRN medication for bowels. Administrative Nurse E would then communicate the findings to the staff for follow-up. Staff did not document on the Medication Administration Record (MAR) when a resident refused a PRN medication, but it was the expectation for them to complete a brief nurse's note if the intervention was offered and declined. The Facility Protocol for Bowel Management, undated, included: If a resident does not have a BM for three days, staff were to give MOM. If a resident does not have a BM for four days, staff were to give a suppository. If a resident does not have a BM for five days, staff were to give an enema, notify the PCP and make a nurses note. If the resident refuses the protocol, staff were to make a brief nurse's note stating the intervention was offered and refused. The facility failed to keep this dependent resident free from unnecessary medications by failing to administer PRN medications for the lack of BMs.

The facility reported a census of 52 residents. Based on observation and interview the facility failed to ensure sanitary food storage in the therapy room refrigerator and failed to maintain the microwave in a sanitary manner. Findings included: - Observation, on 05/29/24 at 01:30 PM, with Maintenance Staff U, revealed unlabeled, undated hamburger patties in the therapy room refrigerator freezer. The freezer also contained two medical devices for cold therapy and multiple cold packs. The lower shelf of the freezer contained a purple sticky substance. The refrigerator contained the following items of concern: 1. An undated open container of almond milk with an expiration date of 12/20/23. 2. Four containers of yogurt with expiration date of 12/23/23 and a multi pack of 24 small containers of yogurt with expiration dated of 12/23/23. 3. A sack which contained various foods in undated, unmarked Styrofoam containers with a date of 04/10/24, found on a small bag of chicken strips. 4. A 32-ounce opened container of chicken broth, without an open date. Observation on 05/29/24 at 01:30 PM, of the microwave in the therapy room revealed the interior with rusted surfaces along the perimeter of the interior, and the interior upper surface with splatters of unidentified substances. Interview with Maintenance Staff U on 05/29/24 at 01:30 PM, confirmed the above items, and stated housekeeping was responsible for daily cleaning of the therapy room, and this would include the refrigerator and microwave. Interview, on 05/29/24 at 02:15 PM, with Therapy Consultant GG, confirmed the above areas of concern, and stated therapy did use the kitchen equipment for resident rehabilitation purposes. Therapy Staff GG stated he did not know who put the food in the freezer/refrigerator. The facility policy Foods Brought in by Family/Visitors dated 10/2023, instructed staff to store perishable foods in resealable containers wit tightly fitting lids in the refrigerator. Staff to label the containers with the resident's name, identification of the item and use by date. The food service staff and nursing staff are responsible for discarding perishable foods on or before the use by date. The facility lacked a policy for cleaning the microwave. The facility failed to ensure staff maintained the therapy room refrigerator, freezer and microwave in a sanitary manner and failed to ensure food items did not exceed the use by date to prevent food borne illness amongst the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 61. The sample included two residents reviewed for abuse. Based on interview, observation and record review, the facility failed to ensure the safety of Resident (R) 2, severely impaired cognition and required total dependence with ADLs, remained free of abuse by R1 with intact cognition, who entered the Advance Alzheimer's Care Unit (AACU) and entered the room of R2, A nurse heard R2 call out and found R1 in R2's room in his wheelchair with his hand on top of R2's incontinent brief rubbing her perineal area. R2 was calling out, No, stop. LN G immediately removed R1 from R2's room and returned R1 to his room on the Advanced Care Unit (ACU) where he resided. Findings included: - R1's 06/06/23 signed Physician Order Sheet (POS), documented the facility admitted the resident on 03/31/23. The resident's diagnoses included osteoarthrosis (chronic arthritis without inflammation) of the right knee, hypotension (low blood pressure), malignant (cancerous) neoplasm (tumor) of prostate (male reproductive gland), and major depressive disorder (mood disorder). R1's admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated an intact cognition. R1's did not display negative behaviors of any type. The resident required two-person extensive assist with bed mobility and ambulating, total dependence with transfer and toileting and utilizing the sit to stand mechanical lift. The resident mobility devices were a walker and wheelchair. The 04/03/23 Baseline Care Plan, revealed R1 required two-person to total dependence for bed mobility, transfer, and toileting. The Revised Care Plan, dated 06/24/23, revealed the resident demonstrated inappropriate sexual behavior at times due to poor impulse control. Staff were to guide the resident to where peers were socializing appropriately. To set limits with behavior and to remind the resident that touching confused or non-consensual individuals was not acceptable. The staff will supervise the resident while out of his room and will not be allowed back on the AACU. The 06/17/23 Progress Note documented the resident made inappropriate comments to a Certified Nurse Aide (CNA). CNA reported to this nurse that the resident said to her, You have some pretty pink panties. The next time the CNA came to this nurse and reported the resident making more inappropriate comments to her stating the resident said, Can I put my hand and rub your [NAME] under those pink panties. CNA stated to resident No, that's not something we are going to be doing. Resident stated Come on, it won't hurt to do it. I just want to rub your [NAME]. On 06/24/23, the SBAR (Situation, Background, Assessment, Response), documented the nurse was taking trash to the shower room when she heard a resident say Stop, No. The nurse went to R2's room (on the AACU) and saw R1 in the room and rubbing R2 in the peri area on top of her incontinent brief. Background: Resident has been having increased sexual behaviors towards staff. Assessment (RN)/Appearance (LPN): The nurse told the resident to get out of the peer resident's room, that he did not need to be in there doing inappropriate things. The staff assisted the resident back to the (ACU) Advanced Care Unit (R1's residing unit) and placed the resident in the recliner in the room. The staff placed R2 on 1:1 monitoring. The staff notified the resident's primary care provider who ordered medication change with addition of Prozac 10 mg daily and the resident would not be allowed to go on the Advanced Alzheimer's Care Unit. A physician order for R1, dated 06/24/23 instructed the staff to administer the resident Prozac Oral Capsule 10 MG; Give one capsule by mouth one time a day for depression. On 6/28/23 at 10:01 AM Administrative Staff A reported R1 resided on the (ACU) Advance Care Unit, and his spouse resided in the (AACU) Advanced Alzheimer's Care Unit. R1 was on the AACU visiting his spouse as he had prior. The charge nurse was exiting the shower room and heard R2 yelling and when she entered her room R1 had his hand on top of her brief. The nurse immediately removed R1 from R2's room. The nurse transferred R1 back to ACU where he resided to his room. Another staff member assisted her to transfer him to his recliner, staff placed him on 1:1, the resident's primary care physician was notified, he was not allowed on the AACU and will be supervised by staff while out of his room. On 06/28/23 at 11:22 AM Licensed Nurse (LN) G reported that she was exiting the shower room on ACCU when she heard R2 yell no, stop, when she entered R2's room, she observed R1 sitting in his wheelchair with his hand on top of R2's brief in the peri area. LN G immediately removed R1 from R2's room and transferred R1 back to the ACU where he resided. LN G reported that she notified Administrative Staff A and the resident's Primary Care Provider (PCP) who gave a new order for Prozac 10 mg one time a day, place the resident 1:1 for 72-hours and the resident would not go back into AACU. The facility Abuse Prevention policy, revised 08/2022, the residents have a right to be free from abuse ie sexual abuse. Sexual abuse is defined as non-consensual sexual contact of any type with a resident.' The facility failed to ensure R2 remained free of sexual abuse when Resident 1 entered her room and placed his hand on top of her incontinent brief in the peri area.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 68 residents with 22 sampled which included one resident reviewed for choices. Based on observation, interview, and record review, the facility failed to provide individual choices for the one sampled dependent Resident (R)55 related to his preferences for clothing selection. Findings included: - Review of the resident's (R)55's, Physician Orders, dated 08/03/2022, revealed diagnoses which included, obstructive pulmonary disease, severe sepsis, acute kidney failure, abnormal results of liver function, pneumonia, cellulitis of right lower limb, type 2 diabetes mellitus with hyperglycemia, and morbid obesity. The admission Minimum Data Set (MDS) dated [DATE], documented the Brief Interview for Mental Status (BIMS) score of 15, which indicated cognitively intact. He required extensive assistance of staff for bed mobility, dressing, personal hygiene, and was totally dependent on staff for transfers. The resident weighed 453 pounds. He reported it was very important to select his clothes to wear. The Quarterly MDS, dated 08/15/22 documented the only change from his prior assessment was his decline in weight to 413 pounds. The ADL Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 05/23/22, documented the resident required limited to extensive assistance of one to two staff with dressing. The Care Plan, (CP) dated 09/08/22, directed staff the resident had activity intolerance and fatigue. He required limited to extensive assistance of one to two staff with dressing. On 09/12/22 at 11:14 AM, the resident rested on the bariatric (larger) bed wearing a hospital gown. The resident reported he had regular clothes in his closet. The staff never offered him an opportunity or assistance to dress in his clothes. He stated he had not worn street clothes since he admitted to the facility. The resident stated he would prefer to wear his regular clothes instead of wearing a hospital gown all the time. On 09/14/22 at 07:58 AM, the resident was in bed sleeping, wearing a hospital gown. On 09/15/22 at 09:58 AM, the resident was in his bed sleeping. He was wearing a hospital gown. Certified Medication Aide (CMA) T stated the resident wore a hospital gown all the time and she did not know he had clothes in his closet. She stated she had not heard staff offer him assistance with dressing in regular clothing. She reported that residents were interviewed about their preferences on admission and should have their preferences honored. On 09/15/22 at 08:53 AM, Licensed Nurse (LN) H stated he had not seen the resident dressed in regular clothes. He confirmed the hospital gown was more convenient for the staff to provide care due to the resident's obesity and for use of the urinal and bedpan. LN H reported that residents should be able to choose the clothing they want to wear as a preference. On 09/15/22 at 02:34 PM, Administrative Nurse D reported that residents were interviewed on admission regarding their preference. She stated the staff should honor the resident's preferences. The facility lacked a policy which addressed the residents clothing preferences. The facility failed to provide this dependent resident with his individual choices for his preferences for clothing selection instead of the hospital gown.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 68 residents, with 22 sampled. Based on observation, interview, and record review, the facility failed to accurately complete a Comprehensive Assessment, and Quarterly Assessment, respectively related to the use of a Continuous Positive Air Pressure (CPAP) machine for one sampled Resident (R)55. Findings included: - Review of the resident's (R) 55's, Physician Orders, dated 08/03/2022, revealed diagnoses which included, chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The admission Minimum Data Set (MDS) dated [DATE], documented the Brief Interview for Mental Status (BIMS) score of 15, which indicated cognitively intact. He exhibited difficulty breathing and/or was short of breath (SOB) on exertion, when sitting at rest, and when lying flat. The MDS lacked documentation of the resident's use of a CPAP machine. The Quarterly MDS, dated 08/15/22, lacked any changes from the prior assessment and continued with failure to identify the resident's use of the CPAP machine. The Care Area Assessment (CAA), dated 05/23/22, documentation lacked address of the use of a CPAP machine for ventilation. The Care Plan, (CP), dated 09/08/22, lacked address of the use of the resident's CPAP for ventilation. The Physician Orders, dated 08/03/2022, lacked an order for use of the resident's CPAP machine, care, and maintenance of the CPAP equipment. On 09/12/22 at 11:14 AM, the resident was lying in bed. The CPAP hose and mask were laying across the bedside table, in direct contact with the bedside table. There was not a storage bag nor container available to store the mask when not in use, to prevent cross contamination. Furthermore, two undated gallon jugs identified as containers for distilled water sat on the bedside table, one was empty. A used undated humidifier bottle was sitting on the bedside table. On inquiry the resident stated the CPAP machine had not been cleaned since his admission. Additionally, he stated the facility had not provided a bag to store the CPAP mask when not in use. On 09/14/22 at 07:58 AM, the resident was sleeping in bed with his CPAP mask in place on his face. Three-gallon jugs labelled distilled water sat on the bedside table. (One empty, one 2/3 filled with distilled water, and the third jug was not open). None of the gallon jugs had a label with an opened date. A used, unlabeled, empty humidifier bottle sat on the bedside table. On 09/14/22 at 08:08 AM, Certified Nurse Aide (CNA) OO, confirmed above, she removed the empty gallon jug and used humidifier bottle. She placed a storage bag for the CPAP mask when not in use. On 09/15/22 at 08:53 AM, Licensed Nurse (LN) H verified the resident used the CPAP machine when sleeping during the day and night. LN H confirmed the resident lacked a physician order for use of the CPAP, and the facility should provide a storage bag for the CPAP mask when not in use. He verified the care plan lacked documentation to direct the staff in the appropriate storage and use of the CPAP. On 09/15/22 at 9:34 AM, Administrative Nurse D confirmed the resident lacked a physician's order for the CPAP. Additionally, she reported the people who have CPAP should have a physician's order. She stated she expected the nurses to clean the CPAP, machine at least weekly. Administrative Nurse D verified the resident's medical record lacked an order for CPAP, lacked documentation of CPAP on either of the above MDS, and lacked care plan to direct the staff in the use and maintenance of the CPAP. The CPAP mask should be stored in bag when not in use and the distilled water should be labelled with the date when opened. She agreed the MDS did not document the resident's use of CPAP on either MDS as expected. The facility failed to accurately complete a Comprehensive Assessment, and Quarterly Assessment, respectively related to the use of a Continuous Positive Air Pressure (CPAP) machine for the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 68 residents with 22 selected for review. Based on observation, interview and record review, the facility failed to develop comprehensive person-centered care plans for one of the sampled residents, Resident (R)30 with range of motion impairments and the lack of a restorative program. Findings included: - Review of Resident (R)30's Physician's Order Sheet, dated 07/28/22, revealed diagnoses included stroke (sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), muscle weakness, and chronic kidney disease. The admission Minimum Data Set (MDS), dated [DATE], assessed the resident with severely impaired cognitive status, and was totally dependent on two staff for bed mobility and transfers. The resident had bilateral (both) impairment of upper and lower extremities. The ADL (Activity of Daily Living) Functional/Rehabilitation Potential Care Area Assessment(CAA), dated 07/24/22 did not trigger for this resident. The Care Plan, reviewed 07/31/22, instructed staff for physical and occupational therapy to evaluate and treat. The care plan instructed staff the resident required turning and repositioning every two hours. The care plan failed to identify the resident's impairmed upper and lower extremity range of motion ability and lacked a restorative program. Review of the resident records revealed the resident lacked a restorative program. Observation, on 09/13/22 at 07:49 AM, revealed Licensed Nurse (LN) H stated the physician started her on medications for gout (inflammation of the joints). The resident had heel protective boots on bilaterally (both feet). The resident moved her right and left arm and was able to grab onto objects. The resident did not move her lower extremities which were encased in pressure relieving boots to her mid-calf area. Observation, on 09/13/22 at 01:32 PM, revealed Certified Nurse Aide (CNA) O provided a bed bath to the resident. The resident moved her arms and hands. CNA O stated she did not remove the heel protective boots to wash or provide any movement to the resident's lower extremities. Interview, on 09/14/22 at 01:42 PM, with CNA M, revealed the resident did not have a restorative program. On 09/15/22 at 11:30 AM, with Administrative Nurse D, confirmed the care plan lacked interventions and strategies for improvement/maintenance of the resident's impairments in her upper and lower extremities. The facility policy F656, F657, F658 Comprehensive Care Plans, revised 08/2022, instructed staff an individualized comprehensive person-centered care plan that includes measurable objectives and time frames to meet the resident's medical, nursing, mental, cultural and psychological needs is developed for each resident. The facility failed to develop a comprehensive person-centered care plan to address this resident's impairments in functional range of motion in her extremities to maintain/improve range of motion.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 68 residents with 22 selected for review including four residents reviewed for activities of daily living (ADL's). Based on observation, interview, and record review, the facility failed to ensure three of the sampled residents, Resident (R)4, R39, and R46, who required staff assistance, received appropriate personal hygiene assistance for cleaning and trimming of their fingernails. Findings included: - The Medical Diagnosis tab located in the electronic medical record (EMR) for Resident (R)4 included diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), cerebral infarction (stroke - damage to tissues in the brain due to a loss of oxygen to the area), and diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin). The Quarterly Minimum Data Set (MDS) dated [DATE] for R4 assessed him with a short-term and a long-term memory problem, impaired decision making, and he did not reject care. He was totally dependent on one staff member for personal hygiene and totally dependent of two or more staff for bathing. The Annual MDS dated 06/02/22 for R4 revealed no changes from the prior assessment. The Care Plan dated 09/11/22, included R4 had limited physical mobility related to dementia and he was to be showered on scheduled days before the evening meal. R4 had a diagnosis of diabetes mellitus and the staff were to refer the resident to a podiatrist/foot care nurse to monitor/document foot care needs and to cut long nails. The Task tab located in the EMR revealed a preference for showers on Tuesdays and Saturdays in the evening, and he received some type of bath on 09/03/22, 09/06/22, and 09/13/22. The Skin Monitoring CNA Shower/Bath Review Sheet revealed on 08/09/22 the staff cleaned and trimmed R4's nails. The staff failed to clean/trim on 08/16/22, R4 refused for nails to be cleaned/trimmed on 08/20/22, 08/23/22, and 08/30/22. The staff failed to clean/trim his nails on 09/03/22, 09/06/22, and 09/10/22, indicating the last time the staff provided fingernail care was on 08/09/22. On 09/12/22 at 04:28 PM, R4 was resting in his room and with long fingernails. On 09/13/22 at 07:47 AM, R4 was sitting up in a reclining wheelchair in the dining room, left hand covered by a clothing protector, right thumb nail was long with a brown substance underneath it. On 09/13/22 at 03:35 PM, R4 was resting in bed, fingernails continued to be long. On 09/14/22 at 10:19 AM, Certified Nurse Aide (CNA) O stated that fingernail cares were done with showers and if a resident was diabetic then they would be referred to the nurse for fingernail care. CNA O stated R4 received a shower twice weekly in the evening time. CNA O stated when a shower was given the staff documented the shower in the electronic record and on the paper shower sheet which then was given to the charge nurse. CNA O stated that R4 had received a shower yesterday. On 09/14/22 at 10:28 AM, CNA LL stated fingernail care was normally done with a shower, cleaning and clipping. If a resident was diabetic, then the nurse would do the nail care. The staff chart in the electronic record when a shower was given and on the paper shower sheet. Both places have an area to mark if the resident refuses. On 09/14/22 at 02:50 PM, Licensed Nurse (LN) H stated the nurses trim fingernails, did not think there was a schedule, and the CNAs would let them know when nail care needed to be done. On 09/14/22 at 04:44 PM, Administrative Nurse D stated the CNAs were responsible for trimming and cleaning fingernails and the activity director has a monthly Mani/pedi day. If a resident was a diabetic, then the nurse would perform the nail care, but anyone can clean the nails. Administrative Nurse D stated fingernails should be cleaned on bath days and in between if needed and would be documented on the bath sheet. Administrative Nurse D stated R4 will fight the staff for nail care. On 09/14/22 at 04:59 PM, observed R14 in his room resting in bed, fingernails of both hands long and with a brown colored substance under some of the fingernails. On 09/14/22 at 05:01 PM, CNA NN stated she has helped R4 with his showers and he will yell out at times but not physically fight the staff in the shower and will allow his nails to be trimmed and cleaned if you talk to him sweetly. CNA NN stated the staff document the fingernail cleaning and trimming on the paper shower sheet. On 09/15/22 at 11:02 AM, Administrative Nurse F stated R4 was a diabetic and the CNAs let the nurses know when nail care needs to be done, and at one time he had an order to clip every Saturday but did not see that in his EMR now. Administrative Nurse F stated he does refuse nail care at times, and they distract him with chocolate or a banana, but it does not always work. Administrative Nurse F stated the staff did get to his nails last night. On 09/15/22 at 01:47 PM, Administrative Nurse D stated the nurses should trim his nails since he is diabetic, and R4 was a chore to get his nails done. Administrative D stated a lot of the times he would be offered ice cream while doing his nails but that does not always do the trick. The facility did not provide a policy for fingernail care. The facility failed to provide appropriate personal hygiene assistance needed for trimming and cleaning this dependent resident's fingernails. - The Medical Diagnosis tab located in the electronic medical record (EMR) for Resident (R)39 included diagnoses of hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body) following cerebral infarction (stroke - damage to tissues in the brain due to a loss of oxygen to the area) affecting right dominant side and diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin). The Annual Minimum Data Set (MDS) dated [DATE] assessed R39 with a Brief Interview of Mental Status score of 13, indicating intact cognition. He did not reject care, was dependent of two or more staff for personal hygiene and required physical help of one staff for part of bathing activity. R39 had a range of motion impairment to one side of his upper extremities. The Quarterly MDS dated 07/26/22, for R39 assessed him with a BIMS score of 12, indicating moderate cognitive impairment. He did not reject care, required extensive assistance of one staff for personal hygiene, and bathing did not occur during the assessment period. There were no changes to R39's upper extremity range of motion status. The Activities of Daily Living [ADL] Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 01/05/22 revealed R39 was right side dominant which was the side affected with paralysis and he was dependent on one to two staff for personal hygiene cares. R39 preferred to have his showers on Monday and Thursday evenings. The Care Plan dated 07/30/22, for R39 revealed he preferred to have his showers on Monday and Friday during the day and sometimes would take only one bath per week. The staff were to offer a sponge bath in the room if he refused a shower. The care plan included he was dependent on one to two staff for personal hygiene. The Skin Monitoring CNA Shower/Bath Review Sheet for R39 revealed the staff assisted with a shower or partial bed bath on these days but failed to clean and trim fingernails: 08/17/22, 08/22/22, 08/29/22, 09/05/22, and 09/12/22. On 09/12/22 at 11:16 AM, observed R39 with long fingernails and a brown substance present under the nails on the left hand. On 09/12/22 at 11:17 AM, R39 stated he gets a shower once a week. On 09/13/22 at 12:40 PM, R39 continued to have long fingernails with a brown substance under the nails of the left hand. On 09/14/22 at 10:11 AM, R39 was sitting up in his wheelchair in his room, his fingernails continue to be long on both hands and a brown substance was present under his fingernails of his left hand. On 09/14/22 at 10:19 AM, Certified Nurse Aide (CNA) O stated that fingernail cares were done with showers and if a resident was diabetic then they would be referred to the nurse for fingernail care. CNA O stated when a shower was given the staff documented the shower in the electronic record and on the paper shower sheet which then was given to the charge nurse. CNA stated R39 was on the schedule for a shower on Monday and Friday on the day shift and he received a shower on 09/12/22. On 09/14/22 at 10:28 AM, CNA LL stated fingernail care was normally done with a shower, cleaning and clipping. If a resident was diabetic, then the nurse would do the nail care. The staff chart in the electronic record when a shower was given and on the paper shower sheet. Both places have an area to mark if the resident refuses. On 09/14/22 at 02:50 PM, Licensed Nurse (LN) H stated the nurse's trim fingernails, did not think there was a schedule, the CNAs would let them know when nail care needed to be done. On 09/14/22 at 02:55 PM, LN H observed fingernails of R39 and confirmed they needed trimmed as well as R39 confirmed at that time also. On 09/14/22 at 04:44 PM, Administrative Nurse D stated the CNAs were responsible for trimming and cleaning fingernails and the activity director has a monthly Mani/pedi day. If a resident was a diabetic, then the nurse would perform the nail care, but anyone can clean the nails. Administrative Nurse D stated fingernails should be cleaned on bath days and in between if needed and would be documented on the bath sheet. The facility did not provide a policy for fingernail care. The facility failed to provide appropriate personal hygiene assistance needed for trimming and cleaning this resident's fingernails who required staff assistance due to dominant side hemiparesis. - Review of the Resident (R)46's, Physician Orders, dated 08/03/22, revealed diagnoses which included, schizoaffective disorder (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), dementia (progressive mental disorder characterized by failing memory, confusion) with behavioral and psychotic (any major mental disorder characterized by a gross impairment in reality testing) disturbances, anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disturbances, and lack of coordination. The Significant Change in Status Minimum Data Set (MDS) dated [DATE], documented Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. She required supervision of staff for toilet use, personal hygiene, and physical help for bathing. The ADL Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 08/04/22, documentation included the resident required staff supervision with activities of daily living (ADLs). She preferred to shower on Mondays, Wednesdays and Fridays during the day. The resident required limited to extensive assistance of one staff for bathing. Review of the Bathing Task, in the Electronic Medical Record, (EMR), revealed documentation that the resident received a bath on 09/12/22 (Monday) and 09/14/22 (today Wednesday). Review of Nail Trimming and Cleaning Tasks, documentation in the EMR for the previous 30 days revealed no data documented. On 09/12/22 at 12:22 PM, the resident's fingernails were one to two inches long, ragged, with a black thick substance beneath them. She stated she thought her nails were to long. On Wednesday, 09/14/22 at 10:44 AM, the resident sat in her w/c in her room. Her fingernails were one to two inches long, ragged, with the same black thick substance beneath them. Certified Medication Aide (CMA) RR confirmed the resident's nails were soiled, long and ragged. CMA RR reported the nails should be cleaned and trimmed with baths and as needed. Additionally, nails should be cleaned before and after meals if indicated. CMA RR stated the substance under the resident's fingernails was probably food. The resident stated she had just gone to the bathroom and that she would let the staff clean and trim her fingernails. On 09/14/22 at 10:44AM, CMA T reported the staff normally clean and trim nails with the residents' showers. She confirmed the resident needed her nails trimmed and cleaned. She stated the staff should make sure the resident's hands were clean and fingernails trimmed before eating and after going to the bathroom. Staff should document in the EMR baths and nail care in the Tasks section when they provided nail care. CMA T commented that the resident's fingernails were longer than she would expect if the resident had received appropriate nail care on her shower day on 09/12/22, two days prior. On 09/14/22 at 03:07 PM, Administrative Nurse E reported the CNA/CMAs provide nail care for the residents with baths and as needed. The CNAs should document the nail care on the shower sheets. On 09/14/22 at 04:49 PM, Administrative D, reported that staff should clean resident's nails when needed and with their bath or shower. The resident's bathing schedule was in the EMR, and the staff should fill out bath sheets indicating the fingernails are cleaned and trimmed. The staff should not serve residents food without ensuring their fingernails are cleaned. Administrative Nurse D agreed the resident was dependent on staff for nail care and she did not usually resist cares. The facility lacked a policy to address the provision of nail care for residents. The facility failed to provide the necessary services to maintain personal hygiene related to nail care for this dependent resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 68 residents with 22 selected for review which included one resident selected for review of hospice services. Based on observation, interview and record review, the facility failed to coordinate care between hospice services and the facility to ensure the resident's advance directive for no resuscitative measures determined and carried out. Findings included: - Review of Resident (R)113's Physician Order Sheet, dated [DATE], revealed diagnoses that included malignant neoplasm (tumor) of the lung, adult failure to thrive and osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain.) The resident admitted to the facility on [DATE] with an order for hospice services. The admission Minimum Data Set (MDS), dated [DATE], assessed the resident with severely impaired cognitive status with altered level of consciousness. The resident required extensive assistance of two staff for bed mobility with no impairment in functional range of motion in the lower and upper extremities. The resident was incontinent of bowel and bladder. The resident had a life expectancy of less than six months and was on hospice care. The Psychosocial Well-Being Care Area Assessment (CAA), dated [DATE], assessed the resident was at risk for decline due to his end of life status. The Cognitive Loss/Dementia CAA, dated [DATE], assessed the resident was on hospice services and he and the staff felt like he was at the end of his life. The care plan, revised [DATE], instructed staff the resident requested CPR (Cardio Pulmonary Resuscitation) measures. Staff instructed to communicate the resident's choice to all appropriate staff. The care plan instructed staff the resident on hospice care due to end of life process. This care plan instructed staff the resident had a terminal prognosis related to malignant neoplasm of the lung and staff instructed to encourage the resident to express his feelings and observe for pain. Staff instructed to work cooperatively with the hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs were met. Review of the electronic medical record, revealed an advanced directive with a named DPOA (durable power of attorney) for health care and financial decisions. The medical record lacked a DNR (Do Not Resuscitate) document . Interview, on [DATE] at 06:11 PM, with Administrative staff A and Administrative Nurse D, revealed they thought the resident wanted a full code even though the hospital records indicated the resident elected a DNR status. Interview, on [DATE] at 02:49 PM, with Social Service Staff X, revealed the resident was unable to sign a DNR and was not aware if he had a DPOA for healthcare. Furthermore, Social Service Staff X, stated only a Blood relative could sign the DNR form and the resident was estranged from family members. Interview, on [DATE] at 10:17 AM, with Hospice Nurse HHH, revealed hospice provided a physician's order for DNR on [DATE] and did not know the facility required a facility specific form signed by the DPOA for healthcare or resident if able. Observation, on [DATE] at 11:30 AM, revealed the resident's cardiac activity ceased and Licensed Nurse H began CPR and called emergency medical services who terminated the CPR at 12:05 PM. Interview, on [DATE] at 01:23 PM with Administrative Nurse D, stated the DNR form that the facility used needed to be signed by a blood relative. Administrative Staff A stated the facility had a specific form for DNR and the DPOA for healthcare and physician needed to sign the specific form for it to be effective. Interview, on [DATE] at 08:30 PM, with the DPOA, revealed he was under the impression that all the needed paperwork was signed. He stated the resident discussed with him prior to becoming incoherent, the desire for DNR. The DPOA stated hospice explained their services and he thought the resident would not be resuscitated as per his request. The DPOA thought he had signed all the necessary paperwork to secure this desire. Interview, on [DATE] at 09:40 AM, with Hospice Social Worker III, revealed the resident and the DPOA met with hospice representative while in acute care and both requested DNR status. Hospice Social Worker III sent the facility a signed Physician's Order dated [DATE] on [DATE], but the facility did not inform hospice of the need for another form with a Blood relative signature until [DATE]. The facility's policy for Hospice Program 684,849 and 552 revised 01/2020, instructed staff to clarify the resident's advanced directives and preferences for end -of- life planning and coordinate with the hospice provider. The facility failed to coordinate care with the hospice provider to ensure the resident's decisions for CardioPulmonary Resuscitation determined and carried out when this resident's cardiac activity ceased.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 68 resident with 22 selected for review, which included four residents reviewed for accidents. Based on observation, interview and record review, the facility failed to ensure safe transfer techniques for one resident (R) 34 of the four residents reviewed. Findings included: - Review of Resident (R)34's Physician Order Sheet, dated 08/02/22, revealed diagnoses included Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure) and dysphagia (swallowing difficulty). The Significant Change Minimum Data Set (MDS), dated [DATE], assessed the resident with severe cognitive deficit, constant inattention and altered level of consciousness. The resident was dependent on two staff for bed mobility and transfers. The resident had impairment in functional range of motion on one side of her upper and lower extremities. The Falls Care Area Assessment (CAA), dated 02/21/22, assessed the resident required staff assistance for stabilization. The Quarterly MDS, dated 07/31/22, assessed the resident with severe cognitive deficit with constant inattention. The resident was dependent on two staff for bed mobility and transfers. The resident had impairment in functional range of motion one side of her upper and lower extremities. The Care Plan, reviewed 08/04/22, instructed staff to ensure the resident had nonskid footwear. when ambulating. The resident was on a functional maintenance program to maintain range of motion in her upper and lower extremities. Staff instructed to provide passive range of motion to her extremities. The resident required one to two staff assistance with transfers and two staff for bed mobility. Observation, on 09/13/22 at 02:07 PM, revealed the resident seated in her wheelchair. Certified Nurse Aide (CNA) O and P changed the resident's shirt, then proceeded to transfer the resident to her bed. CNA O and CNA P placed their flexed elbows under the resident's axilla (arm [NAME]), and each held onto the back of the resident's pants by the waistband with their other hands. The resident's legs were drawn up and her feet did not touch the floor to pivot. Staff failed to apply a gait belt for the transfer. CNA P stated at that time that the resident was care planned to transfer with a mechanical lift or one or two persons. Observation, on 09/13/22 at 04:54 PM, revealed CNA PP and QQ prepared to transfer the resident from her bed to her wheelchair. CNA PP stated staff utilized a lift for transfers, then stated the resident was a one to two-person transfer. The resident's knees and elbows were in a flexed position. Staff did not put shoes, socks or a gait belt on the resident. The resident did not follow directions. Staff lifted the resident under her axilla and held onto the back waistband of her pants. The resident's feet did not touch the floor but remained in a flexed position. Observation, on 09/14/22 at 01:57 PM, revealed the resident seated in her wheelchair. CNA M and RR placed a gait belt on the resident and lifted the resident with the gait belt to transfer her into her bed. The resident did not bear weight and kept her legs in a flexed position during the transfer. CNA M confirmed the resident did not bear weight during the transfer, and staff should use a lift. Interview, on 09/14/22 at 04:46 PM, with Administrative Nurse E, revealed she would expect staff to use a gait belt with transfers and to notify her of issues with the resident's range of motion and inability to bear weight. The facility policy Safe Lifting and Movement of Residents, reviewed 05/2022, instructed staff to protect safety and wellbeing of staff and residents, staff to utilize appropriate techniques and devices to lift and move residents. Resident safety, dignity comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. Staff responsible for direct resident care will be trained in the use of manual gait/transfer belts, lateral boards and mechanical lifting devices. The facility failed to ensure staff utilized safe transfer techniques for this dependent resident to prevent accidents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 68 residents with 22 selected for review including two residents reviewed for urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag). Based on observation, interview, and record review, the facility failed to ensure one of the two residents, Resident (R)20's catheter drainage bag remained below bladder level and failed to drain the catheter bag in a sanitary manner to prevent urinary tract infection. Findings included: - The Medical Diagnosis tab located in the electronic record (EMR) for Resident (R)20 included diagnoses of infection and inflammatory reaction due to indwelling urethral catheter, overactive bladder, and a pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) stage four (full thickness tissue loss with exposed bone, tendon or muscle) of the sacral (area of the lower back near the spine) region. The Annual Minimum Data Set (MDS) dated [DATE] assessed R20 with a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition. She was totally dependent of two or more staff for toilet use. R20 had an indwelling catheter and a stage four pressure ulcer. The Quarterly MDS dated 07/05/22 assessed R20 with the same BIMS score. She required extensive assistance of two or more staff for toilet use and continued to have an indwelling catheter and a stage four pressure ulcer. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 04/13/22 revealed R20 had an indwelling catheter and a stage four pressure area to her sacrum. The staff were to position the catheter bag and tubing below bladder level. The Care Plan dated 09/04/22 revealed R20 had an indwelling catheter and a stage four pressure ulcer to her sacrum. The staff were to position the catheter bag and tubing below the level of the bladder. The Orders tab located in the EMR revealed on 08/15/22 an order for a catheter for a stage four sacral wound. The Medication Administration Record (MAR) located in the EMR for 07/2022 through 08/2022 revealed an order for the staff to administer Augmentin (medication used to treat bacterial infections), 875-125 milligrams (mg), orally, twice daily, for 14 administrations, for a urinary tract infection, starting 07/26/22. Prior to that, on 07/19/22, there was on order for Cipro (medication used to treat infections) 250 mg, orally, twice a day, for 10 administrations, for a urinary tract infection, completed on 07/24/22. On 09/13/22 at 07:35 AM, R20 rested in bed with her urinary drainage bag hanging from the frame of the bed in front of the dignity bag cover on the side of the bed away from the room doorway. On 09/13/22 at 02:18 PM, Certified Medication Aide (CMA) R and Activity Staff Z transferred R20 from the wheelchair to the bed with use of a mechanical lift. While connecting the lift sling straps to the mechanical lift and during the transfer R20 had urine present in the catheter tubing and Activity Staff Z observed holding the urinary catheter drainage bag above R20's bladder level. This included the time spent lowering her back down to the wheelchair and adjusting the lift sling and lifting her back up from the wheelchair. After R20 was in bed and while she was being turned to remove the lift sling out from under her, Activity Staff Z held the urinary catheter drainage bag above R20's bladder level. On 09/13/22 at 02:33 PM, Activity Staff Z stated the urinary catheter bag should be at bladder level during transfers and confirmed she had held it above bladder level. On 09/13/22 at 02:40 PM, CMA S emptied R39's urinary catheter drainage bag into a graduate dated 08/25/22 and with the word Dirty wrote on it. After draining the bag, he replaced the drain tubing back into the holder of the urinary catheter drainage bag without cleansing the drainage tubing. CMA S then took the graduate of the urine and emptied it into the toilet bowl tapping the side of the graduate to the inside of the toilet bowl against the toilet seat, which had dried brown splatters present to the bowl, then placed the graduate into a plastic bag hanging in the bathroom. Next to the dirty graduate bag was another bag hanging up with a graduate that had the word Clean wrote on the side. On 09/13/22 at 02:42, PM CMA S stated R20 would get a new graduate on 09/25/22, when the staff changed them out monthly. On 09/15/22 at 01:19 PM, Administrative Nurse D stated when the staff empty the urinary catheter drainage bag they should clean the drain tube of the bag with alcohol after emptying, and the collection device should be rinsed and cleaned after use and placed in a bag. The staff should not make contact with the toilet seat with the collection device and they are to use a separate container to rinse the collection device. Administrative Nurse D stated the urinary catheter drainage bag should be kept below the level of the bladder. The facility policy Indwelling Urinary Catheters dated 06/2022 included the urinary drainage bag must be held or positioned, lower than the bladder at all times, to prevent the urine in the tubing and drainage bag form flowing back into the urinary bladder. the staff were to empty the drainage bag regularly using a separate, clean collection container for each resident. The facility failed to ensure the urinary catheter bag remained below the resident's bladder level at all times and failed to ensure the staff performed the process of draining the urinary catheter bag in a sanitary manner, increasing the risk for catheter-associated urinary tract infections, for R20, who had a history of urinary tract infections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 68 residents, with 22 sampled, which included one resident sampled for respiratory care. Based on observation, interview, and record review, the facility failed to provide appropriate respiratory care to maintain respiratory equipment to prevent the spread of infection, for the one sampled Resident (R) 55. Findings included: - Resident (R) 55's Physician Orders, dated 08/03/2022, revealed diagnoses which included, chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The admission Minimum Data Set (MDS) dated [DATE], documented the Brief Interview for Mental Status (BIMS) score of 15, which indicated cognitively intact. The resident required extensive assistance of staff for bed mobility. He exhibited difficulty breathing and/or was short of breath (SOB) on exertion, when sitting at rest, and when lying flat. The MDS lacked documentation of the use of a Continuous Positive Airway Pressure (CPAP). The Quarterly MDS, dated 08/15/22, documentation lacked any differences from the prior MDS above. The Care Area Assessment (CAA), dated 05/23/22, documentation failed to address of the use of a CPAP machine for ventilation for the resident. The Care Plan, (CP), dated 09/08/22, failed to address the use of the resident's CPAP for ventilation. The Physician Orders, dated 08/03/2022, lacked an order for the resident's CPAP machine to include use, care, and maintenance of the CPAP equipment. On 09/12/22 at 11:14 AM, the resident was lying in bed. The CPAP hose and mask were laying across and in direct contact with the bedside table. There was not a storage bag nor container available to store the mask when not in use, to prevent cross contamination. Furthermore, two undated gallon jugs identified as containers of distilled water, sat on the bedside table, one being empty. A used undated humidifier bottle was sitting on the bedside table. On inquiry the resident stated the CPAP machine had not been cleaned since his admission. Additionally, he stated the facility had not provided a bag to store the CPAP mask when not in use. On 09/14/22 at 07:58 AM, the resident was sleeping in bed with his CPAP mask in place on his face. Three-gallon containers labelled distilled water sat on the bedside table. (One empty, one 2/3 filled with distilled water, and the third jug was not opened). None of the gallon jugs had a label with a date. A used, unlabeled, empty humidifier bottle sat directly on the bedside table. On 09/14/22 at 08:08 AM, Certified Nurse Aide (CNA) OO, confirmed the above concerns, she removed the empty gallon jug and used humidifier bottle. She placed a storage bag for the CPAP mask when not in use. On 09/15/22 at 08:53 AM, Licensed Nurse (LN) H verified the resident used the CPAP when sleeping during the day and night. LN H confirmed the resident lacked an order for use of the CPAP machine, and the facility failed to provide a storage bag for the CPAP mask when not in use. He verified the care plan lacked documentation to direct the staff in the appropriate cleaning, storage, and use of the CPAP machine. On 09/15/22 at 9:34 AM, Administrative Nurse D confirmed the resident lacked a Physician's Order, for the CPAP use. Additionally, she reported the people who have a CPAP should have a physician order for it. She stated she expected the nurses to clean the CPAP machine at least weekly. Administrative Nurse D verified the resident's medical record lacked an order for the CPAP, lacked documentation of use of the CPAP on either of the above MDSs and lacked a care plan for the CPAP. The CPAP mask should be stored in bag when not in use and the distilled water should be labelled with the date when opened. She agreed the MDS did not document the resident's use of the CPAP on either MDS. The facility lacked a policy regarding the appropriate maintenance and care of respiratory equipment to include CPAP machines. The facility failed to provide appropriate respiratory care in maintaining respiratory equipment to prevent the spread of infection for this resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 68 residents with 22 selected for review. Based on record review and interview the facility failed to notify the physician for one of the residents, Resident (R)20, when she experienced a significant weight loss. Findings included: - The Medical Diagnosis tab located in the electronic medical record (EMR), for Resident (R)20, included diagnoses of a pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) stage four (full thickness tissue loss with exposed bone, tendon or muscle) of the sacral (area of the lower back near the spine) region, morbid obesity (a disorder involving excessive body fat, body mass index [BMI] greater than 40), and lymphedema (swelling caused by accumulation of lymph [a fluid that flows through the lymphatic system). The admission Minimum Data Set (MDS) dated [DATE], assessed R20 with a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition. She required supervision and setup for eating and drinking. R20's height was 60 inches and she weighed 263 pounds and it was not known if she had any weight loss greater than five percent in the last month or greater than 10 percent in the last six months. She was not on a mechanically altered diet, however, received a therapeutic diet. R20 admitted to the facility on [DATE]. The Activities of Daily Living (ADL) Care Area Assessment (CAA) dated 04/13/22 revealed R20 required setup and supervision for eating. The Nutritional Status CAA dated 04/13/22 revealed R20 was at risk for altered nutritional status related to a therapeutic diet and wounds. Her diet was regular texture with double protein (meat/eggs), and protein powder with her meals. The staff were to provide and serve supplements as ordered by the physician, alert the Registered Dietician (RD) to any decline in intake, and honor her food preferences. The Quarterly MDS dated 07/05/22 assessed R20 with the same BIMS score, she was independent with eating with setup assistance from staff. R20's height was 60 inches and weighed 219 pounds. R20 had a weight loss of five percent or more in the last month or 10 percent or more and was not on a physician prescribed weight loss regimen. She was not on a therapeutic or mechanically altered diet. The Care Plan dated 09/04/22 revealed R20 had oral health problems related to edentulous status (lacked natural teeth) and encouraged her to report any chewing difficulties. The staff were to provide a regular diet, double protein (meat/eggs), protein powder with meals, yogurt with breakfast, honor her food preferences, provide the diet as ordered by the physician, and provide and serve supplements as ordered by the physician. The staff were to alert the RD to any decline in her meal intake. R20 could feed herself with setup and supervision by the staff. The Weights/Vitals tab revealed on 03/31/22, R20 weighed 262.8 pounds. The Weights/Vitals tab revealed on 04/29/22, R20 weighed 234.0 pounds, a total loss of 28.8 pounds, which was a significant loss of 10.96 percent in the past month. The Weights/Vitals tab revealed on 05/23/22, R20 weighed 244.4 pounds, an increase of 4.4 percent since the prior month and remained a decrease since the admission weight at seven percent (18.4 pounds). The Weights/Vitals tab revealed on 06/06/22 R20 weighed 238.3 pounds, a decline of 9.32 percent since admission (24.1 pounds). The Weights/Vitals tab, revealed on 06/21/22, R20 weighed 219.4 pounds, indicating an additional significant decline in weight from the last month at 10.23 percent. The Weights/Vitals tab revealed on 08/08/22 R20 weighed 206.3 pounds, a significant weight loss of 5.58 percent in the past month. The Weights/Vitals tab located in the EMR dated 09/03/22 revealed R20 weighed 200.9 pounds, a significant loss of 15.69 percent in three months and a significant loss of 23.55 percent since admission. The Progress Note attached to the electronic mail, dated 09/16/22 at 02:07 PM, revealed the Nutrition Note by Dietary Consultant Staff HH from 08/22/22. Physician extender JJ included a handwritten note Recently started on Zoloft (antidepressant medication) For depression, we are continuing to monitor. Continue with Plan of Care with protein supplements. The handwritten note lacked a date signed by physician extender JJ. On 09/15/22 at 03:46 PM, Administrative Nurse D stated she was unable to locate any physician progress notes about R20's weight loss. On 09/16/22 at 02:02 PM, Administrative Staff A documented per electronic mail Please find attached the progress note that the NP (Nurse Practitioner) had received and stated she was aware of the weight loss for R20. On 09/19/22 at 10:34 AM, the physician extender JJ stated she did not know of R20's weight loss prior to last week. Physician extender JJ recently started R20 on some medication for her mood, the facility should have contacted her sooner about the weight loss, and did not recall receiving any notes about the weight loss from a RD. The facility policy Guidelines for Notifying Physician of Clinical Problems dated 05/2022 revealed the guidelines were to help ensure all significant changes in resident's status were assessed and documented in the medical record. The policy lacked when to notify the physician of significant weight loss. The facility failed to notify the physician/physician extender of the resident's significant weight loss, which occurred three different months. This included a 10.96 percent loss in one month from 03/31/22 to 04/29/22, a 10.6 percent loss in one month from 05/23/22 to 06/30/22, and a 23.55 percent loss from 03/31/22 to 09/03/22.

The facility reported a census of 68 residents. The sample of 22 residents included six residents reviewed for unnecessary medications. Based on observations, interviews, and record review, the facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of multiple medications as ordered by the physician, for one resident of the six sampled residents; (R)60 related to pain medication and medications to treat gastrointestinal acid reflux (indigestion/heartburn). Findings included: - Review of the resident's (R)'s, Physician Orders, dated 08/03/22, revealed diagnoses which included fracture around right hip joint, hematemesis (person vomits blood due to internal bleeding), gastroesophageal reflux disease (backflow of stomach contents to the esophagus), peripheral vascular disease (a blood circulation disorder that causes the blood vessels outside of the heart and brain to narrow which typically causes pain), fracture of right foot metatarsal bone(s) (broken bones in the forefoot), cellulitis (skin infection) left lower limb, and fracture of the right femur (broken bone of the right thigh). The Care Plan, (CP), dated 09/02/22, directed staff the resident used medications to help manage some of his health problems. Staff should administer medications as ordered by the physician. The Physician Orders, dated 08/03/22, included medication orders for the following: 1. Tramadol Hydrochloric (HCL) tablet, 50 milligrams (mg), give two tablets by mouth three times a day for pain related to fracture around internal prosthetic right hip, ordered on 09/07/22. 2. Lansoprazole Capsule Delayed Release 15 mg, give one tablet by mouth daily related to gastroesophageal reflux disease without esophagitis, ordered on 08/21/22. Review of the Medication Administration Record, (MAR) dated 09/2022, revealed the following concerns: 1. Staff failed to administer the physician ordered Tramadol Hydrochloric (HCL) tablet, 50 mg, give two tablets by mouth three times a day for pain on 09/11/22, 09/12/22, and 09/13/22 for a total of eight doses documented as being due to the medication not available. 2. Staff failed to administer the physician ordered Lansoprazole Capsule Delayed Release 15 mg, on 09/06/22, 09/08/22, 09/09/22, and 09/12/22 as due to the medication not being available. On 09/01/22 through 09/05/22, 09/07/22, 09/10/22, and 09/11/22, the MAR lacked documentation that the medication was administered and/or the code explaining why it was not administered. The Progress Notes, (PN), in the electronic medical record (EMR) documentation included the following: PN, dated 09/07/2022 at 11:58 AM, documented the nurse practitioner was in to see the resident and gave a new order to schedule his Tramadol for three times a day for pain. PN, dated 09/09/2022 at 06:46 AM, documented the nurse reordered the Lansoprazole Capsule Delayed Release 15 mg and was waiting to hear from the pharmacy about delivery. PN, dated Friday 09/09/2022 at 10:18 AM, documented the facility received a telephone call from the pharmacist to inform the facility Lansoprazole would not be available from the pharmacy until the following Monday that the medication Lansoprazole was unavailable until Monday 09/12/22. The medication would be delivered to facility at that time. PN, dated 09/09/2022 at 11:03 AM, documented the nurse spoke to the physician's office and requested a prescription refill for Tramadol 100mg, by mouth be sent to the pharmacy. PN, dated 09/10/2022 at 7:45 PM, documented, . awaiting on new script from primary care physician (PCP),for Tramadol. PN, dated 09/11/2022 at 8:18PM, documented, . awaiting on new script from primary care physician (PCP),for Tramadol. Nurse notified. PN, dated 09/12/2022 at 05:27AM, documented Lansoprazole Capsule Delayed Release 15 MG medication, waiting for delivery, will discusses with on-coming nurse to see about calling pharmacy or talking to Director of Nursing about medication not available. PN, dated 09/13/2022 at 08:34 AM, documented awaiting a new script from PCP for Tramadol. PN, dated 09/13/2022 at 1:12 PM, documented the nurse placed a call to the physician's nurse regarding the resident's pain at his right hip with messages left two times at 12:20 PM and 01:00PM. The nurse awaiting a return call. On 09/13/22 at 09:16 AM, the resident stated he could not sit on the commode any longer. CNA LLL and CMA RR assisted the resident to stand and pivot to his chair and then to stand pivot and transfer to his bed at which time he complained of pain in his right groin area. On 09/13/22 at 09:25 AM, CMA RR administered the resident's scheduled medication. which lacked the ordered Tramadol. CMA RR stated the resident did not have Tramadol available to administer which she reported to the nurse. She confirmed the resident had not received several doses of the ordered Tramadol over the previous couple of days. On 09/13/22 at 12:22 PM, CNA LLL reported the resident refused therapy earlier today and did not want to eat because of the pain in his leg. On 09/13/22 at 09:40 AM, Licensed Nurse (LN) I stated she called the pharmacy to get the Tramadol refilled on Thursday (09/08/22). Upon review of the resident's EMR/ MAR, LN I confirmed the resident had orders for routine Tramadol for pain and Lansoprazole Capsule Delayed Release 15 mg for GERD. LN I explained that the medication aides administer the scheduled medications and notifies the nurse when it is time to reorder them. The resident last received Tramadol on Sunday 09/11/22 at 08:00 AM. The resident had not received eight doses of Tramadol. Additionally, the resident did not receive 12 doses of the ordered Lansoprazole. On 09/15/22 at 09:34 AM, Administrative Nurse D, confirmed the above finding. She reported the medication aide was responsible for administering the scheduled/routine medications and they are responsible for notifying the nurse when the medications need to be reordered. The nurse should ensure the resident's medications are given as ordered by the physician, when medication is not available from the pharmacy, they should notify the administrative nurses to follow-up with the pharmacy to prevent the resident from missing doses of his medication. She reported she was not made aware the resident's medication were unavailable prior to 09/13/22. The facility undated policy for, Documentation of Medication Administration F755, documentation included the facility shall maintain a medication administration record to document all medications administered. The policy lacked address of the lack of available medications from the pharmacy. The facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of multiple medications as ordered by the physician for the resident.

The facility reported a census of 68 residents which included five residents reviewed for influenza and pneumococcal vaccines. Based on interview and record review the facility failed to ensure two of the five residents (R24 and R 12) or their representatives received information/education for the benefits, risks, or medical contraindications regarding pneumococcal immunization. Findings included - On 09/14/22 review of Resident (R) 24 and (R) 12's immunization records revealed the medical records lacked evidence of pneumococcal education provided, prior to consent or refusal of the pneumococcal vaccination. On 09/14/22 at 01:24 PM, Administrative Nurse E verified the above findings related to immunization. She stated the resident and/or their representative should be provided with education regarding the benefit verses the risks of the pneumococcal vaccine prior to deciding to receive or refuse the vaccine. She agreed the facility lacked evidence the facility provided education to R24 and R12 and/or their representatives prior to their giving consent or refusing the vaccine, as required. The Facility policy Pneumococcal Vaccine F883, documentation included before receiving the pneumococcal vaccination, the resident or legal representative shall receive information and education regarding the benefits and potential side effects of the pneumococcal vaccine. Provision of such education shall be documented in the resident's medical record. The facility failed to ensure education provision to the residents and/or their representatives prior to pneumococcal vaccine offers.

The facility reported a census of 68 residents. Based on observation, interview, and record review, the facility failed to provide necessary housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior in resident areas including rooms, bathrooms and in a shower room. Findings included: - A brief tour of resident rooms and care areas beginning on 09/15/22 at 09:13 AM, revealed the following areas of concern: Five bathrooms with caulking missing/cracked/dirty around the toilets. Two rooms with gaps in the tile and debris present in the gaps. Five resident bathrooms with dirty floors. Two bathrooms with a dirty toilet. One room with an approximate 6 inch by 6 inch, hole in the wall. Five rooms with chipped paint to the doorways. One room with peeling wall paint. One room with a wash basin and bedpan stored directly on the floor. One room with a urinal dated 07/26/22, stored in a bag, with yellow liquid at the bottom of the bag. One of the shower rooms had rust-colored caulking around the toilet, a slow drip from the sink, the toilet had water running in the bowl, a darkened color between the tiles near the toilet, and the doorway had chipped paint. On 09/15/22 at 09:35 AM, Maintenance Staff U stated the facility utilized a TELS work order system. Sometimes the staff would just tell him, and he would put the work order in or just go fix the problem. On 09/15/22 at 10:07 AM, Maintenance Staff U stated he was not aware of the dripping sink or the running toilet in the shower room. He was hoping they would be getting new bathroom floors, but there was not a plan written about needed repairs. On 09/16/22 at 12:52 PM, Administrative Staff A stated a repair log was done on 08/15/22 and taken to the QAPI (quality assurance performance improvement) meeting on 08/25/22. The log was an ongoing log that they continue to update with new areas of concern or ongoing projects identified as areas that need addressed. The facility does a full repair log sweep monthly and updated the log prior to QAPI meetings. Review of the Repair Log lacked dates the staff identified the items, lacked estimated goal date, and lacked completion date. The shower room listed included a running toilet, which during tour Maintenance Staff U was not aware of the issue. The facility policy Safe, Clean, Comfortable, Homelike Environment dated 06/2022 revealed the residents have a right to a safe, clean, comfortable environment and homelike environment. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include cleanliness and order. The facility failed to provide necessary housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior in these resident areas.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - The Medical Diagnosis tab located in the electronic medical record (EMR), for Resident (R)20, included diagnoses of a pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) stage four (full thickness tissue loss with exposed bone, tendon or muscle) of the sacral (area of the lower back near the spine) region, morbid obesity (a disorder involving excessive body fat, body mass index [BMI] greater than 40), and lymphedema (swelling caused by accumulation of lymph [a fluid that flows through the lymphatic system]). The admission Minimum Data Set (MDS) dated [DATE], assessed R20 with a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition. She required supervision and setup for eating and drinking. R20's height was 60 inches and she weighed 263 pounds and did not/was not known if she had any weight loss greater than five percent in the last month or greater than 10 percent in the last six months. She was not on a mechanically altered diet, however, received a therapeutic diet. R20 had no natural teeth and had a stage four pressure ulcer present. R20 admitted to the facility on [DATE]. The Quarterly MDS dated 07/05/22 assessed R20 with the same BIMS score. She was independent with eating, with setup assistance from staff, was 60 inches tall, and weighed 219 pounds. R20 had a weight loss of five percent or more in the last month or 10 percent or more in the past six months and was not on a physician prescribed weight loss regimen. She was not on a therapeutic or mechanically altered diet. She continued to have a stage four pressure ulcer present. The Activities of Daily Living (ADL) Care Area Assessment (CAA) dated 04/13/22 revealed R20 required setup and supervision for eating. The Nutritional Status CAA dated 04/13/22 revealed R20 was at risk for altered nutritional status related to a therapeutic diet and wounds. Her diet was regular texture with double protein (meat/eggs), and protein powder with her meals. The staff were to provide and serve supplements as ordered by the physician, alert the Registered Dietician (RD) to any decline in intake, and honor her food preferences. The Pressure Ulcer/Injury CAA dated 04/13/22 revealed R20 had a stage four sacral pressure ulcer and the staff were to monitor her nutritional status, serve her the diet as ordered, and monitor her intake and record the meal intake. She required supplemental protein as ordered to promote wound healing. The Care Plan dated 09/04/22 revealed R20 had oral health problems related to edentulous status (lacked natural teeth) and encouraged her to report any chewing difficulties. The staff were to provide a regular diet, double protein (meat/eggs), protein powder with meals, yogurt with breakfast, honor her food preferences, provide the diet as ordered by the physician, and provide and serve supplements as ordered by the physician. The staff were to alert the RD to any decline in her meal intake. R20 could feed herself with setup and supervision by the staff. The Weights/Vitals tab located in the EMR, revealed on 03/31/22, R20 weighed 262.8 pounds. The diet order, located in the EMR dated 03/31/22 ordered a regular diet, regular texture, double protein meat/egg, and protein powder to meals. The Nutrition: RD admission (Initial) Assessment - V 2 dated 04/07/22, revealed R20's current meal intake was adequate and there were nutritional concerns due to a stage four pressure ulcer to her sacrum and morbid obesity due to excess calories, with a goal for her wound to heal. R20 had nutritional interventions of double meat/egg. The staff were to continue with the current plan of care, monitor her weights, and follow up with the RD as needed. The Weights/Vitals revealed on 04/29/22, R20 weighed 234.0 pounds, a total of 28.8 pounds, that was a significant loss of 10.96 percent in the past month. The Orders tab located in the EMR, revealed on 05/03/22, R20 was to receive ice cream two times a day for weight loss, scheduled at 11:30 AM and 05:30 PM. The facility failed to revise the care plan to include the addition of ice cream twice daily. The 05/22/22 IDT: Patient at Risk (PAR) - V1 assessment located under the assessment tab in the EMR and the first PAR note since admission revealed there was no risk related to weights. The Weights/Vitals tab revealed on 05/23/22, R20 weighed 244.4 pounds, an increase of 4.4 percent since the prior month and remained a decrease since the admission weight at seven percent (18.4 pounds). The 05/22/22 IDT: Patient at Risk (PAR) - V1 assessment in the EMR revealed R20 was at risk related to her weights, she had a gain from her previous weight and intakes were 76-100 percent of meals. The goal was to maintain weight and the current interventions were effective. The Weights/Vitals tab revealed on 06/06/22 R20 weighed 238.3 pounds, a decline of 9.32 percent since admission (24.1 pounds). The IDT: Patient at Risk (PAR) - V1 located under the assessment tab in the EMR dated 06/08/22 revealed the most recent weight was 238.3 pounds which was a loss from the previous weight. R20's intakes were 76-100 percent. The goal was to maintain weight and no changes would be made, R20 would like to have weight loss. The facility failed to add R20's desire to have weight loss to the care plan. The 06/15/22 IDT: Patient at Risk (PAR) - V1 assessment in the EMR (seven days after the previous PAR meeting note) revealed R20 had a weight of 236 pounds on 06/13/22, a loss from her previous weight. R20's intakes were 76-100 percent and the facility started providing super cereal (a recipe that combines different ingredients and nutrients to cereal that when combined makes a high-calorie, nutritious, and fortified cereal) to help maintain, and double portions related to her wound. (This intervention of super cereal would conflict with the previous weeks note regarding weight loss desire). The Orders tab R, revealed on 06/18/22, R20 was to receive super cereal one time a day for weight loss. The facility failed to add the intervention to the care plan. The Weights/Vitals tab, revealed on 06/21/22, R20 weighed 219.4 pounds, indicating an additional significant decline in weight from the last month at 10.23 percent. The IDT: Patient at Risk (PAR) - V1 dated 06/22/22, revealed a weight of 219.4 on 06/21/22, a loss from previous weight and intakes remained at 76-100 percent. Current interventions included super cereal, double portions and protein powder, and the current interventions were effective. The PAR note included R20 was losing some weight with recent start of super cereal and would continue as is for now. The Weights/Vitals tab revealed on 06/30/22, R20 weighed 218.5 pounds, a significant weight loss of 10.63 percent in the past month. The Nutrition Note located under the progress note tab in the EMR, dated 07/05/22 at 11:23 PM, revealed R20's chart reviewed by the RD related to her wound status. R20 had a stage four pressure ulcer on her sacrum and an open lesion on her left calf. R20 also had some decrease in weight and was on a regular diet plus snacks, ice cream, and super cereal. Her intakes were 75-100 percent of meals. The staff stated she could be a picky eater and would hide food she did not like under a napkin. The note included a list of preferences reviewed with R20 and for breakfast, she preferred scrambled eggs, sausage, no bacon, and biscuits and gravy. R20 did not like spinach or bread, included buns for hamburgers, preferred just the patty. The RD was to follow up as needed. The Weights/Vitals tab dated 07/06/22 revealed R20 weighed 218.5 pounds, which was the same as her weight on 06/30/22. The IDT: Patient at Risk (PAR) - V1 dated 07/06/22 revealed R20's most recent weight on 07/06/22 was 218.5 pounds, a loss from previous weights. Her intakes were 51-75 percent and she had interventions of super cereal, ice cream, double protein meat and eggs, and the interventions were effective. The Orders tab on 07/12/22 a diet order for regular texture, scrambled eggs, sausage, no bacon, biscuit, and gravy, give yogurt at breakfast, double protein meat/egg, and protein powder at meals. The facility failed to revise the care plan to include R20's preferences. The Weights/Vitals tab revealed on 08/08/22 R20 weighed 206.3 pounds, a significant weight loss of 5.58 percent in the past month. The IDT: Patient at Risk (PAR) - V1 dated 08/10/22 and 08/18/22 revealed R20 not at risk related to her weights. The 08/22/22 Nutrition Note in the revealed R20's chart reviewed due to weight changes. R20 was on a regular diet with meal intakes of 75-100 percent plus an evening snack, ice cream, and super cereal. She has a 21 percent, 56-pound weight loss from March 2022 to August 2022. Although hard to understand in the interview, R20 stated her appetite was not good and it had been that way for some time. R20 had no teeth or dentures, and the staff reported she had no issues with eating and ate 100 percent of meals. The note included a recommendation of more protein for protein and to add yogurt with breakfast. (Yogurt was an intervention on 07/12/22). R20 was unsure why she was having weight changes with her good oral intake. The staff were to monitor for further weight changes and oral intake and the RD would follow up. The Weights/Vitals tab located in the EMR dated 09/03/22 revealed R20 weighed 200.9 pounds, a significant loss of 15.69 percent in three months and a significant loss of 23.55 percent since admission. The 09/07/22 IDT: Patient at Risk (PAR) - V1 revealed R20's most recent weight of 200.9 pounds on 09/03/22 was a loss from her previous weight and her intakes were 51-75 percent. The current interventions were yogurt, ice cream twice daily, and super cereal. The note included edema to lower extremities improved and there were no changes at this time. The Progress Note attached to the electronic mail, dated 09/16/22 at 02:07 PM revealed the Nutrition Note by Dietary Consultant Staff HH from 08/22/22. Physician extender Consultant Staff JJ included a handwritten note Recently started on Zoloft (antidepressant medication) For depression, we are continuing to monitor. Continue with Plan of Care with protein supplements. The handwritten note lacked a date signed by physician extender JJ. On 09/15/22 at 08:02 AM, R20 was in her room in bed, with juice and milk in front of her on her overbed table, and the staff had not served her breakfast yet. On 09/15/22 at 08:03 AM, R20 stated she wanted to lose weight, she did not have a goal weight in mind, did not know what her current weight was, but thought the staff weighed her recently. R20 stated sometimes she does not eat the meat served because she cannot chew it and believed she had talked to the dietician about that. On 09/15/22 at 08:26 AM, Certified Medication Aide (CMA) R confirmed R2 received pancakes, bacon, and cream of wheat for breakfast and was not served yogurt. The facility failed to serve scrambled eggs, sausage, biscuits and gravy, and yogurt. The facility served her bacon, which she preferred not to receive. On 09/15/22 at 08:29 AM, R20 told CMA R she was not going to eat; however, she drank her juice and her milk. On 09/15/22 at 08:30 AM, CMA R stated R20 was Not much of a breakfast eater. On 09/15/22 at 08:35 AM, R20 stated the staff did not serve her yogurt with breakfast, and she likes yogurt, and would eat the yogurt if they (staff) brought it to her. On 09/15/22 at 08:40 AM, Dietary Staff CC stated she did not receive the meal tray tickets for today, she did not know if they had been printed or not, and they usually got new ones every day. The Dietary Manager printed the tickets. On 09/15/22 at 08:43 AM, Dietary Staff BB stated the staff should add the protein powder to the oatmeal or cream of wheat, they try to add it to foods where it would not be recognized. Dietary Staff BB stated when R20 first admitted to the facility, her family brought her in the yogurt. The breakfast meal tray ticket dated 09/15/22 revealed the instructions lacked to serve the yogurt, double meat/eggs, or protein powder. On 09/15/22 at 11:04 AM, Licensed Nurse (LN) F stated she thought R20 had weight loss and she had a lot of edema when she first came in. LN F stated R20 had a poor appetite and was particular about what she would eat. LN F stated yogurt was a preference of R20's and sometimes the kitchen would send it out and sometimes there was some available in the fridge, she would not always accept it, and the staff were to offer it to her every morning. LN F stated R20 did not eat much for breakfast and was unaware if the resident was to receive double meat for breakfast or for all her meals. When a diet order changes, the staff should fill out a communication slip and the kitchen should get a copy of it. When the staff are passing meal trays, they should check the trays with the meal tray slip to see if they match. LN F stated R20 would occasionally voice problems chewing. She did not want her diet downgraded in the past, and she declined when offered. LN F stated her diet order included double protein for her wound and her weight loss, she should receive ice cream twice a day with lunch and supper, and super cereal, but was not sure if super cereal was oatmeal or if the kitchen made the cream of wheat as a super cereal. On 09/15/22 at 12:29 PM, R20 received her lunch tray in her room of a single serving of turkey bake, mixed vegetables, biscuit, and cake. On 09/15/22 at 12:30 PM, R20 stated sometimes staff serve her ice cream or sherbet, but was not served ice cream twice a day, every day. The meal tray ticket for the lunch dated 09/15/22, included a regular diet, however, did not include double meat, protein powder, or ice cream, and did include she was to get margarine for her biscuit. On 09/15/22 at 12:36 PM, CNA Q stated when R20 received ice cream, it was when ever it was part of the regularly scheduled meal and had not seen her served any yogurt. CNA Q stated sometimes she delivers the resident's meal trays but had not seen her get double portions of her meat. On 09/15/22 at 12:39 PM, CMA R stated the ice cream order is on the MAR (medication administration record). On 09/15/22 at 12:40 PM, R20 had her napkin over her lunch plate and had not eaten anything. CMA R questioned R2 if she would like something else, offered a peanut butter and jelly sandwich. R20 declined and stated she would like yogurt. On 09/15/22 at 12:43 PM CMA R stated R20 would occasionally refuse her ice cream, but she would usually take it. The order for the super cereal shows up on the MAR as well. CMA R stated she received the Malt o meal this morning and the Oat cereal was the super cereal. On 09/15/22 at 12:48 PM, Dietary Staff BB stated when he received the Diet Order and Communication slip, he would change the order in the computer and just learned on 09/09/22 how to update the tray card slips as someone else entered them before that. Dietary Staff BB confirmed R20's breakfast tray ticket lacked super cereal, double meat portions, no bacon. Dietary Staff BB stated the double meat portions were for breakfast and not the other meals, and he makes super cereal with oatmeal and cream of wheat. R20's super cereal was sent out on her tray this morning and the turkey bake had the protein powder. Dietary Staff BB stated the RD came to the facility twice a month and would generate a report of who to look at such as an annual or quarterly review and the Director of Nursing may also include someone to look at. The RD would send a report after the review and last reviewed R20 on 08/22/22, which she included to add yogurt at breakfast. Dietary Staff BB stated today was the first day the staff had asked for ice cream, however they have a freezer in the break area with ice cream in it. On 09/15/22 at 01:19 PM, Administrative Nurse D stated R20 had gradually been losing weight since she admitted and at one point said she wanted to lose weight and was happy that she was losing weight. Administrative Nurse D stated she did not know if R20 had a goal for her weight loss, did not see a note about a weight loss goal, and staff should document on the care plan if the resident had a desire to lose weight. Administrative Nurse D stated the diet order for double meat would be for every meal, not just for breakfast, and the yogurt was put into place on 07/12/22 from a dietary recommendation. RD recommendations go to her and to Dietary Staff BB. On 09/15/22 at 01:31 PM, Administrative Staff A stated she expected the diet order to be on the tray cards. On 09/15/22 at 03:46 PM, Administrative Nurse D stated she was unable to locate any physician progress notes about R20's weight loss. On 09/16/22 at 02:02 PM, Administrative Staff A documented per electronic mail Please find attached the progress note that the NP (Nurse Practitioner) had received and stated she was aware of the weight loss for R20. On 09/19/22 at 10:13 AM, Dietary Consultant HH stated she started working at the facility in June 2022, did not know R20 had a desire to lose weight, and when mentioned to R20 about why she might be losing weight, R20 did not know why and did not mention if she was trying or cutting back on portions. Dietary Consultant HH stated when a resident desired to lose weight she documents that in her notes, visits with the resident about what they typically ate and drank, what their choices were, and goals to make sure they were realistic or not, then followed up the following month. The facility staff would make any changes on the care plan. Dietary Consultant HH stated R20 needed her protein for wound healing, and the note on 08/22/22 was mis-typed and should have read she needed more protein. R20 was not open to more eggs and she did mention that she had been receiving yogurt. Consultant Staff HH stated she w yogurt was already part of her orders, and knew she was on super cereal and ice cream. Dietary Consultant HH stated the dietary orders should be on the tray tickets and the staff should follow the diet order. Dietary Consultant HH stated her understanding, as she had not observed a meal tray pass, was the staff were to check the ticket with the diet served to make sure they matched. R20 should be served biscuits and gravy every breakfast along with sausage, super cereal, scrambled eggs, and yogurt. The staff not following the dietary order could have contributed to the resident's weight loss. On 09/19/22 at 10:34 AM, the physician extender JJ stated she did not know of R20's weight loss prior to last week. She expected the facility to inform her of R20's desire to lose weight, expected the RD to be involved in a plan for weight loss, and the facility should follow the diet order. There should be a weight loss goal, or the facility should keep an eye on the weights. She recently started R20 on some medication for her mood, the facility should have contacted her sooner about the weight loss, and did not recall receiving any notes about the weight loss from a RD. Furthermore, nutrition was important for the resident due to her wound. The facility policy Weight Assessment and Intervention dated 07/2022, included the Interdisciplinary team (IDT) would strive to prevent, monitor, and intervene for undesirable weight loss or gain for residents. Any weight change of five pounds or more (pounds) since the last weight assessment would be retaken the next day for confirmation. If the staff verified the weight change, the RD would be notified per facility protocol. The threshold for significant unplanned and undesired weight change would be based on the following criteria: 1. In one month, a five percent change would be significant, greater than five percent would be severe. 2. In three months, a 7.5 percent change would be significant, greater than 7.5 percent would be severe. 3. In six months, a 10 percent weight change would be significant, greater than 10 percent would be severe. If the weight change was desirable, staff would document this and no change in the care plan would be necessary. The IDT would analyze the assessment information and conclusions would be made regarding the resident's target weight range and whether and to what extent weight stabilization or improvement could be anticipated. Approximate calories, protein, and other nutrient needs compared with intake, and relationship between current medical condition or clinical situation and recent fluctuations in weight. The IDT team would identify conditions and medications that could be causing anorexia (loss of appetite), weight gain, or increasing risk of weight loss. The care plan should address the identified cause of the weight change, goals and benchmarks for improvement, and time frames and parameters for monitoring and reassessment. Interventions for undesirable weight change should be based on resident choices and preferences, nutrition and hydration need, chewing and swallowing abnormalities and the need for diet modifications, and the use of supplementation. If a resident declined to participate in a weight loss goal, documentation would include the resident's wishes. The facility failed to revise the care plan to include R20's nutritional preference and interventions. The facility reported a census of 68 residents with 22 selected for review. Based on observation, interview and record review, the facility failed to review and revise the plan of care for four of the 22 residents reviewed including; Resident (R) 34 for safe transfers; R20 for planned weight loss; R113 and R30 for pressure ulcer prevention. Findings included: - Review of Resident (R)34's Physician Order Sheet, dated 08/02/22, revealed diagnoses included Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure) and dysphagia (swallowing difficulty). The Significant Change Minimum Data Set (MDS), dated [DATE], assessed the resident with severe cognitive deficit, constant inattention and altered level of consciousness. The resident was dependent on two staff for bed mobility and transfers. The resident had impairment in functional range of motion on one side of her upper and lower extremities. The Falls Care Area Assessment (CAA), dated 02/21/22, assessed the resident required staff assistance for stabilization. The Quarterly MDS, dated 07/31/22, assessed the resident with severe cognitive deficit with constant inattention. The resident was dependent on two staff for bed mobility and transfers. The resident had impairment in functional range of motion one side of her upper and lower extremities. The Care Plan, reviewed 08/04/22, instructed staff to ensure the resident had nonskid footwear when ambulating. The resident was on a functional maintenance program to maintain range of motion in her upper and lower extremities. Staff instructed to provide passive range of motion to her extremities. The resident required one to two staff assistance with transfers and two staff for bed mobility. the care plan failed to identify the resident's inability to bear weight on her legs and specific instructions to the staff of how to provide safe transfers with the resident. Observation, on 09/13/22 at 02:07 PM, revealed the resident seated in her wheelchair. Certified Nurse Aide (CNA) O and P changed the resident's shirt, then proceeded to transfer the resident to her bed. CNA O and CNA P placed their flexed elbows under the resident's axilla (arm [NAME]), and each held onto the back of the resident's pants by the waistband with their other hands. The resident's legs were drawn up and her feet did not touch the floor to pivot. Staff failed to apply a gait belt for the transfer. CNA P stated at that time that the resident was care planned to transfer with a mechanical lift or one or two persons. Observation, on 09/13/22 at 04:54 PM, revealed CNA PP and QQ prepared to transfer the resident from her bed to her wheelchair. CNA PP stated staff utilized a lift for transfers, then stated the resident was a one to two-person transfer. The resident's knees and elbows were in a flexed position. Staff did not put shoes, socks or a gait belt on the resident. The resident did not follow directions. Staff lifted the resident under her axilla and held onto the back waistband of her pants. The resident's feet did not touch the floor but remained in a flexed position. Observation, on 09/14/22 at 01:57 PM, revealed the resident seated in her wheelchair. CNA M and RR placed a gait belt on the resident and lifted the resident with the gait belt to transfer her into her bed. The resident did not bear weight and kept her legs in a flexed position during the transfer. CNA M confirmed the resident did not bear weight during the transfer, and staff should use a lift. Interview, on 09/14/22 at 04:46PM, with Administrative Nurse E, revealed she would expect staff to use a gait belt with transfers and to notify her of issues with the resident's range of motion and inability to bear weight. She further explained that she would need to update this resident's care plan to include safe transfer interventions. The facility policy F656, F657, F658 Comprehensive Care Plans reviewed 08/2022, instructed staff the Care Planning/Interdisciplinary Team was responsible for the periodic review and updating of care plans. The facility failed to review and revise this resident's care plan to include instructions to the staff for safe transfer interventions for this resident who could not bear weight on her legs. - Review of resident (R)113's Physician Order Sheet, dated 09/05/22, revealed diagnoses that included malignant neoplasm (tumor) of the lung, adult failure to thrive and osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain. The resident admitted to the facility on [DATE] with an order for hospice services. The admission Minimum Data Set (MDS), dated [DATE], assessed the resident with severely impaired cognitive status with altered level of consciousness that comes and goes. The resident required extensive assistance of two staff for bed mobility. The resident was at risk for pressure ulcer and had no unhealed pressure ulcers at the time of this assessment. The resident had a pressure reducing device to his bed and chair and was on a turning and repositioning plan. The Pressure Ulcer Care Area Assessment CAA, dated 08/28/22, assessed the resident was at risk for pressure ulcers possible due to end of life and decrease in appetite that may cause pressure related injuries or Kennedy ulcers (an area of skin breakdown due to terminal illness and multi organ failure). The resident was incontinent of bowel and bladder and required extensive assistance of two staff for toileting and incontinence care, the resident's skin may be exposed to prolonged moisture that may cause irritation and breakdown. The resident does have very thin and fragile skin. The Care Plan, reviewed 09/05/22, instructed staff the resident had a pressure wound to his left elbow, mid spine and right hip. Staff instructed to cleanse the right hip area with wound cleanser, apply xeroform (Vaseline dressing) and apply skin prep to the peri wound (tissue around the wound). The care plan lacked the need for heel protectors until 09/13/22, lacked pressure relieving mattress and turn and reposition schedule. A Nursing Weekly Skin Evaluation, dated 08/31/22 documented redness on the right ankle, left buttock, unspecified sole of left foot arch area and old fading bruises to the ribs and mid back with two to three plus edema in the right lower extremity. Review of the Skin Wound Note, dated 09/03/22, documented the resident had a seven-centimeter (cm) area to his right hip with skin shearing and barrier cream and dry dressing applied. A Nursing Weekly Skin Evaluation, dated 09/07/22 documented the resident had dry red skin with open areas. Redness to the right outer ankle, right elbow, left buttock and sole of left foot arch area and two to three plus edema in the right lower extremity. The evaluation contained no measurements of these areas for description. A Nurse Note, dated 09/08/22, indicated an air mattress to be delivered this evening or in AM. An SBAR (a communication tool that documents the situation, background, assessment and recommendations) dated 09/09/22, indicated the resident developed a stage two pressure area to the right hip. A Nurse Note, dated 09/12/22, documented staff turned the resident every two hours to prevent further breakdown. Observation, on 09/13/22 at 07:30AM, revealed the resident positioned in bed leaning onto his left side with his head slightly elevated and oxygen per nasal canula. Interview, on 09/13/22 at 7:45 AM, with Certified Nurse Aide (CNA) O stated the resident did not eat breakfast and did not wake up. Observations continued every 15 minutes through 10:45 AM, in which revealed the resident remained in the same position. Observation, on 09/13/22 at 10:45 AM, revealed the resident positioned in bed on his left side. The resident had sheepskin heel protectors on his heels bilaterally, however, they were not positioned to protect his heels which were positioned directly on the mattress. Administrative Nurse F, and Certified Nurse Aide (CNA) O provided urinary incontinence care. Administrative Nurse F removed a piece of foam dressing from his left hip which revealed an area of red brown unblanchable (area that does not refill with redness when pressure is applied, then released) tissue and measured the area as 4.9 by 7.5 centimeter (cm) with no depth and classified the area as deep tissue injury. Administrative Nurse F cleansed the area, applied Vaseline gauze dressing and a foam dressing. Administrative Nurse F proceeded to remove the right hip dressing and cleansed the area. The right hip ulcer contained two islands of yellow slough, and one area of shearing. Administrative Nurse F measured the ulcer as 5.3 by 7.0cm and a depth of 0.1cm with 50 percent (%) of the wound covered with epithelial (exterior skin) tissue, 20% granulation (new connective and microscopic blood vessels that form on a wound's surface during healing) and 20% slough (dead tissue). Administrative Nurse F stated the resident's wound deteriorated as his terminal status progressed. Both of the resident's heels had black areas approximately 2 cm diameter. The resident lacked a pressure relieving air mattress. Interview, on 09/13/22 at 12:08 PM, with Administrative Staff F, revealed the resident should be turned and repositioned more frequently, and the sheepskin heel protectors may not be enough to prevent heel breakdown this should be added to the care plan. Observation, on 09/13/22 at 2:40 PM, revealed the resident positioned on his back in bed with a pillow under his right hip. The resident had the sheepskin heel protectors on bilaterally, but the heels remained directly on the mattress. The resident lacked an off-loading device. Observations continued at 15-minute intervals and revealed the resident did not reposition himself, and staff did not reposition the resident until a skin check was requested at 05:36 PM. CNA PP and CNA QQ did not know wh[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 68 residents with 22 selected for review including nine residents reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as result of pressure, pressure in combination with shear and/or friction). Based on observation, interview, and record review, the facility failed to provide treatment to Resident (R)43 in a timely manner to a pressure ulcer on the coccyx (the area below the sacrum commonly known as the tailbone), failed to ensure a dressing was in place and the air mattress settings were correct for R20 who had a stage four (full thickness tissue loss with exposed bone, tendon or muscle) pressure ulcer of the sacral (area of the lower back near the spine) region, failed to ensure R11's who admitted with a stage four sacral wound and acquired an unstageable pressure area due to eschar to both heels that the air mattress was at the appropriate setting. Additionally, the facility failed to implement interventions and turn/reposition appropriately for R113 who developed an unstageable and a stage two pressure ulcer and failed to ensure R30's heels were positioned appropriately, had an air mattress in place, and failed to turn/reposition appropriately resulting in development of deep tissue injuries to bilateral heels. Findings included: - The Patient Health Summary located under the miscellaneous tab in the electronic medical record (EMR) for Resident (R)43 included diagnoses of sacral (area of the lower back near the spine) decubitus ulcer (pressure ulcer), infection of above knee amputation with complication, atherosclerotic (build-up of fats, cholesterol, and other substances in and on the artery walls) occlusive disease, and diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin). The Minimum Data Set (MDS) tab, located in the EMR for R43 revealed he entered the facility on 07/15/22, discharged with return anticipated on 07/18/22, re-entered on 07/22/22, discharged with return anticipated on 07/23/22 and re-entered on 07/28/22. The admission MDS dated 08/04/22 for R43 assessed him with a Brief Interview of Mental Status (BIMS) score of 13 indicating intact cognition. R43 rejected cares one to three days of the seven day assessment period and required extensive assistance of two or more staff for bed mobility, transfers, and toilet use. R43 used a wheelchair for mobility and had a range of motion impairment to one side of his upper and lower extremities. He was occasionally incontinent of bowel and bladder, was at risk for developing pressure ulcers, and had a stage two (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, may also present as an intact or open/ ruptured blister) pressure ulcer which was present on admission/entry or re-entry. R43 had a pressure device for his chair and bed, was not on a turning/repositioning program nor a nutrition or hydration intervention to manage skin problems, received pressure ulcer care, received surgical wound care, application of nonsurgical dressings with or without topical medications other than to feet, and receive application of ointment/medications other than to feet. The Activities of Daily Living [ADL] Care Area Assessment (CAA) dated 08/10/22 revealed R43 had limited physical mobility related to a left above knee amputation, required limited to extensive assistance from one to two staff for bed mobility, toileting, and transfers, and at times may be dependent on staff for transfers. The Pressure Ulcer/Injury CAA dated 08/10/22 revealed R43 was at risk for skin breakdown related to his surgical procedure, amputation of left leg, and a pressure ulcer to his sacrum. The Baseline Care Plan dated 07/16/22 included under the Pressure Ulcers/Skin Conditions area a goal to prevent skin breakdown/further healing and an intervention marked not applicable. The Care Plan dated 09/11/22 included a problem dated 07/23/22 which revealed R43 was at risk for skin breakdown related to a surgical procedure, amputation of left leg and left-hand finger. The staff revised the problem on 08/10/22 to include a pressure ulcer to his sacrum. The problem included an intervention for a treatment to the coccyx wound daily due to actual skin impairment. The Care Plan included R43 was resistive to cares and had limited physical mobility which required limited to extensive assistance of one to two staff for bed mobility, toileting, and transfers. R43 at times may be dependent on staff for transfers. The hospital Health Summary dated 07/15/22 included an active diagnosis of a sacral decubitus ulcer with an onset date of unknown. The Nursing: admission Eval - V9-V4 located under the assessment tab in the EMR dated 07/15/22 revealed R43 did not have any pressure ulcers. The Braden Scale for Predicting Pressure Sore Risk dated 07/16/22 assessed R43 with a score of 15 indicating at risk. The eInteract Transfer Form V5 located under the assessment tab in the EMR dated 07/18/22 revealed R43 did not have any pressure ulcers. The hospital History of Present Illness dated 07/18/22 revealed R43 had a past history of decubitus sacral ulcers and under the physical exam section included a coccygeal wound approximately 3.0 by 1.5 by 0.6 centimeters (cm). The Nursing: admission Eval - V9-V4 dated 07/22/22 revealed R43 had a stage two pressure ulcer to his sacrum which measured 1.5 by 1.0 by 0.3 cm. The hospital Patient Health Summary dated 07/18/22 for R43 included a diagnosis of a pressure ulcer, stage three (full thickness loss of skin usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Review of the EMR lacked a Nursing: admission Eval - V9-V4 for when R43 readmitted on [DATE] and the progress notes lacked any nursing assessment information completed upon re-entry on 07/28/22. The Treatment Administration Record (TAR) for July 2022 lacked a treatment order for the pressure ulcer to the coccyx/sacrum. The facility failed to implement a treatment order on 07/28/22 when he re-entered the facility through 07/31/22 (three days). The Nursing: Weekly Skin Evaluation - V2 dated 08/04/22 for R43 lacked an assessment of a pressure area. The Skin and Wound Evaluation V5.0 dated 08/09/22 revealed a stage four pressure ulcer, present on admission, present over two years, measuring 2.1 cm by 1.6 cm, by 1.6 cm with 70 percent of the wound base covered with slough (dead tissue, usually cream or yellow in color). The TAR for August 2022, lacked a treatment order for the coccyx/sacrum until 08/07/22. The TAR included a code of 9 indicating other, see progress note on 08/07/22, the staff failed to document they completed the treatment on 08/08/22 and 08/09/22 as evidenced by blanks for those dates, and the first treatment completed by staff was on 08/10/22 (13 days after re-entry to the facility). The wound advanced in stage and size since the assessment on 07/22/22. On 09/13/22 at 07:30 AM R43 observed to be sitting up in his wheelchair, a cushion was in place to the seat of the chair. On 09/13/22 at 09:03 AM Licensed Nurse (LN) F stated R43 had been approached about doing his dressing change, but he wanted to do it later. Dressing supplies were tied up in a bag and stored at the bottom of the treatment cart. On 09/14/22 at 10:46 AM LN H stated he had approached F43 about doing his dressing change and he refused at that time and refused to have surveyor observe the dressing change later. On 09/14/22 at 02:28 PM Administrative Nurse E stated when a resident admits to the facility the staff take a photo of any wounds and alert LN F and Administrative Nurse D. The staff do not stage the wound at that time however they do a full body assessment and the assessment would be documented in the admission nursing evaluation under the assessment tab in the EMR. The nurse would describe the wound and measure it and LN F would stage the wound. LN F analyzes the wound for changes and notifies the physician and Administrative Nurse D. On 09/14/22 LN H stated he did not know when R43's pressure ulcer developed but when he took care of him prior to admission to the facility in June he did not have a pressure ulcer at that time. LN H stated when a resident returns to the facility from the hospital a head to toe skin assessment would be completed and documented. On 09/14/22 at 05:10 PM R43 stated the wound on his bottom developed several years ago, he hadn't been sleeping in a bed and was staying in a chair when it developed. R43 stated he has had two surgeries to the area and was not sure if it had ever healed. On 09/15/22 at 10:59 AM Administrative Nurse F stated R43 had a stage four pressure ulcer to his sacrum and that he told her it had been there for about three years. Administrative Nurse F stated she did not admit him when he first came on 07/15/22. R43 repositions himself and the facility provided him with a cushion for his chair as he was using a pillow. On 09/15/22 at 01:36 PM Administrative Nurse D stated the staff did not identify a pressure ulcer on admission on [DATE] and he should have had a treatment order in place when he came in on 07/28/22 and the record lacked an order or that a nursing admission evaluation was done. The pressure area should have been assessed upon re-entry on 07/15/22. The facility policy Pressure Injury/Skin Breakdown - Clinical Guidelines dated 06/2022 revealed the nursing staff will, upon admission, completed an evaluation of the residents' skin and resulting risk factors for developing pressure injuries, for example immobility, recent weight loss and a history of pressure ulcers. The staff will examine the skin of a new admission and/or re-admission for ulcerations or indications of a stage one pressure ulcer that has not yet ulcerated at the surface. The facility failed to complete a skin assessment on admission and ensure a treatment intervention was in place resulting with 12 days R43 went without a treatment to a stage three pressure area that advanced to a stage four pressure area. - The Medical Diagnosis tab located in the electronic medical record (EMR) for Resident (R)20 included diagnoses of a pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) stage four (full thickness tissue loss with exposed bone, tendon or muscle) of the sacral (area of the lower back near the spine) region, morbid obesity (a disorder involving excessive body fat, body mass index [BMI] greater than 40), and muscle weakness. The admission Minimum Data Set (MDS) dated [DATE], assessed R20 with a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition and she did not reject care. R20 was totally dependent on staff for bed mobility and transfers. She had an indwelling catheter (tube placed in the bladder to drain urine into a collection bag) and was continent of her bowels. R20 had a stage four pressure area present, a pressure device for her bed and chair, was on a turning/repositioning program, and received nutrition or hydration interventions to manage skin problems. Additionally, she received pressure ulcer and surgical wound care, application of nonsurgical dressing with or without medications other than to feet and application of ointments/medications other than to feet. The Activities of Daily Living (ADL) Care Area Assessment (CAA) dated 04/13/22 revealed R20 had a self-care performance deficit related to her pressure ulcer to her sacrum, activity intolerance, fatigue, and impaired balance. The Pressure Ulcer/Injury CAA dated 04/13/22 revealed R20 had a stage four sacral pressure ulcer and the staff were to provide treatments as ordered and monitor for effectiveness. The staff were to assess/record/monitor wound healing per facility protocol and measure the length, width, and depth where possible. The staff were to follow facility policies/protocol for the prevention/treatment of skin breakdown. R20 was to be assisted to turn/reposition at least every two hours and more often as needed or requested. The Quarterly MDS dated 07/05/22 assessed R20 with the same BIMS score and she continued not to reject care. She required extensive assistance of two or more staff for bed mobility and continued to be totally dependent of two or more staff for transfers. R20 continued to have the urinary catheter in place and continence of her bowels. She continued with a stage four pressure area present, a pressure device for her bed and chair, was on a turning/repositioning program, and received nutrition or hydration interventions to manage skin problems. Additionally, she continued to receive pressure ulcer care, application of nonsurgical dressing with or without medications other than to feet and application of ointments/medications other than to feet The Care Plan dated 09/04/22 revealed R20 had bowel incontinence and the staff were to check her every two hours and assist with toileting as needed. She had a stage four pressure ulcer to her sacrum that was present on admission. The staff were to provide treatments as ordered and monitor for effectiveness. The staff were to assess/record/monitor wound healing per facility protocol and measure the length, width, and depth where possible. The staff were to follow facility policies/protocol for the prevention/treatment of skin breakdown. R20 was to be assisted to turn/reposition at least every two hours and more often as needed or requested. The Care Plan revealed R20 did not get out of bed very much and was dependent on two or more staff for bed mobility and transfers. The Order tab in the EMR revealed an order dated 08/11/22 which instructed the staff on R20's sacral wound care. The staff were to cleanse the wound with wound cleanser to irrigated, apply calcium alginate (highly absorbent dressing made of soft, non-woven fibers made from seaweed or kelp), fill loosely with gauze, cover with a dry dressing, daily and as needed. The Weight/Vitals tab located in the EMR revealed R20 weighed 200.9 pounds on 09/03/22. The Skin and Wound Evaluation V5.0 dated 09/06/22, revealed the stage four pressure area measured 6.9 centimeters (cm) by 5.2 cm by 2.0 cm and currently receiving treatment of Bactrim (medication used to treat bacteria infections) for wound infection. On 09/12/22 at 10:45 AM, observed R20 in her room in bed. An air mattress was in place and was set on 350 pounds. R20 was laying on her back. A green wedge pillow was on the bedside table. On 09/12/22 at 10:46 AM, R20 stated she had a wound on her bottom and the staff used a wedge sometimes to position her on her side. On 09/12/22 at 03:37 PM, observed R20 resting in bed positioned on her back. The green wedge pillow remained on the bedside table. On 09/12/22 at 03:38 PM, R20 stated the nurse had not done her wound care yet, had said she was going to do it later, and she had not come back to do it yet. R20 stated she had not been positioned on her side. On 09/13/22 at 07:35 AM R20 in her room positioned slightly to her left side. The air mattress continued to be set to 350 pounds. On 09/13/22 at 09:12 AM R20 remained in bed with the wedge to her right side and appears it is beside her and not tilting her position on the bed. The head of the bed was in a slightly elevated position. On 09/13/22 at 09:13 AM, R20 stated she can feel some pressure to her bottom. On 09/13/22 at 09:14 AM, Certified Nurse Aide (CNA) O and CNA P enter room to turn R20. The wedge pillow was beside her and her position did not change when the staff removed it. CNA O and CNA P used the turn sheet under her to move her to the right and placed the wedge pillow to her left side. The staff failed to check R20 to ensure she had not had a bowel movement or if the dressing to her sacrum was intact. On 09/13/22 at 10:50 AM, Administrative Nurse F stated R20's dressing gets frequently contaminated with bowel, as the wound was less than half a cm from her rectum and numerous treatments had been tried. Administrative Nurse F stated sometimes the dressing had to be changed half a dozen times a day. On 09/13/22 at 10:52 AM, CNA M was in R20's room to assist Administrative Nurse F perform the dressing change to her sacral area. CNA M removed the wedge pillow and turned R20 to her side. The sacral wound lacked a dressing over the wound and a piece of calcium alginate remained. There was blood on the chux (disposable incontinence pad) under R20. On 09/13/22 at 10:55 AM, R20 stated the staff took the dressing off because it had stuff on it. On 09/13/22 at 10:57 AM, Administrative Nurse F measured the sacral wound after cleansing. The wound measured 8.3 cm by 5.8 cm, by 3 cm. On 09/13/22 at 11:19 AM, Administrative Nurse F stated the staff should have let her know the dressing was not there, did not get report today, and did not know how long the dressing had been off of the wound. The staff should turn her every two hours completely so they can see if she is clean and if the dressing is in place. R20 does not like to be positioned on her side and the wedge was in place about as far as she will let us. On 09/13/22 at 02:18 PM, after Certified Medication Aide (CMA) R and Activity Staff Z transferred R20 to the bed with the mechanical lift, they removed the lift sling and Activity Staff Z placed the wedge pillow to R20's left side, leaving the incontinence brief in place without checking to see if R20 was clean or if the dressing was in place to her sacral wound. CMA R and Activity Staff Z checked the brief after surveyor questioned and both responded the brief was okay. On 09/13/22 at 02:30 PM, CMA R and Activity Staff Z stated R20 wears a brief while in the bed and she did not feel comfortable without it. The staff failed to check to see if the dressing was intact when they repositioned R20 at 09:14 AM who had not been repositioned since the observation at 07:35 AM, indicating R20 did not have a dressing in place to her wound for more than three hours. On 09/14/22 at 04:46 PM, Administrative Nurse D stated the air mattress settings are set up when the mattresses are brought in based on the resident weight. If the resident weighed for example, 300 pounds, then the mattress setting should be set for 300 pounds. The facility staff know how to adjust them and there had not been any staff monitoring them to ensure they were on the right setting. On 09/15/22 at 11:04 AM, Administrative Nurse F stated that there are times R20 was not aware of her stool incontinence and she prefers to just have a chux under her and not a brief. On 09/15/22 at 01:19 PM, Administrative Nurse D stated when a dressing was loose or missing to a wound, she expected the staff to notify the nurse so the dressing can be replaced. When the staff are turning her, they should check to see if she had a bowel movement and if the dressing is in place. The facility policy Pressure Injury Treatment Guidelines dated 08/2022 revealed the purpose of this procedure was to provide guidelines for the care of the existing pressure injury and the prevention of additional pressure injury(s). Interventions included maximizing the potential for healing. The staff were to notify the supervisor if the resident refuses the procedure or interventions and report other information in accordance with facility policy and professional standards of practice. The facility failed to ensure R20's air mattress was at the appropriate settings and failed to ensure a dressing remained in place at all times, to minimize the risk of infection to the stage four pressure ulcer. - Review of the resident's (R)11's, Physician Orders, dated 09/01/22, revealed diagnoses which included, open wound of lower back and pelvis, local infection of skin subcutaneous tissue and multiple pressure ulcer with the highest stage four. The admission Minimum Data Set (MDS) dated [DATE], documented the Brief Interview for Mental Status (BIMS) score was not completed with severe cognitive ability. She was totally dependent on staff for all activities of daily living (ADL's) using a w/c. The resident was at risk for pressure ulcers, had one or more pressure ulcers, and currently had one stage two and one stage four present on admission. The resident used a pressure reducing device in the chair and bed. The electronic medical record (EMR) recorded the resident admitted to a hospital on [DATE], with one unhealed stage four pressure ulcer which continued as present on admission. The resident reentered the facility on 08/15/22, with the stage four pressure ulcer. The Care Plan dated 07/12/22, identified current pressure ulcers and directed staff to provide treatment and care to promote healing and prevent the development of further pressure ulcers. The care plan lacked instructions for the specific settings on the resident's special pressure relief bed mattress and monitoring for effectiveness. The progress notes, dated 08/27/2022 at 06:40 AM, documented the resident had bilateral heels noted to be red and boggy. The left heel: 5.5 centimeters (cm) by 4.5 cm, and the right heel: 2.3 cm by 2.5 cm. The resident had heel protectors in place. On 09/14/22 at 08:16 AM, the resident rested on the back, on a low air loss alternating mattress which felt very firm to the touch. The digital setting on the control panel at the foot of the bed displayed the setting at 300. Additionally, the resident had bilateral off load boots on her lower extremities. On 09/14/22 at 9:12 AM, Licensed Nurse (LN) I came in the room and checked the resident's legs and bilateral boots with positioning. LN I when questioned explained she knew nothing about the bed settings. She assumed the settings were made by the technician that set-up the low air loss mattress. She confirmed the current setting was at 300 and that the mattress had a very firm to touch surface. On 09/14/22 at 10:07 AM, Certified Medication Aide (CMA) LLL and an additional Certified Nurse Aide (CNA) turned, repositioned, and provided incontinence care to the resident in the bed. On inquiry both staff reported they did not know anything about the settings on the special mattress. They both confirmed the setting was 300 on the display at the foot of the bed. On 09/14/22 at 03:07 PM, Administrative Nurse E, confirmed the mattress setting was 300. She stated she was not aware of the criteria for the proper setting for the mattress that she assumed the mattress company representative calculated and set the mattress up. She confirmed the resident was on the mattress when she developed the stage two wounds on her heel. She stated that was why they initiated the use of the offload boots. The staff at the facility did not adjust or check the mattress settings. On 09/14/22 at 02:40 PM, Administrative Nurse E stated she contacted the manufacturer of the mattress to get the instructions for the settings. She provided the data sheet which documented the settings for the mattress should be set at the resident's weight to be effective. Administrative Nurse E verified the residents weight average was 177 to 185. The current mattress setting of 300 was not effective nor appropriate for the resident to provide proper pressure relief and comfort. The manufacturer's Air Force 1000 Instruction for Use guide, dated 2002, documentation included please read the instructions for use carefully before setting up and using the device. Pay special attention to the warnings and other safety information. Use of genuine components are essential for optimum performance of the anti-decubitus air alternating pressure mattress. Center the patient on the mattress. Adjust the mattresses' internal pressure according to the weight by using the weight in pounds. The facility failed to ensure the resident received the appropriate special air loss mattress setting to promote healing and to prevent new ulcers from developing for this resident with a history of chronic skin ulcers. - Review of resident (R)113's Physician Order Sheet, dated 09/05/22, revealed diagnoses that included malignant neoplasm (tumor) of the lung, adult failure to thrive and osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain. The resident admitted to the facility on [DATE] with an order for hospice services. The admission Minimum Data Set (MDS), dated [DATE], assessed the resident with severely impaired cognitive status with altered level of consciousness that comes and goes. The resident required extensive assistance of two staff for bed mobility with no impairment in functional range of motion in the lower and upper extremities. The resident was incontinent of bowel and bladder. The resident had a life expectancy of less than six months and was on hospice care. The resident was at risk for pressure ulcer and had no unhealed pressure ulcers at the time of this assessment. The resident had a pressure reducing device to his bed and chair and was on a turning and repositioning plan. The Pressure Ulcer Care Area Assessment CAA, dated 08/28/22, assessed the resident was at risk for pressure ulcers possible due to end of life and decrease in appetite that may cause pressure related injuries or Kennedy ulcers (an area of skin breakdown due to terminal illness and multi organ failure). The resident was incontinent of bowel and bladder and required extensive assistance of two staff for toileting and incontinence care, the resident's skin may be exposed to prolonged moisture that may cause irritation and breakdown. The resident does have very thin and fragile skin. The Care Plan, reviewed 09/05/22, instructed staff the resident had a pressure wound to his left elbow, mid spine and right hip. Staff instructed to cleanse the right hip area with wound cleanser, apply xeroform (Vaseline dressing) and apply skin prep to the peri wound (tissue around the wound). The care plan lacked the need for heel protectors until 09/13/22, lacked pressure relieving mattress and turn and reposition schedule. The resident received hospice services and the facility was to coordinate for durable medical equipment. The Nursing admission Evaluation, dated 08/24/22, documented the resident had scattered bruising to his arms legs and torso. A Nursing Weekly Skin Evaluation, dated 08/31/22 documented redness on the right ankle, left buttock, unspecified sole of left foot arch area and old fading bruises to the ribs and mid back with two to three plus edema in the right lower extremity. Review of the Skin Wound Note, dated 09/03/22, documented the resident had a seven-centimeter (cm) area to his right hip with skin shearing and barrier cream and dry dressing applied. A Nursing Weekly Skin Evaluation, dated 09/07/22 documented the resident had dry red skin with open areas. Redness to the right outer ankle, right elbow, left buttock and sole of left foot arch area and two to three plus edema in the right lower extremity. The evaluation contained no measurements of these areas for description. A Nurse Note, dated 09/08/22, indicated an air mattress to be delivered this evening or in AM. A Physician's Order, dated 09/08/22, instructed staff to cleanse the right hip with wound cleanser, apply skin prep to the surrounding tissue and cover with Vaseline gauze and foam dressing every other day. An SBAR (a communication tool that documents the situation, background, assessment and recommendations) dated 09/09/22, indicated the resident developed a stage two pressure area to the right hip. A Nurse Note, dated 09/12/22, documented staff turned the resident every two hours to prevent further breakdown. Observation, on 09/13/22 at 07:30AM, revealed the resident positioned in bed leaning onto his left side with his head slightly elevated and oxygen per nasal canula. Interview, on 09/13/22 at 7:45 AM, with Certified Nurse Aide (CNA) O stated the resident did not eat breakfast and did not wake up. Observations continued every 15 minutes through 10:45 AM, in which the resident remained in the same position. Observation, on 09/13/22 at 10:45 AM, revealed the resident positioned in bed on his left side. The resident had sheepskin heel protectors on his heels bilaterally, however, they were not positioned to protect his heels which were positioned directly on the mattress. Administrative Nurse F, and Certified Nurse Aide (CNA) O provided urinary incontinence care. Administrative Nurse F removed a piece of foam dressing from his left hip which revealed an area of red brown unblanchable (area that does not refill with redness when pressure is applied, then released) tissue and measured the area as 4.9 by 7.5 centimeter (cm) with no depth and classified the area as deep tissue injury. Administrative Nurse F cleansed the area, applied Vaseline gauze dressing and a foam dressing. Administrative Nurse F proceeded to remove the right hip dressing and cleansed the area. The right hip ulcer contained two islands of yellow slough, and one area of shearing. Administrative Nurse F measured the ulcer as 5.3 by 7.0cm and a depth of 0.1cm with 50 percent (%) of the wound covered with epithelial (exterior skin) tissue, 20% granulation (new connective and microscopic blood vessels that form on a wound's surface during healing) and 20% slough (dead tissue). Administrative Nurse F stated the resident's wound deteriorated as his terminal status progressed. Both of the resident's heels had black areas approximately 2 cm diameter. The resident lacked a pressure relieving air mattress. Observation, on 09/13/22 at 2:40 PM, revealed the resident positioned on his back in bed with a pillow under his right hip. The resident had the sheepskin heel protectors on bilaterally, but the heels remained directly on the mattress. The resident lacked an off-loading device. Observations continued at 15-minute intervals and revealed the resident did not reposition himself, and staff did not reposition the resident until a skin check was requested at 05:36 PM. CNA PP and CNA QQ did not know when staff repositioned the resident last. CNA PP and CNA QQ provided incontinence care to the resident for a smear of stool and urinary incontinence. CNA QQ and PP repositioned the resident onto his right side with a pillow under his left hip and in between his knees. His heels lay directly on the bed without offloading. Interview, on 09/13/22 at 04:30 PM, with Administrative Staff Q and Administrative Nurse D, revealed the facility did place an order for a pressure relieving air mattress, but cancelled it as it was thought the resident was going to transfer to another facility. Administrative Nurse D stated the resident's status had declined and did not think he would be transferring. Administrative Nurse D stated she would expect staff to provide off loading of the resident's heels and provide repositioning at least every two hours for the prevention of further skin breakdown. The facility policy Pressure Injury Treatment Guidelines, revised 08/2022, instructed staff to redistribute pressure, implement pressure redistributing devices in accordance with the resident's assessed needs. The facility [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 66 residents with 22 selected for review, which included five residents reviewed for dialysis. Based on observation, interview, and record review, the facility failed to coordinate dialysis (a process that filters wastes and fluids from the body when the kidneys fail) care of pre and post weight assessments and details of the dialysis sessions with the dialysis provider as required for five of the five residents reviewed, 02 Resident (R)53, R41, R118, and R262. Findings included: - Review of Resident (R)50's Physician Order Sheet, dated 08/09/22, revealed diagnoses included end stage renal (kidney) disease and diabetes (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). The Significant Change Minimum Data Set (MDS), dated [DATE], assessed the resident with normal cognition, and received dialysis. The Care Plan, revised 08/25/22, instructed staff the resident received dialysis on Mondays, Wednesdays and Fridays. Staff to monitor for edema and to obtain vital signs and weight per protocol. The Dialysis Communication in the Assessment tab of the electronic medical record revealed the following areas of concern: The monthly weight of 216lbs., obtained on 06/06/22, auto-populated as the pre and post weight for 07/04 and 06/29/22 The monthly weight of 209 lbs., obtained on 07/04/22, auto-populated as the pre and post weight for 07/6, 07/08, 07/11, 07/13, 07/15, 07/18, 07/25, and 07/27/22. The monthly weight of 211 lbs., obtained on 08/08/22, auto-populated as the pre and post weight for 08/10, 08/17, 08/22, 08/24, 08/29 and 08/31/22. The monthly weight of 215.5 lbs., obtained on 09/03/22, auto-populated as the pre and post weight for 09/12 and 09/14/22. Interview, on 09/14/22 at 11:45 AM, with Licensed Nurse (LN) H, revealed he did not weigh the resident pre or post dialysis, but did fill out a paper form Dialysis/Nursing Facility Communication Form. LN H also sent the form with the other dialysis residents R53, R41, R118 and R262 that go to dialysis, but the dialysis providers did not or seldom returned the form to the facility. LN H stated he did complete the post dialysis assessment in the electronic record assessment, Dialysis Communication which included vital signs, and dialysis site status. LN H verified he did not obtain weights on the dialysis residents pre and post dialysis services. Interview, on 09/15/22 at 10:04 AM, with the resident, revealed the nursing facility did not obtain any pre and post weights for her and confirmed that the dialysis provider does not give her a Communication Form to give back to the nursing facility. Interview, on 09/15/22 at 10:57 AM, with Administrative Nurse D, revealed she would expect staff to obtain the Dialysis/ Nursing Facility Communication Form from the dialysis provider after each treatment. Administrative Nurse D did not know staff did not obtain pre/post weights or that the pre and post weights auto-populated from the monthly weight. The facility policy Dialysis, Care for a Resident with reviewed 01/2021, instructed staff communication between the community and dialysis facility shall contain information if medication was administered, new orders and results of labs, and current vital signs. The pre and post dialysis documentation should contain the pre-dialysis weight and upon return from dialysis staff to document the post weight that may come from the center, and any complications. The facility failed to maintain a system to obtain pre and post dialysis weights and/or to effectively communicate with the dialysis provider to ensure the resident received adequate dialysis care. This also affected the other four residents that receive dialysis.

The facility reported a census of 68 residents. Based on observation, interview, and record review, the facility failed to provide necessary housekeeping and maintenance services to the facility kitchen areas, to maintain a sanitary, orderly, and comfortable interior for the residents of the facility. Findings included: - The initial tour of the kitchen on 09/12/22 at 10:03 AM, revealed the following items/areas of concern: 1. The door frame and the inside of the door entering the kitchen had areas of chipped paint. 2. Under the counter of the dishwashing area near the entry door lacked cove base and the strip of cove base under the dishwasher pipes was loose. 3. The wall below the dishwasher had a large area of chipped paint. 4. The ice machine drain hoses were in the drain and the drain lacked a cover. On 09/14/22 at 03:03 PM, the kitchen tour revealed the following concerns: 1. The ceiling by the light above the microwave area had a crack approximately one-and-a-half feet long. 2. The light cover near the dishwasher had dead insects/debris in it. 3. The cove base was missing in the small storage area, near the handwashing sink, behind the metal shelf, and to the right of the doorway. The facility failed to provide necessary maintenance and housekeeping services to maintain a comfortable sanitary environment in these kitchen areas for the residents of the facility.

The facility reported a census of 68 residents. Based on observation, interview, and record review, the facility failed to maintain an effective pest control program, for the residents of the facility, with the presence of flies in various areas of the facility. Findings included: - The pest control Service Inspection Report dated 06/24/22 revealed the facility reported no issues. The fly lights were checked, and glue boards replaced as needed. The kitchen drains were dusted, and an application of an aerosol fly bait were applied to multiple areas for small fly control. The pest control Service Inspection Report dated 07/29/22 revealed the facility reported no issues. The fly light glue boards were replaced as needed and an application of an aerosol fly bait to multiple areas of the kitchen for small fly control. The pest control Service Inspection Report dated 08/25/22 revealed all fly light glue boards were replaced as needed and applied an aerosol fly bait to the dish sink area in the kitchen for small fly control. On 09/14/22 at 11:34 PM, observation in the kitchen food areas revealed four live flies that were landing on serving items and cake being cut up for the residents' lunch meal. On 09/14/22 at 12:09 PM, observation revealed one fly floating in the steam table water pan. On 09/14/22 at 03:03 PM, observation revealed live flies about in the kitchen food areas. On 09/14/22 at 04:07 PM, observation revealed a few live flies about in the dining room on the dementia unit. On 09/14/22 at 04:16 PM, observation revealed 10 live flies about in the dining area across from the east nurse's station. On 09/15/22 at 10:04 AM, Maintenance Staff U stated the fly lights have been present in the facility for at least a year when the facility switched pest control companies, they check them when they come in for their routine inspection. If the staff have complaints, I make attempts to address it and I have not had anyone come to me for flies. Maintenance staff U stated he was not sure what could be done about it. The facility did not provide a policy for pest control. The facility failed to maintain an effective pest control program with staff failure to report these various areas with fly concerns to maintenance who could inform the pest control company a possible change in program may be needed.

The facility reported a census of 68 residents. Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions for the residents of the facility. Findings included: - During the initial tour of the kitchen on 09/12/22 at 10:10 AM, Dietary Staff EE was cleaning the refrigerator in the kitchen using a sanitizing solution. Testing of the cleaning solution, at that time, revealed 0 ppm result when checked with a test strip. The liquid sanitizing solution the staff used to sanitize the refrigerator lacked any actual sanitizing solution in the water. On 09/12/22 at 10:12 AM, Dietary Staff EE stated the solution should be between 150-200 ppm and she had made the cleaning solution five to 10 minutes prior to this testing. Dietary Staff EE stated she checks the cleaning solution twice during her shift. Dietary staff EE made a new solution which tested at 400-500 ppm. On 09/14/22 at 11:34 AM, Dietary Staff EE was placing the pureed cake from the mixer into a bowl upon entry into the kitchen to observe pureed diet meal prep. On 09/14 22 at 11:39 AM. four live flies noted in the kitchen, landing on serving bowls and a cake that was being cut into pieces for lunch. On 09/14/22 at 12:09 PM, a dead fly floated in the water of a steam table pan. On 09/14/22 at 03:03 PM, the kitchen tour revealed the following concerns: 1. The hall trays stacked together and stored on a metal shelf ready for use had moisture between them. 2. The three - compartment sink under the wall air conditioner had chipped floor tile below it. The air conditioner above it had dirty vents and the windowsill under it had a black powder substance covering it. 3. The metal shelf above the stove had debris and grease on it, with darkened oil -appearing runs on the front side of the shelf. 4. The knife holder on the wall had dust build-up across the top by the holes where the knives inserted to be stored. 5. The stored plates stacked together ready for use had moisture between them. 6. The trays under the stored plastic bowls contained crumbs over them. 7. The vent near the steam table had lint build-up around the edges. 8. The ceiling by the light above the microwave area had a crack approximately one-and-a-half feet long. 9. The ceiling vent by the refrigerator had lint build-up. 12. The west side unit refrigerator, near the nurse's desk had debris over the top and in the inside of it also. On 09/14/22 at 04:07 PM, observation of the kitchen area revealed the following areas of concern: 1. A layer of dust to the top of the refrigerator. 2 .Inside of the refrigerator had a dried yellow/brown substance at the bottom and on the three shelves of the door. 3. An opened bottle of salad dressing lacked a opened date. 4 .Under the sink of the counter in the dining room was a measuring cup uncovered which lacked a date of the white powder substance. 5. The cabinet under the sink had a dried brown liquid spill and sawdust. The cabinet contained a box of disposable straws. On 09/14/22 at 04:16 PM, observation of the dining/kitchen area near the east nurse's station revealed a note on the refrigerator that read Nutrition staff responsible for cleaning daily. Further observation of the area revealed the following concerns: 1. The refrigerator contained a 32-ounce container of expired plain yogurt. 2. In the door of the refrigerator there were two uncovered plastic cups, which lacked a date, of a dried white substance. 3. The door of the refrigerator had two undated, opened bottles of salad dressing and an undated opened bottle of mayonnaise. 4. There was a square container of an unknown food substance that lacked a date. 5. One undated round refillable bottle of what appeared to be salad dressing. 6. A covered plate lacked a date, which contained a dry piece of meat loaf, mashed potatoes, and green beans. 7. An undated plastic bag of what appeared to be cut up pieces of cantlope with an orange liquid at the bottom of the bag. 8. A foam container with plastic lid with a red liquid was undated. 9. A round plastic container with a red lid that was loose contained dried shredded meat and with eating utensils inside of it. 10. A small plastic undated container with a light orange colored liquid in it. 11. Three individual slices of cheese lacked a date located in the bottom left drawer. 12. The microwave on the counter had 3 areas of finish missing on the inside frame where the door rests against it exposing rust. The inside of the microwave had multiple brown splatters on the inside, the turntable had a large area of a yellow/orange substance, the top of the microwave had debris on it and the door had multiple dried smears on the inside. 13. In the drawer below the microwave was an undated, uncovered, measuring cup with a white powder substance in it. 14. The cabinet below the sink had a dried brown liquid spot and sawdust. On 09/14/22 at 04:31 PM, Dietary Staff BB stated he thought the white powder was thickener. Dietary Staff BB became aware of the concern issues in the area at this time and reported not being aware dietary staff were responsible for cleaning the refrigerator. The facility policy Sanitization dated 12/2021 revealed all kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish, and protected from rodents, roaches, flies, and other insects. Sanitizing of environmental surfaces must be performed with one of the following solutions: 1. 50-100 ppm chlorine solution. 2. 150-200 ppm quaternary ammonium compound (QAC). 3. 12.6 ppm iodine solution. The Food Services Manager will be responsible for scheduling staff for regular cleaning of kitchen and dining areas. Food service staff will be trained to maintain cleanliness throughout their work areas during all tasks, and to clean after each task before proceeding to the next assignment. The facility policy Food Safety Storage dated 06/2022 revealed food will be stored and protected in a safe sanitary manner and in accordance with the Food Code. Dietary employees will maintain clean food storage areas at all times. Wrap, cover or seal all refrigerated foods and label and date per Food Code guidelines. Once opened, foods that have been stored in dry storage should either be refrigerated or sealed in airtight containers and returned to dry storage. The facility failed to store, prepare, and serve food under sanitary conditions for the residents in the facility.

The facility reported a census of 68 residents. Based on observation, interview and record review, the facility failed to maintain an effective quality assurance committee that identified, developed and implemented appropriate intervention plans of action in a timely manner to ensure the residents received adequate needed quality care from the facility. Findings included: - Interview, on 09/15/22 at 01:41 PM, with Administrative Staff A, revealed the facility Quality Assurance Committee met monthly and the last meeting was on 09/2021. Administrative Staff A revealed the committee identified concerns with pressure ulcers, restorative and therapy communication issues, maintenance and housekeeping issues, and food temperatures. However, these areas were not corrected with the QAA interventions as the resurvey included these areas and others as reflected below: 1.) Refer to F 561: The facility failed to provide individual choices for the one sampled dependent Resident (R)55 related to his preferences for clothing selection 2.) Refer to F F677: The facility failed to ensure three of the sampled residents, Resident (R)4, R39, and R46, who required staff assistance, received appropriate personal hygiene assistance for cleaning and trimming of their fingernails. 3.) Refer to F 684: The facility failed to coordinate care between hospice services and the facility to ensure the resident's advance directive for no resuscitative measures determined and carried out. 4.) Refer to F 686: The facility failed to provide treatment to Resident (R)43 in a timely manner to a pressure ulcer on the coccyx (the area below the sacrum commonly known as the tailbone), failed to ensure a dressing was in place and the air mattress settings were correct for R20 who had a stage four (full thickness tissue loss with exposed bone, tendon or muscle) pressure ulcer of the sacral (area of the lower back near the spine) region, failed to ensure R11's who admitted with a stage four sacral wound and acquired an unstageable pressure area due to eschar to both heels that the air mattress was at the appropriate setting. Additionally, the facility failed to implement interventions and turn/reposition appropriately for R113 who developed an unstageable and a stage two pressure ulcer and failed to ensure R30's heels were positioned appropriately, had an air mattress in place, and failed to turn/reposition appropriately resulting in development of deep tissue injuries to bilateral heels. 5.) Refer to F688: The facility failed to ensure five of the seven sampled residents received restorative nursing services to increase range of motion, prevent further decrease in range of motion, and/or prevent decrease in mobility. Resident (R)16 received therapy services and then no restorative nursing services and declined in range of motion and walking ability; R112 who received no restorative services after therapy; R34, R30, and R12 for no restorative nursing program when they had range of motion impairments. 6.) Refer to F 689: The facility failed to ensure safe transfer techniques for one resident (R) 34 of the four residents reviewed. 7.) Refer to 690: The facility failed to ensure one of the two residents, Resident (R)20's catheter drainage bag remained below bladder level and failed to drain the catheter bag in a sanitary manner to prevent urinary tract infection. 8.) Refer to 692: The facility failed to ensure adequate parameters of nutritional status for one of the two residents reviewed. The facility failed to ensure Resident (R)20 received her diet as ordered, failed to involve the Registered Dietician with R20's desire to lose weight, failed to appropriately monitor the resident's weight, and failed notify the physician of the significant weight loss. R20 experienced a 10.96 percent weight loss from 03/31/22 to 04/29/22, a 10.6 percent weight loss from 05/23/22 to 06/30/22, and a 23.55 percent weight loss from 03/31/22 to 09/03/22. 9.) Refer to F 695: The facility failed to provide appropriate respiratory care to maintain respiratory equipment to prevent the spread of infection, for the one sampled Resident (R) 55. 10.) Refer to F 698: The facility failed to coordinate dialysis (a process that filters wastes and fluids from the body when the kidneys fail) care of pre and post weight assessments and details of the dialysis sessions with the dialysis provider as required for five of the five residents reviewed, 02 Resident (R)53, R41, R118, and R262. 11.) Refer to F 760: The facility failed to ensure Resident (R) 24, remained free from a significant medication error when staff failed to administer antihypertensive medication (a drug used to lower blood pressure) as ordered by the physician on 117 instances between 07/05/22 through 08/21/22. This failure resulted in a hypertensive crisis (a severe increase in blood pressure that can lead to a heart attack, stroke, or other life-threatening health problems), which required hospitalization intervention/treatment. The facility policy Quality Assessment and Performance Improvement Plan and Program reviewed 09/2020, instructed staff the facility shall develop implement and maintain an effective comprehensive data driven Quality Assessment and Performance Improvement program (QAPI) that focuses on indicators of the outcomes of care and quality of life. The facility failed to maintain an effective quality assurance committee that identified, developed and implemented appropriate intervention plans of action in a timely manner to ensure the residents received adequate needed quality care from the facility.

The facility reported a census of 68 residents. Based on observation, interview and record review the facility failed to handle, store, process and transport linens to prevent the spread of infection for the residents of the facility. Findings included: - On the laundry tour, on 09/15/22 at 07:58 AM, with Maintenance/Laundry Director staff U, explained that the laundry staff had not arrived for work so the laundry tour would in effect demonstrate how the laundry was left by the laundry staff the previous evening. The tour with maintenance/Housekeeping Director U revealed the following concerns: 1. The washing machine was full of clothes. 2. The vinyl floor throughout the laundry was heavily soiled. 3. The soiled laundry room had four plastic bags of soiled laundry directly on the floor. 4. The soiled laundry sorting area with three uncovered barrels of soiled laundry had linen spilling over the sides of the barrels. 5. The laundry room walls in the clean linen processing area had loose peeling sheet rock with multiple holes in the sheet rock, which created an unsanitizable surface. 6. Corroded hot water pipes extended from the wall in the clean linen processing area. 7. Multiple shelves were made of bare wood, and used to store clean linen, which could not be sanitized. 8. The dryer room with peeling paint from the ceiling. 9. Two dryers with a thick coating of lint over the filters. 10. Clothes were inside the dryer tumble cage from the night before. 11. The linen cart used to transport clean linen throughout the facility with a worn unsanitizable shredded cover. 12. Two rolling baskets/carts used to transport linen with broken unsanitizable rubber gasket around the top of the baskets, which was in direct contact with clean laundry. On 09/15/22 at 08:25 AM, Maintenance/Laundry Staff U, confirmed the above findings. He stated he did not know if the clothes had been left wet in the washing machine or was preloaded to start processing. The staff had not deep cleaned the floor in six months to a year and the laundry staff had not cleaned the floor or lint filters from the night before as they should. He stated he expected staff to clean the dryer filters every three loads and at the end of each shift. He reported the facility was undergoing renovation, but he was not aware of a scheduled renovation of the laundry area. Maintenance laundry staff U stated it was not appropriate for staff to leave laundry in the washer or dryer overnight, that all linen should be fully processed prior to staff leaving for the day. Additionally, he reported the soiled linen should be contained to prevent cross contamination and the spread of infection. The facility lacked a policy to address the processing and maintenance of the laundry to prevent cross contamination and the spread of infection. The facility failed to handle, store, process, and transport linens to prevent the spread of infection for the residents of the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - Review of Resident (R)207's Physician Order Sheet, dated 02/22/21, revealed diagnoses of acquired absence of right below the knee amputation (amputation is the removal of a limb by trauma, medical illness, or surgery), and personal history of urinary tract infection. The admission Minimum Data Set (MDS), dated 01/14/21, assessed the resident with a moderate cognitive impairment and dependence on two staff assistance for transfers using a mechanical lift, to roll side to side in the bed and dressing. The ADL (Activity of Daily Living) Function Rehabilitation Potential Care Area Assessment (CAA), dated 01/27/21, documented that the resident was dependent on staff for ADL's. The Urinary Incontinence and Indwelling Catheter CAA, documented that the resident had an indwelling urinary catheter. The care plan, dated 03/01/21, documented the resident had an indwelling urinary catheter related to surgery. A Physician order, instructed staff to insert a Foley Catheter 18 French with a 10 cubic centimeters (cc) bulb for urinary retention and right lower extremity surgical wound healing. Change as needed when compromised. Observations, on 03/02/21 at 07:58 AM, showed the resident lying in bed with the head of bed elevated, coloring and watching television. The resident's urinary catheter's collection bag was on the end of the bed and lacked a dignity bag, (covering over the urine collection bag). The resident's urine in the collection bag was visible from the hallway. On 03/02/21 at 03:26 PM, the resident's urine collection bag remained without a privacy bag covering it. On 03/03/21 at 08:23 AM, the resident rested in bed, with the urine collection bag not in a privacy bag nor covered with a sheet or blanket. Interview, on 03/02/21 at 02:07 PM, with Certified Nurse Aide (CNA) S revealed that residents with catheters and urinary collection bags should be inside of a privacy bag. Interview, on 03/03/21 at 04:11 PM, with Licensed Nurse (LN) J revealed catheter urinary collection bags should be placed in a dignity bag (covering). Interview, on 03/03/21 at 04:18 PM, with CNA PP revealed a catheter urinary collection bag should be placed in a privacy bag (covering). The facility policy for, Indwelling Catheters, with a review date 01/21/21, advised staff to cover the urine bag to provide the resident with privacy. The facility failed to ensure the resident received care in a dignified manner, when the facility staff failed to place her catheter's urine collection bag in a privacy bag to maintain her dignity. The facility reported a census of 58 residents with 17 residents sampled, including four residents reviewed for dignity. Based on observation, interview, and record review, the facility failed to provide care and services to maintain and enhance the dignity of two of the four sampled residents including Resident (R)37, regarding privacy while undressed in the shower room, and R 207, regarding not having a dignity bag for coverage of his urinary catheter bag. Findings included: - The Physician Order Sheet (POS), dated 02/10/21, documented Resident (R)37 had a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The Annual Minimum Data Set (MDS), dated [DATE], documented the staff assessment for cognition revealed the resident had severely impaired cognition. She required extensive assistance of two staff for dressing and total assistance of one staff for personal hygiene. The Activities of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 04/16/20, did not trigger. The ADL care plan, dated 01/28/21, instructed staff the resident preferred showers on Tuesdays and Saturdays during the day. Staff were to avoid scrubbing of the resident's skin while bathing. Review of the Tasks tab in the resident's electronic medical record (EMR), from 02/01/21 through 03/02/21, revealed the resident required limited to total assistance of one staff for showering. On 03/02/21 at 09:27 AM, the resident sat, naked, on the shower chair in the shower room, awaiting Certified Nurse Aide (CNA) M to give her a shower. As resident sat naked, CNA P opened the shower room door wide and exited the shower room, exposing the resident to anyone passing in the hallway. On 03/02/21 at 09:27 AM, CNA P confirmed she exposed the resident when she walked out of the shower room. CNA P stated, she would have closed the privacy curtain, but the privacy curtain was not there. On 03/02/21 at 09:27 AM, CNA M stated, residents should not be exposed while they are naked. Staff had not covered the resident with a towel before leaving the shower room and this exposed the resident to anyone in the hall. The privacy curtain was not hanging in the shower room. On 03/03/21 at 08:59 AM, Maintenance staff U stated, he did not know that the shower room previously lacked a privacy curtain. On 03/02/21 at 09:27 AM, Licensed Nurse (LN) H stated, staff should have covered the resident before opening the door to the shower room. The resident was not able to cover herself to shield herself from being visible to anyone in the hallway. On 03/03/21 at 08:51 AM, Administrative Nurse D stated, the staff previously removed the privacy curtain to be laundered. She would expect staff to cover a resident before they exited the shower room in order to not expose them to anyone in the hall. The facility policy for Resident Rights, effective January 2020, included: The facility will make every effort to assist each resident in exercising her rights to assure that the resident was always treated with dignity. The facility failed to maintain and enhance the dignity of this dependent resident while undressed in the shower room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 58 residents. The sample contained 17 residents, with three residents reviewed for activities of daily living (ADL). Based on observation, interview, and record review, the facility failed to adequately assist two of the three residents to maintain their personal hygiene needs, Residents (R)14 for fingernail hygiene/shaving and R17 for bathing. Findings included: - The signed Physician Order Sheet (POS), dated 02/03/21, documented R14's diagnoses included schizophrenia (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), dementia (progressive mental disorder characterized by failing memory, confusion), and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness). A Significant Change Minimum Data Set (MDS), dated [DATE], documented R14 had short and long-term memory problems, and severely impaired cognitive skills for daily decision making. He was completely dependent on staff for personal hygiene. R14's care plan, dated 09/02/20, instructed R14 was completely dependent on staff for his personal hygiene needs. On 03/01/21 at 12:14 PM, R14 had several days growth of beard, tousled hair, and long fingernails with dark debris underneath, creating an overall unkempt appearance. On 03/02/21 at 07:55 AM, R14's face was free of hairs, but he still had the same dark debris under his one fourth inch long fingernails. On 03/02/21 at 11:50 AM, R14 had the dark debris under his one fourth inch long fingernails. On 03/02/21 at 12:29 PM, R14 sat the dining room, prior to the lunch meal, with a dried, flaky orange debris around his lips. On 03/02/21 at 10:22 AM, Certified Nursing Assistant (CNA) MM stated the staff do everything for him, even feed him. The staff use two people for most of the resident's cares. On 03/02/21 at 03:28 PM, Licensed Nurse I stated the staff wash the resident hands before and after meals and at other times if needed. Nurses monitor the care of the CNAs. The hands, nails and faces of the residents should be kept clean. On 03/02/21 at 04:15 PM, CNA Q stated the staff wash the resident hands before and after meals. On 03/03/21 at 03:24 PM, CNA OO stated when residents go for a meal the staff wash the residents' hands. When they come back from a meal the staff use a warm rag and wipe their hands and faces if they need it also. On 03/04/21 at 12:58 PM, Administrative Nurse D stated she expected that residents look neat and clean, be shaved, have clean faces, and their hands should be clean, including clean nails. A facility policy titled Quality of Life Activities of Daily Living, dated 01/2020, instructed staff to ensure residents who are unable to carry out activities of daily living receive the necessary care and services to maintain good grooming and personal hygiene. The facility failed to provide services needed to maintain good grooming and personal hygiene for this dependent resident. - The Physician Order Sheet (POS), dated 02/03/21, documented Resident (R)17 had a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The Annual Minimum Data Set (MDS), dated [DATE], documented the staff assessment for cognition revealed the resident had severely impaired cognition. She had no rejection of care during the look back period. The resident required limited assistance of one staff for transfers. Bathing did not occur during the look back period. The Activities of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 12/19/20, did not trigger. The Quarterly MDS, dated 09/21/20, documented the resident had a Brief Interview for Mental Status (BIMS) score of 7, indicating severely impaired cognition. She had no rejection of care during the look back period. The resident required limited assistance of one staff for transfers. Bathing did not occur during the look back period. The care plan for ADLs, dated 12/25/20, instructed staff the resident needed assistance of at least one staff for showers. Review of the Tasks tab in the resident's electronic medical record (EMR), from 02/01/21 through 03/02/21, revealed she only received two showers. Staff documented the resident refused three showers during these dates. On 03/01/21 at 11:03 AM, the resident had greasy hair and her face was unshaven with visible long facial hairs . On 03/02/21 at 09:10 AM, the resident continued to have greasy hair and an unshaven face. On 03/02/21 at 01:25 PM, Certified Nurse Aide (CNA) P stated, staff were to offer a shower to residents three times. If the resident refused three times, the staff would notify the nurse. This resident did not refuse cares and was cooperative with staff. CNA P was unable to state why staff had not bathed the resident and confirmed the resident had greasy hair and her face was unshaven. On 03/02/21 at 03:05 PM, CNA O stated, staff shower the resident on the day shift. CNA O confirmed the resident had greasy hair and was unshaven. The resident did not have behaviors and was cooperative with staff. On 03/03/21 at 10:35 AM, Licensed Nurse (LN) G stated, if a resident refused their shower, the staff were to offer three times. If the resident refused three times, staff were to notify the nurse. LN G stated staff had not notified her of the resident refusing her showers. The resident was easily redirected. On 03/03/21 at 08:51 AM, Administrative Nurse D stated, residents are scheduled for three showers per week. Staff are to document shower refusals on the computer. Three showers in the past 30 days was not adequate. The facility policy for Quality of Life Activities of Daily Living, dated January 2020, included: Residents who are unable to carry out activities of daily living will receive the necessary care and services to maintain personal hygiene. The facility failed to provide this dependent resident with adequate bathing opportunities and assistance to shave her facial hairs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 58 residents with 17 residents sampled, including five residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to safely transport two of the five sampled Residents (R)17 and R 37 while in their wheelchairs. Findings included: - The Physician Order Sheet (POS), dated 02/03/21, documented Resident (R)17 had a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The Annual Minimum Data Set (MDS), dated [DATE], documented a staff assessment for cognition which revealed the resident had severe cognitive impairment. She required limited assistance of one staff for locomotion on the unit and used a wheelchair for mobility . The Activities of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 12/19/20, did not trigger. The Quarterly MDS, dated 09/21/20, documented the resident had a Brief Interview for Mental Status (BIMS) score of seven, indicating severely impaired cognition. She required supervision for locomotion on the unit and used a wheelchair for mobility . The ADL care plan, dated 12/25/20, instructed staff the resident required a wheelchair for mobility at times, when having knee pain. Review of Tasks in the resident's electronic medical record (EMR), dated 02/01/21 through 03/02/21, revealed the resident used a wheelchair for locomotion with limited assistance of one staff for mobility. On 03/02/21 at 09:10 AM, Activity staff Z, propelled the resident in her wheelchair from the dining room to the TV room on the unit. The wheelchair lacked foot pedals and the resident's socked feet skimmed along on the floor during the transport. On 03/03/21 at 12:00 PM, Certified Nurse Aide (CNA) P, propelled the resident in her wheelchair into the dining room for lunch. The wheelchair lacked foot pedals and the resident's socked feet skimmed along on the floor during the transport. On 03/02/21 at 09:10 AM, Activity staff Z stated, the resident did not have foot pedals on her wheelchair because the resident would propel herself using her feet at times. Staff would only push the resident in her wheelchair when the resident required assistance. On 03/02/21 at 01:25 PM, CNA P stated, staff do not have foot pedals on the resident's wheelchair because she likes to propel herself using her feet. When staff propel the resident in the wheelchair, they tell the resident to lift her feet. CNA P confirmed the resident's feet skimmed along on the floor during the transport. On 03/03/21 at 10:35 AM, Licensed Nurse (LN) G stated, residents who are not able to hold their feet up while being transported in their wheelchairs should have foot pedals. Residents feet should not ever skim the floor. On 03/03/21 at 08:51 AM, Administrative Nurse D stated, residents' feet should not skim the floor while being pushed by staff in their wheelchairs. The facility lacked a policy regarding wheelchair pedals for resident safety. The facility failed to safely transport this dependent resident in her wheelchair without any foot pedals to prevent accidents. - The Physician Order Sheet (POS), dated 02/10/21, documented Resident (R)37 had a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The Annual Minimum Data Set (MDS), dated [DATE], documented the staff assessment for cognition revealed the resident had severely impaired cognition. The resident required limited assistance of one staff for locomotion on the unit with the use of a wheelchair. The Activities of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 04/16/20, did not trigger. The Quarterly MDS, dated 01/18/21, documented the staff assessment for cognition revealed the resident had severely impaired cognition. She required extensive assistance of one staff for locomotion on the unit with the use of a wheelchair. The ADL care plan, dated 01/28/21, instructed staff the resident used a wheelchair for ambulation, at times. Review of Tasks in the resident's electronic medical record (EMR), dated 02/01/21 through 03/02/21, revealed the resident used a wheelchair for locomotion with independent to extensive assistance of one staff. On 03/01/21 at 10:37 AM, Certified Nurse Aide (CNA) P, transported the resident in her wheelchair down the hall. The wheelchair lacked foot pedals and the resident's feet skimmed along on the floor during transport. On 03/01/21 at 12:09 PM, CNA N, transported the resident in her wheelchair to the dining room for lunch. The wheelchair lacked foot pedals and the resident's feet skimmed along on the floor and underneath the wheelchair seat. On 03/01/21 at 12:09 PM, CNA N stated, staff did not use foot pedals on the resident's wheelchair because she would propel herself at times. On 03/02/01 at 09:27 AM, CNA P stated, the resident did not have foot pedals on her wheelchair because the resident would propel herself at times using her feet. Staff do not put foot pedals on the wheelchair when they propel her. On 03/03/21 at 10:35 AM, Licensed Nurse (LN) G stated, residents who are not able to hold their feet up while being transported in their wheelchairs should have foot pedals. Residents feet should not ever skim the floor. On 03/03/21 at 08:51 AM, Administrative Nurse D stated, residents' feet should not skim the floor while being pushed by staff in their wheelchairs. The facility lacked a policy regarding wheelchair pedals for safety. The facility failed to safely transport this dependent resident in her wheelchair without any foot pedals to prevent accidents.

The facility reported a census of 58 residents with 17 selected for review which included three residents reviewed for urinary catheter. Based on observation, interview and record review, the facility failed to provide sanitary catheter handling to prevent urinary tract infection and failed to provide a catheter anchoring device to prevent meatus trauma for one resident (R)8 of the three residents reviewed for urinary catheter. Findings included: - Review of R8's Physician Order Sheet, dated 12/20/20, revealed diagnoses included urinary retention and urinary tract infection (ESBL: extended spectrum beta lactamase, an antibiotic resistant bacterium,) cerebral vascular accident (sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain,) diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin,) and chronic kidney disease (a gradual loss of kidney function). The Annual Minimum Data Set (MDS), dated 09/19/20, assessed the resident with moderate cognitive impairment, required limited assistance of one staff for toileting and personal hygiene and occasionally incontinent of urine. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 09/19/20, assessed the resident required at least one staff for toileting. The care plan updated 01/07/21, instructed staff the resident had a urinary catheter and to monitor the output. The resident had frequent urinary tract infection with frequent antibiotic use and poor kidney function. A Physician Order, dated 12/29/20, instructed staff to insert a number 16 urinary catheter to direct drainage for urinary retention and to monitor for signs and symptoms of infection and obstruction. Observation, on 03/01/21 at 11:21 AM, revealed the resident seated on her bed, with approximately seven inches of the catheter tubing laying directly on the floor. Observation, on 03/02/21 at 08:00 AM, revealed the resident seated in her wheelchair in the dining room, with approximately seven inches of the catheter tubing laying directly on the floor. Certified Nurse Aide (CNA) S propelled the resident to her room with the catheter tubing dragging along directly on the floor. CNA S transferred the resident into her bed and found the resident did not have an anchoring device (a device to hold the catheter in place to prevent the urinary meatus [external opening of the urinary tract] trauma) for her catheter. CNA S stated the catheter should have an anchoring device. Observation, on 03/02/21 at 02:30 PM, revealed CNA NN emptied the resident's urine collection bag and found the catheter lacked an anchoring device. CNA NN confirmed the catheter should have an anchoring device. Interview, on 03/03/21 at 10:30 PM, with Licensed Nurse (LN) I, stated the resident had a urinary catheter for urine retention and confirmed that urinary catheters should have an anchoring device. The facility Urinary Catheter policy, reviewed 01/2021, instructed staff to ensure the catheter remained secured with a leg strap to reduce friction and movement at the insertion site. The catheter tubing should be strapped to the resident's inner thigh. Staff instructed to keep the catheter tubing and drainage bag off the floor. The facility failed to provide catheter care in a sanitary manner to prevent urinary tract infection and failed to provide an anchoring device for this resident's catheter to prevent urinary meatus trauma.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 58 residents with 17 residents sampled, including two residents reviewed for behaviors. Based on observation, interview, and record review, the facility failed to effectively manage behaviors for one of the two sampled Residents (R)107. Findings included: - The Medical Diagnosis tab in the resident's electronic medical record (EMR) revealed the resident had diagnoses, including: Parkinson's (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness) and Schizoaffective disorder (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought). The resident's Minimum Data Set was not complete as the resident admitted to the facility on [DATE]. The Behavior care plan, dated 03/01/21, instructed staff the resident displayed verbal and physical aggression, cursing and yelling and refusal of medications and cares. Staff were to administer medications, as ordered and to monitor and document effectiveness of the medications. Staff were to assist the resident in developing appropriate methods of coping and interacting such as 1:1, watching TV, or listening to music. Staff were to protect the rights and safety of other residents. On 03/01/21 at 12:15 PM, the resident sat in his wheelchair in the hall. The resident yelled threats and obscenities to staff. Licensed Nurse (LN) E attempted to talk with the resident, but the resident cursed and threatened the LN. On 03/01/21 at 12:51 PM, the resident remained in his wheelchair in the hall. The resident continued to yell threats and obscenities to staff. On 03/02/21 at 07:55 AM, the resident sat in his wheelchair outside of the dining room, cursing loudly. On 03/02/21 at 09:17 AM, the resident sat in his wheelchair in the hall. The resident was cursing at unseen others. On 03/01/21 at 12:15 PM, Certified Nurse Aide (CNA) N stated the resident was new to the facility and she did not know what to do about the resident's behaviors. CNA N did not want to get too close to the resident due to being afraid the resident would hit her. On 03/02/21 at 08:45 AM, CNA P stated, she would try to redirect the resident by telling him everything was okay. CNA P stated she did not know what other any interventions for his behaviors would be. On 03/03/21 at 10:35 AM, LN G stated, she was not sure what more the staff could do about the resident's behaviors other than try to redirect him. On 03/04/21 at 09:11 AM, Administrative Nurse D stated, the resident's behaviors occurred daily since his admission. The staff had been attempting to redirect the resident. The staff are trying to learn what works for the resident's behaviors. The facility policy for Problematic Behavior Management, effective January 2020, included: The staff will identify pertinent interventions, other than medications, for the nature and causes of the individual's problematic behavior. The facility failed to effectively manage this dependent resident's behaviors.

The facility reported a census of 58 residents with two medications rooms. Based on observation, interview and record review, the facility failed to properly log discontinued medications in a timely manner in one of the two medication rooms that served 36 residents. Findings included: - Observation, on 03/03/21 at 01:44 PM, revealed a box for discontinued medications (no controlled substances) in the medication room which was overflowing. The box contained 92 physician ordered medication cards. The cards contained a variety of medications which included examples of: four cards of Bactrim DS (an antibiotic), for a total of 37 doses, 21 doses of Zoloft (an antidepressant), 63 doses of Gabapentin, 30 doses of Risperidone (an antipsychotic), 21 doses of Lexapro (an antidepressant), 21 doses of Cymbalta (an antidepressant), nine doses of Trazodone (an antidepressant) 420 doses of Reglan (a medication to treat heartburn) , packaged injectable medications, intravenous fluids, liquid medications, a Combivent inhaler, 11 boxes of Albuterol for nebulizer inhalation(breathing treatment,) fifteen insulin pens, and three opened tubes of Diclofenac (topical anti-inflammatory pain medication). Interview, on 03/03/21 at 01:44 PM, with Licensed Nurse (LN) I, revealed the nursing staff did not log the discontinued medications or sign how many doses were left on the cards prior to placing them in the box. Interview, on 03/03/21 at 2:45 PM, with Administrative Nurse D, revealed she used a computer program to log the discontinued medications, but the facility no longer required nursing staff to document how many doses were left prior to placing the medications in the discontinued box. Administrative Nurse D stated the medications could not be returned to the pharmacy because of COVID-19 guidelines. Administrative Nurse D stated she did the documentation and destruction as time allowed. The facility policy Discarding and Destroying Medications, dated 01/2021, instructed staff that medications that can't be returned to the dispensing pharmacy shall be destroyed as permitted by state regulation. The facility failed to adequately log and destroy discontinued medications in a timely manner to ensure accurate disposition of the discontinued physician ordered medications for the 36 residents on this nursing unit.

The facility reported a census of 58 residents. Based on observation, interview and record review, the facility failed to maintain floors in the kitchen, dry food storage room, pot and pan storage room and walk in freezer in a clean and sanitary manner. Findings included: - Observation, on 03/01/21 at 08:17 AM revealed the walk-in freezer floor contained debris and accumulation of grime. The floor in the kitchen contained black scrapes and grime over the surface, and beneath the dishwasher on the dirty and clean sides, revealed the floors with cracks in three tiles which exposed the under flooring and had an accumulation of grime and debris. Observation, on 03/03/21 at 03:30 PM, during the environmental kitchen tour with Dietary staff EE, revealed the following in need of cleaning: 1.) The floor in the clean pot and pan storage room revealed the threshold contained three cracked tiles and the perimeter contained a build-up of grime. 2.) The floor in the dry food storage room contained a perimeter with a build-up of grime. 3.) The floor behind the ice machine, contained grime and accumulation of debris. The floor area also contained a dry stained towel. Interview, on 03/03/21 at 3:30 PM, with Dietary staff EE, confirmed the above and stated staff required to clean the floors daily, but they needed stripping and waxing. Dietary staff EE stated the ice machine had a leak in the past, and she thought staff used the towel to mop up the water. The facility Sanitation policy, reviewed 02/2021, instructed staff the kitchen shall be kept clean and free of litter. Kitchen and dining room surfaces not in contact with food should be cleaned on a regular schedule and frequently enough to prevent accumulation of grime. The facility failed to ensure the floors in the kitchen areas were maintained in a clean and sanitary manner.

The facility reported a census of 58 residents. Based on observation, interview and record review, the facility failed to store, prepare, and serve food to the residents of the facility in a sanitary manner. Findings included: - Observation on 03/01/21 at 08:17 AM, revealed the walk-in freezer floor contained debris and a frozen discolored substance . A frozen package of broccoli directly directly on the floor, and a cardboard box containing frozen broccoli sat directly on the floor. Three boxes of ½ cup servings of ice-cream sat directly on the floor. Observation on 03/03/21 at 03:00 PM during the environmental tour of the kitchen with Dietary staff EE, revealed the following areas of concern: 1.) Stacks of the food warmer covers were stacked uncovered beneath the paper towel dispenser adjacent to the handwashing sink, which allowed drops of water from staff reaching for the paper towels to drop directly onto the lids. 2.) The electrical cords connecting the steam table to the wall outlet at the level of the food surface were covered with grime. 3.) Six knobs on the stove contained grime. 4.) The coffee maker surfaces contained grime, and three coffee pots contained highly stained interiors. 5.) Three stacked clean steam table pans contained wet interiors. Two stacked large steam table pans contained wet interiors. 6.) Five carts containing clean dishes and serving items contained debris and grim on the shelves. 7.) A two-shelf cart containing flour and sugar contained debris. 8.) Three bins containing cooking/serving utensils contained debris in the interior bottom. Interview, on 03/03/21 at 03:30 PM, with Dietary staff EE, confirmed the above and stated staff had specific days to clean various areas of the kitchen. The facility Sanitation policy, reviewed 02/2021, instructed staff equipment, food contact surfaces and utensils shall be washed and sanitized and allowed to air dry whenever practical. Kitchen and dining room surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime. The facility failed to store, prepare, and serve food in a sanitary manner to prevent the spread of food borne illness for the residents of the facility.

The facility reported a census of 58 residents. Based on observation, interview and record review, the facility failed to ensure kitchen equipment including the stove, oven, and the steam table, remained in repair and in good working order to ensure consistent temperatures during cooking and serving of the residents' food. Findings included: - Observation on 03/03/21 at 11:00 AM, revealed Dietary staff EE obtained the temperature of the barbeque chicken pieces on the steam table and found the temperature registered 150 degrees Fahrenheit. Dietary staff EE advised Dietary staff DD to place the chicken in the oven to ensure the temperature raised to 165 degrees. At 11:45 AM, Dietary staff EE, obtained a temperature of the chicken of 165 degrees, and removed the chicken to the steam table. Observation, on 03/03/21 at 11:00 AM revealed Dietary staff FF, cut the butterscotch cookie bars with difficulty. Dietary Staff FF stated, at that time, that the bars were hard around the perimeter and softer on the interior of the pan due to the way the oven heated. Observation of the stove revealed the ovens contained compromised seals around the doors to both ovens. The seal of the (facing the stove) right oven contained a build-up of a black burnt on substance and had sections of the seal missing. The seal of the (facing the stove) left side contained an approximate two inch section of the seal protruding outside the oven door. The steam table was missing four knobs to control the temperature. The stove contained a missing light plate, exposing a small light bulb. Interview, on 03/03/21 at 03:30 PM, with Dietary Staff EE, confirmed the above issues. Dietary Staff EE stated the steam table maintained the same temperature, but staff could not change the temperature. The facility Sanitation policy, reviewed 02/2021, instructed staff to keep seals, hinges, and fasteners to ensure proper use and cleaning. The facility failed to ensure the stove, oven, and steam table remained in good repair and operating order to ensure consistent temperatures during cooking and serving of the residents' food.