**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure treatment for a non-pressure related skin impairment was completed as ordered by the physician for Resident #65 and failed to appropriately assess and treat a cigarette burn on Resident #59's thumb following the injury. Actual harm occurred on 06/16/21 when Resident #65 was admitted to the hospital and diagnosed with osteomyelitis (inflammation of bone or bone marrow, usually due to infection) of the second left toe had to have the second left toe amputated. Treatment for non-pressure related skin impairment to the toe area was not completed as ordered after 05/13/21. This affected two residents (#59 and #65) of three residents reviewed for hospitalization and/or skin conditions. Findings Include: 1. Record review revealed Resident #65 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), type two diabetes mellitus, anxiety, depression, insomnia, constipation, right below the knee amputation, deep vein thrombosis (DVT) and congestive heart failure (CHF). Review of the facility Non-Pressure Skin Condition Record, dated 04/28/21 revealed a skin tear to the left second toe of Resident #65 measured 3.0 centimeters (cm) long by 2.0 cm wide by 0.1 cm deep. On 05/03/21 the area was documented to measure 3.3 cm wide by 2.5 cm long, by 0.3 cm deep. Review of a physician order, dated 05/03/21 revealed an order was obtained at that time to cleanse the second toe to the left foot with soap and water, pat dry, apply calcium alginate and apply a clean, dry dressing. The order for the dressing was to be completed every other day and as needed until resolved. Review of the Treatment Administration Records (TARs) for 05/2021 and 06/2021 revealed physician ordered treatments were documented as being completed to the area on the left second toe until 05/13/21 when the treatment was discontinued on the TAR and documentation on the TAR identified the area had resolved. Continued review of the assessment records revealed on 05/31/21 the area to the left second toe measured 4.8 cm long, by 2.2 cm wide, by 0.2 cm deep. On 06/07/21 the area measured 4.8 cm long, by 2.2 cm wide, by 0.2 cm deep. Weekly Skin Integrity reviews for Resident #65, dated 04/28/21, 05/05/21, 05/12/21, 05/19/21, 05/26/21, 06/02/21 and 06/09/21 revealed the resident was documented to have a skin tear to the second left toe during each assessment. There was no evidence after 05/13/21 staff had identified the lack of treatment order or need for treatment to the area. Review of a podiatry visit note, dated 06/16/21 revealed Resident #65 was seen due to a large, infected wound to his left second toe which contained necrotic tissue and had bone visible. An order was obtained on 06/16/21 to send Resident #65 to the emergency room (ER) for further evaluation. Review of hospital documentation, dated 06/16/21 through 06/18/21 revealed Resident #65 was admitted to the hospital with diagnoses including osteomyelitis of the second left toe resulting in the second left toe being amputated. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/12/21 revealed Resident #65 was assessed to require extensive assistance from one staff member for bed mobility. Review of the care plan, revised on 08/25/21 revealed Resident #65 had the potential for altered skin integrity related to diagnoses including diabetes mellitus, depression and chronic obstructive pulmonary disorder (COPD). Interventions included weekly skin checks, follow physician order for preventive treatment and Braden scale quarterly. On 09/01/21 at 1:55 P.M. interview with the Director of Nursing (DON) verified the physician ordered treatment for Resident #65's wound to the left second toe had not been completed after 05/13/21 as staff had incorrectly documented on the TAR the area was resolved. The DON verified weekly skin assessments and weekly wound measurements showed the wound remained to the second toe from 04/28/21 through 06/16/21 when the resident was sent to the hospital and his second left toe was amputated. On 09/01/21 at 2:30 P.M. Resident #65 was observed with a small scabbed area to the second left toe which had been amputated. 2. Review of the medical record for Resident #59 revealed an admission date of 11/02/16 with diagnoses including schizophrenia and chronic obstructive pulmonary disease. Review of the MDS 3.0 assessment, dated 08/06/21 revealed the resident had moderate cognitive impairment with a Brief Interview for Mental Status score of 10. On 08/30/21 at 12:01 P.M. and 08/31/21 at 3:06 P.M. Resident #59 was observed to have a band-aid on his left thumb. Interview with Resident #59 on 08/31/21 at 3:06 P.M. revealed he burned his thumb while smoking. Interview with Licensed Practical Nurse (LPN) #999 on 09/01/21 at 2:20 P.M. revealed Resident #59 had a burn on his thumb from a cigarette. She stated he smokes his cigarettes down to the end and refuses to use any adaptive smoking equipment. She stated the burn was noticed a couple days ago. She stated a treatment was being completed to the burn daily. Observations, at that time, revealed LPN #999 removed the band-aid from Resident #59's thumb. The resident was observed with a dime sized red area with the top layer of skin gone from the back of his thumb. LPN #999 cleaned his thumb, applied Bacitracin with zinc ointment, and applied a new band-aid. Review of the medical record revealed no documentation regarding the burn on the thumb. There was no evidence the physician was notified, no evidence of a physician's order for a treatment to the thumb, no documentation of any treatment being done to the thumb, and no evidence of a non-pressure skin condition form being initiated to monitor the condition of the burn. Review of the facility policy titled Care of Skin Tears, Abrasions and Minor Breaks revealed the purpose of the procedure was to guide the prevention and treatment of abrasions, skin tears, and minor breaks in the skin. The policy revealed to obtain a physician's order as needed and document physician notification in the medical record. Generate a non pressure form and complete. The policy revealed an abrasion was an area on the skin that had been damaged by friction, scraping, rubbing or trauma. The policy indicated to complete an in-house investigation of causation, how the resident tolerated the procedure, any complications and interventions implemented to prevent additional abrasions. Interview with the Director of Nursing on 09/02/21 at 8:00 A.M. confirmed non pressure skin conditions were to be monitored on a non pressure skin condition record when identified and weekly. Interview with LPN #999 on 09/01/21 at 2:20 P.M. confirmed there was no documentation related to the burn on Resident #59's thumb. She confirmed there was no evidence the physician was notified, a treatment was ordered, or a skin condition form was initiated to assess and monitor the burn.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to provide nutritional interventions, including timely and adequate assistance with meals to Resident #65 to prevent weight loss. Actual harm occurred when Resident #65, who was dependent on staff for eating and assessed to sustain a 20.9% severe weight loss in 180 days (on 02/12/21 the resident weighed 240.6 pounds and on 08/10/21 the resident weighed 190.2 pounds loss of 50.4 pounds in 180 days) did not receive adequate or timely assistance with meals on 08/30/21 and 09/01/21. This affected one resident (#65) of four residents reviewed for weight loss. Findings include: Record review revealed Resident #65 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), type two diabetes mellitus, anxiety, depression, insomnia, constipation, right below the knee amputation, deep vein thrombosis (DVT) and congestive heart failure (CHF). Resident #65's weight on admission [DATE]) was documented to be 254 pounds. Review of Resident #65's meal intake records revealed in January 2021 staff documented the resident was consuming 75% to 100% of meals. Continued meal intake records from February 2021 through April 2021 revealed the resident's intakes had decreased. On 03/26/21 the resident was assessed to weigh 230 pounds. The next recorded weight, on 04/07/21 was 210 pounds. This reflected a 20 pound weight loss in 12 days. There was no evidence a re-weight was obtained at that time. In April 2021 the dietitian recommended nutritional shakes twice a day which were documented as being provided as ordered. Review of the care plan, dated 05/14/21, revealed Resident #65 was at risk for imbalanced nutrition related to diuretic use, diabetes mellitus, hypertension and COPD. Interventions included to monitor for signs or symptoms of dysphagia such as pocketing or holding food in mouth, dental consult as needed and assist with feeding as needed. Review of the meal intake records from June through August 2021 continued to reflect the resident had decreased intake for meals. There was no evidence the facility re-assessed to cause of the decreased intakes at this time or implemented new interventions to increase meal intake or prevent additional weight loss. Review of the facility Vital Sign and Weight Record from 02/12/21 through 08/10/21 revealed Resident #65 experienced a 20.9% severe weight loss in 180 days. On 02/12/21 Resident #65's weight was 240.6 pounds (lbs). On 08/10/21, Resident #65's weight was 190.2 lbs, a loss of 50.4 lbs in the past 180 days. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/12/21 revealed the resident's cognition was intact with a Brief Interview for Mental Status (BIMS) score of 15. This resident was assessed to require extensive assistance from one staff member for bed mobility and set-up assistance and supervision for meals. The MDS revealed the resident had a significant weight loss of over 10% in six months and was not on a prescribed weight loss regimen. Review of the dietary progress notes, dated 08/12/21 revealed the weight history for Resident #65 showed a significant weight loss over 180 days and a moderate weight loss over 90 days. The weight loss over 180 days had been contributed to a large fluid loss and decline in the residents status. There was no evidence of any new nutritional interventions being considered or implemented at this time. In addition, record review revealed no evidence the resident was prescribed diuretic medication. Review of the corresponding nursing progress notes from 01/13/21 to 08/30/21 revealed no evidence Resident #65 had any type of edema noted. Observations of the resident throughout the annual survey, from 08/30/21 through 09/01/21 revealed no signs of edema noted. In addition, there were no notes related to diuretic use. On 08/30/21 at 12:30 P.M. observation of the lunch meal revealed meal trays arrived to the unit on the dining cart at this time. Observation on 08/30/21 at 12:38 P.M. revealed State Tested Nursing Assistant (STNA) #777 placed the lunch tray for Resident #65 on his bedside table and placed the table over the resident. STNA #444 opened the containers and cut up the chicken Parmesan on the resident's plate and walked out of the room. Observation on 08/30/21 at 12:56 P.M. revealed Resident #65 was leaning to his left side in the bed attempting to use his fork to pick up pieces of chicken but was unable to and was pushing the food off his plate onto his tray. No staff members were observed in the room while the resident was attempting to consume his lunch meal. Observation on 08/30/21 at 1:06 P.M. revealed Resident #65 was slumped to his left side in the bed with his lunch meal in front of him on the bedside table and had consumed less than 10% of his lunch meal. Multiple gnats were observed to have landed on the resident's lunch meal. Resident #65 was rolling a substance around in his mouth and spit out a piece of unchewed chicken Parmesan which was covered in saliva onto his tray. Interview with Registered Nurse (RN) #99 and Licensed Practical Nurse (LPN) #58 on 08/30/21 at 1:06 P.M. verified gnats had landed on Resident #65's lunch meal, the resident was slumped over to his left side, and the did not appear to be able to chew the chicken Parmesan on his lunch tray or feed himself his lunch meal. RN #99 revealed she would get an order to downgrade Resident #65's diet from regular texture to a dysphagia advanced diet. Observation on 08/30/21 at 1:10 P.M. revealed LPN #58 began cutting the food on Resident #65's tray into smaller pieces and was observed to feed the resident his lunch meal. Interview with STNA #777 on 08/30/21 at 1:20 P.M. revealed staff did not provide assistance with meals to Resident #65 as he was able to feed himself after his meal was set-up. Observation on 09/01/21 at 12:12 P.M. revealed STNA #959 removed the lunch meal tray for Resident #65 from the dining cart, took it into his room, removed the lid from his plate, and set it on his tray table which was located next to his bed out of his reach as he was lying in bed with the head of his bed not raised. STNA #959 exited the room without opening the container of milk or removing the lids from the container of ice cream of cup of coffee. Observation on 09/01/21 at 12:30 P.M. revealed Resident #65 continued to lie in bed with the head of his bed not raised. The lunch meal for Resident #65 continued to remain on the tray table next to his bed which was not within his reach. Gnats were observed to be landing on the residents meat loaf, mashed potatoes, and peas. Interview with Resident #65 on 09/01/21 at 12:30 P.M. revealed the resident stated he was hungry, wanted to eat and thought he could sit up by himself to be able to eat his lunch meal but was unable to do so. Attempts to obtain additional information from the resident regarding assistance with meals/feeding could not be obtained as the resident was noted to have some cognitive impairment and could only answer simple questions and would not engage in conversation with the surveyor. Observation on 09/01/21 at 12:42 P.M. revealed STNA #959 walked back into the room of Resident #65 and attempted to sit him up on the side of the bed but was unable to. STNA #959 raised the head of the resident's bed instead and positioned the tray table containing his lunch meal across him, did not open his container of milk or remove the lids from his coffee and ice cream, and then exited the room. Resident #65 was observed to ask where his milk was after STNA #959 exited the room, but no staff members were around to hear his question. Interview with Resident #65 on 09/01/21 at 12:47 P.M. revealed he was unsure where his container of milk was at and stated staff normally opened it and handed it to him. Observation on 09/01/21 at 12:52 P.M. revealed Resident #65 was picking peas up one at a time with his fingers and was putting them into his mouth. Observation on 09/01/21 at 12:54 P.M. revealed STNA #959 entered Resident #65's room, asked the resident if his food was good, moved the container of milk to the edge of the resident's tray but did not open it, then exited the residents room. Observation on 09/01/21 at 12:56 P.M. revealed Resident #65 picked up his straw from his tray, removed the wrapper, and was attempting to place the straw into the unopened container of milk. Interview with RN #5000 on 09/01/21 at 1:05 P.M. verified only a few peas and one bite of mashed potatoes had been eaten by Resident #65, gnats were flying around the residents food, and the cup of coffee and container of ice cream remained unopened on the residents tray. Interview on 09/01/21 at 2:55 P.M. with Registered Dietician (RD) #1000 revealed she was aware of the weight loss experienced by Resident #65. Dietician #1000 verified the Resident #65 continued to have gradual weight loss every week since being admitted to the facility and was unsure as to why the resident's weight continued to decline. As a result of the interview, there was no evidence the dietician had considered the weight loss a result of the resident requiring and not receiving adequate assistance from staff with meal intake. Resident #65 had a current plan of care intervention to assist with feeding as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure timely dental services were provided for Resident #9 and Resident #65. Actual harm occurred on 09/02/21 when Resident #65, who had been referred for tooth extraction (on 04/27/21) was assessed to have an infected tooth which required antibiotic treatment. The facility failed to ensure a follow up appointment for the extraction was completed timely after the need for the extraction was identified on 04/27/21 resulting in the resident developing an infection. This affected two residents (#9 and #65) of the three residents reviewed for dental services. Findings Include: 1. Record review revealed Resident #65 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), type two diabetes mellitus, anxiety, depression, insomnia, constipation, right below the knee amputation, deep vein thrombosis (DVT) and congestive heart failure (CHF). Review of a physician order, dated 04/20/21 revealed Resident #65 was ordered the antibiotic Clindamycin 150 milligrams (mg) four times a day for 10 days due to an oral abscess. A dental visit progress note, dated 04/27/21 revealed Resident #65 was seen at the facility by the dentist and was recommended to have his one remaining tooth extracted. A referral was left with the facility to send the resident out to have the tooth extracted. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/12/21 revealed Resident #65 was assessed to require extensive assistance from one staff member for bed mobility and set-up assistance and supervision for meals. Review of a physician's order, dated 09/02/21 revealed Resident #65 was prescribed the antibiotic, Amoxicillin 500 mg by mouth three times a day for seven days due to a tooth infection. Interview with the Director of Nursing (DON) on 09/01/21 at 4:00 P.M. verified Resident #65 had been seen by the dentist on 04/27/21 and the dentist had recommended Resident #65 be sent to another dental facility to have his one remaining tooth extracted. The DON was unable to provide evidence the referral had been made or evidence of any follow-up regarding the needed appointment. The DON verified Resident #65 had not been seen by a dentist since 04/27/21 and no follow-up appointment had been scheduled. Interview with Licensed Practical Nurse (LPN) #999 on 09/02/21 at 1:30 P.M. revealed Resident #65 was seen at the facility by the Nurse Practitioner (NP) on this date and the NP had been prescribed antibiotics due the resident's tooth being infected. This was the tooth the dentist had recommended being extracted on 04/27/21. 2. Review of Resident #9's medical record revealed an admission date of 05/07/21 with the admitting diagnoses of chronic obstructive pulmonary disease, vascular dementia, diabetes mellitus, gastrostomy, protein-calorie malnutrition, dysphagia, anemia, metabolic encephalopathy, anxiety disorder, major depressive disorder, constipation, insomnia and hypertension. Review of the resident's admission assessment, dated 05/07/21 revealed the resident had his own teeth with no carried or broken teeth. Review of the resident's comprehensive MDS 3.0 assessment, dated 05/14/21 revealed the resident had clear speech, understood others, made himself understood and had a moderate cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of nine. The resident was dependent on one staff for personal hygiene. The assessment indicated the resident had obvious or likely cavity or broken natural teeth. Review of the resident's plan of care revealed the resident had no plan of care related to the likely cavity or broken natural teeth. Review of the resident's medical record failed to provide any documented evidence the resident had seen or had been offered to be seen by a dentist since admission to the facility. On 08/30/21 at 10:35 A.M. observation of Resident #9 revealed the resident had obvious carries to his teeth. On 09/01/21 at 1:22 P.M. interview with Medical Records #400 verified the resident had not seen a dentist since being admitted to the facility.