Every finding on record at Aidan Senior Living at Reedsport

Based on observation, interview and record review it was determined the facility failed to ensure food was stored properly in 1 of 1 resident refrigerator, and failed to ensure food was stored, prepared, and handled properly in 1 of 1 kitchen. This put residents at risk for food borne illnesses. Findings include: During the initial kitchen observation on [DATE] at 9:18 AM, the following item was found in the cook's freezer: - One unlabeled clear plastic cup with frozen brown liquid inside and no open date. During the initial kitchen observation on [DATE] at 9:22 AM, the following items were found in the walk-in freezer: - One opened and used bag of frozen sliced bananas with no open date. - One opened and used bag of frozen blueberries with no open date. - One opened and used bag of filled square pasta with no open date. - One opened and used bag of frozen cherries with no open date. During the initial kitchen observation on [DATE] at 9:26 AM, the following items were found in the walk-in refrigerator: - One closed plastic container labeled vanilla mousse with a use by date of [DATE]. - One closed plastic container labeled blondie bits with a use by date of [DATE]. - One closed plastic container labeled [NAME] cream with a use by date of [DATE]. - One closed plastic container labeled coffee extract with a use by date of [DATE]. - One closed plastic container labeled chocolate cake with a use by date of [DATE]. - One opened and used bottle of key lime juice with no open date. - One closed plastic container labeled cake with a use by date of [DATE]. On [DATE] at 9:31 AM, Staff 52 (Dietary Aide) acknowledged all items found and stated the policy was for all foods to be labeled with an open date and all expired foods to be discarded. During a review of the resident refrigerator on [DATE] at 12:29 PM, the following item was found: - One bottle of whipped topping with no open date. On [DATE] at 12:33 PM, Staff 5 (Activities Director) acknowledged the item found and stated the policy was for all foods to be labeled with an open date. During the meal tray preparation and meal service on [DATE] at 11:33 AM, the following were observed: - Staff 51 (Cook) did not remove her dirty gloves before portioning out salad mix until instructed. She stated the policy was to change gloves between touching kitchen items and touching food items. - Staff 50 (Cook) did not remove her dirty gloves before touching meatloaf until instructed. She stated the policy was to change gloves between touching kitchen items and touching food items. On [DATE] at 12:12 PM, Staff 49 (Dietary Manager) stated the policy was for staff to change their gloves before touching food items and after touching kitchen items. He also stated the expectation was for all expired foods to be discarded.

Based on interview and record review it was determined the facility failed to follow physician orders for 2 of 5 residents (#s 18 and 19) reviewed for medications. This placed residents at risk for delayed treatment and unmet needs. Findings include: 1. Resident 18 was admitted to the facility in 3/2024 with diagnoses including dementia and insomnia. A 3/2025 MAR instructed staff to instill two drops of Ciprofloxacin (an antibiotic used to treat bacterial infections) in both eyes every two hours for conjunctivitis (also known as pink eye, a bacterial or viral infection, or allergic reaction) for two days, starting on 3/21/25. The MAR referred the reader to Administration Notes on 3/21/25 at 12:30 AM, 2:29 AM, 4:30 AM, and 3/22/25 at 6:30 AM. Administration Notes revealed the following for Resident 18 and Ciprofloxacin: -3/21/25 at 1:52 AM: Resident was asleep, refused. -3/21/25 at 3:30 AM: Resident was asleep. -3/21/25 at 4:17 AM: Resident was asleep. -3/22/25 at 6:46 AM: Resident was asleep. On 3/28/25 at 8:17 AM, Staff 10 (LPN) stated she was instructed not to wake Resident 18 to instill her/his eye drops as she/he became agitated. Staff 10 did not think the physician was notified. On 3/28/25 at 11:50 AM, Staff 1 (Administrator), Staff 7 (DNS), and Staff 49 (Regional Nurse Consultant) confirmed staff should have contacted the physician regarding instructions for when Resident 18 was asleep and did not receive her/his eye drop. 2. Resident 19 was admitted to the facility in 7/2024 with diagnoses including dementia and depression. A review of the signed physician orders dated 1/31/25 instructed staff to administer Rexuliti (used to treat schizophrenia, and as an add-on treatment for major depressive disorder) in the morning for depressive disorder, with a start date of 1/2/25. A 3/2025 MAR instructed staff to administer Rexuliti in the morning for depressive disorder, with a start date of 1/2/25. On 3/6/25, 3/7/25, 3/8/25, and 3/9/25 the MAR referred the reader to Administration Notes. Administration Notes revealed the following for Rexuliti: -3/6/25 was not administered as the medication needed to be ordered from the pharmacy. -3/7/25 waiting for delivery of the medication. -3/8/25 medication was not in stock; the nurse was notified. -3/9/25 medication was not in stock, ordered from the pharmacy. On 3/28/25 at 8:06 AM Staff 8 (LPN) stated Resident 19's Rexuliti did not arrive at the facility from the pharmacy. Staff 8 stated she did not remember if she called the pharmacy on 3/6/24 when she documented Rexuliti needed to be ordered from the pharmacy. On 3/28/25 at 11:44 AM Staff 1 (Administrator), Staff 7 (DNS), and Staff 49 (Regional Nurse Consultant) stated if a medication was not available, the expectation would be for staff to notify the physician to obtain instructions.

Based on interview and record review it was determined the facility failed to ensure a personalized care plan was created for 1 of 1 resident (#4) reviewed for activities. This put residents at risk for lack of personal preferences being honored. Findings include: The facility Care Planning policy, revised 9/2013, indicated the care planning team, including the activities director/coordinator, was responsible for developing an individualized comprehensive care plan for each resident. Resident 4 admitted to the facility in 11/2024 with diagnoses including depression and diabetes. A 12/6/24 Admission MDS indicated Resident 4 had mild cognitive impairment and depression. The MDS also indicated being around animals, doing things with groups of people, doing her/his favorite activities, and going outside to get fresh air in good weather were somewhat important to her/him. A 3/4/25 Activities Participation Review indicated Resident 4 liked independent activities in her/his room, liked to color pictures, liked to watch the deer on the patio, and liked to watch tv in her/his room. Resident 4's care plan, revised on 3/5/25, contained no personalized goals, interventions, or information under the activities focus area. During an interview on 3/28/25 at 12:59 PM, Staff 5 (Activities Director) stated Resident 4's care plan was up to date with personalized goals and interventions. She reviewed the care plan and acknowledged it did not have personalized information about Resident 4's activities. On 3/28/25 at 1:56 PM, Staff 7 (DNS) acknowledged Resident 4's care plan did not have personalization for the activities focus area. She stated the expectation was for care plans to be personalized in all focus areas.

Based on interview and record review it was determined the facility failed to ensure a resident's environment remained free from accident hazards for 1 of 1 sampled resident (#19) reviewed for falls. This placed residents at risk for accidents. Findings include: Resident 19 was admitted to the facility in 7/2024 with diagnoses including dementia and disc degeneration (condition when the discs between the vertebrae in the spine wear down). A 7/26/24 admission MDS revealed Resident 19 sustained a fall in the last two to six months. A Care Plan Report revealed on 7/29/24 Resident 19 required the assistance of one person for toileting. Resident 19 had a history of falls and impaired safety awareness. Interventions included to review information on past falls and attempt to determine the cause of the falls. Record possible root causes and alter and remove any potential causes. A 9/29/24 Unwitnessed Fall investigation revealed on 9/29/24 at 11:27 AM Resident 19 sustained a fall in the bathroom. The CNA reported Resident 19's call light was activated and the CNA found Resident 19 on the floor in the bathroom. The investigation determined it was an isolated incident, and the care plan was not revised. A 11/11/24 Unwitnessed Fall investigation revealed on 11/11/24 at 4:28 PM Resident 19 was found on the floor in her/his bathroom by the CNA. The CNA reported she took Resident 19 to the bathroom, assisted her/him onto the toilet, and gave her/him the call light. The CNA heard the toilet flush and entered the bathroom and found Resident 19 on the floor. It was determined Resident 19's care plan needed to reflect she/he should not be left unattended while in the bathroom. A Care Plan Report revealed on 12/5/24 Resident 19 required assistance of one staff member for toileting and was not to be left unattended while on the toilet. A 12/31/24 Unwitnessed Fall investigation revealed on 12/31/24 at 6:30 AM Resident 19 was found on the floor in the bathroom. Staff 30 assisted Resident 19 on to the toilet in the bathroom and pulled the curtain for privacy. Staff 37 (CNA) and Staff 30 (CNA) were in the resident's room at the time of the fall. Staff 30 and 37 heard Resident 19 fall in the bathroom and responded. On 3/24/25 at 12:24 PM Witness 1 (Family Member) stated Resident 19 sustained three falls. Witness 1 stated staff would assist Resident 19 to the toilet and leave her/him unattended. On 3/27/25 at 9:24 AM Staff 37 stated on 12/31/24 she was working with Resident 19's roommate when Resident 19 fell . Staff 37 stated when a care plan instructed staff not to leave a resident unattended she understood unattended as staff should not leave a resident where they could not be seen. On 3/28/25 at 7:51 AM Staff 30 stated she was straightening Resident 19's bed when Resident 19 fell in the bathroom on 12/31/24. Staff 30 stated she should not have left Resident 19 alone in the bathroom because Resident 19 was care planned not to be left unattended. On 3/28/25 at 11:44 AM Staff 1 (Administrator), Staff 7 (DNS), and Staff 49 (Regional Nurse Consultant) stated the expectation was for staff to follow Resident 19's care plan.

Based on observation, interview and record review it was determined the facility failed to ensure resident medication was not expired for 1 of 1 medication storage refrigerator. This placed residents at risk for lack of medication efficacy and adverse reactions from expired medications. Findings include: The Tuberculin manufacturer insert indicated a multi-dose vial of Tuberculin should be dated when opened and thrown away after 30 days to avoid oxidation and degradation. During an observation of the medication storage refrigerator on 3/25/25 at 3:42 PM, the following was found: - One open and used multi-dose vial of Tuberculin (solution used in testing for Tuberculosis) with an open date of 2/18/25. On 3/25/25 at 3:48 PM, Staff 8 (LPN) stated the expectation was Tuberculin vials were to be destroyed 28 days after being opened. On 3/27/25 at 1:37 PM, Staff 7 (DNS) stated all Tuberculin multi-dose vials should be dated when opened and thrown away after 28 days.

Based on observation, interview and record review it was determined the facility failed to follow infection control standards for 1 of 5 residents (#18) reviewed for medications. This placed residents at risk for exposure and contraction of infectious diseases. Findings include: Resident 18 was admitted to the facility in 3/2024 with diagnoses including dementia and insomnia. A 3/7/25 Annual MDS revealed Resident 18 had a severe cognitive impact. A 3/2025 MAR instructed staff to instill two drops of Ciprofloxacin (an antibiotic used to treat bacterial infections) in both eyes every two hours for conjunctivitis (Also known as pink eye, a bacterial or viral infection, or allergic reaction) for two days, starting on 3/21/25. The MAR referred the reader to Administration Notes on 3/21/25 at 12:30 AM, 2:29 AM, 4:30 AM, and 3/22/25 at 6:30 AM. Administration Notes revealed the following for Resident 18 and Ciprofloxacin: -3/21/25 at 1:52 AM: Resident was asleep and refused. -3/21/25 at 3:30 AM: Resident was asleep. -3/21/25 at 4:17 AM: Resident was asleep. -3/22/25 at 6:46 AM: Resident was asleep. No documentation was found in Resident 18's clinical record indicating she/he had been placed on precautions for an infection. On 3/24/25 at 12:04 PM, Staff 48 (RN) stated to be careful in Resident 18's room as she/he had conjunctivitis. Staff 48 stated he did not think Resident 18 needed to be on any type of precautions as she/he was on the downside of it. No infection control precaution signs were observed on or around Resident 18's room. On 3/26/25 at 11:18 AM, Staff 22 (CNA) stated she wore gloves while assisting Resident 18 and she did not know Resident 18 had an infection. On 3/26/24 at 12:49 PM, Staff 19 (CNA) stated Resident 18 touched many items, including the handrails in the hallways, and her/his name plate on her/his door. Staff 19 stated she provided care to Resident 18 and was not notified she/he had an infection. On 3/28/25 at 9:32 AM, Staff 28 (CNA) stated she worked with Resident 18 on 3/21/25 through 3/24/25. Staff 28 stated she would set up Resident 18's meals, clean up after she/he completed her/his meals, and assist her/him with showers. Staff 28 stated on occasion she would have to remind Resident 18 to wash her/his hands. Staff 28 stated she was not aware Resident 18 had any type of infection. Staff 28 stated she would receive information verbally during shift change if a resident required precautions. On 3/28/25 at 7:18 AM, Staff 4 (Infection Preventionist LPN) stated staff would use contact precautions with gloves and no gowns for Resident 18's conjunctivitis. Staff 4 stated after 72 hours, Resident 18 would no longer be infected, and staff would stop using the gowns. On 3/28/25 at 10:07 AM Staff 9 (LPN) stated she would inform CNAs verbally of any changes for residents during shift change. On 3/28/25 at 11:51 AM, Staff 1(Administrator), Staff 7 (DNS), and Staff 49 (Regional Nurse Consultant) confirmed staff should be notified when a resident was on precautions.

Based on observation, interview, and record review it was determined the facility failed to follow care plan transfer interventions for 1 of 2 sampled residents (#1) reviewed for accidents. This failure resulted in a fall for Resident 1 with hospitalization for a fractured back. Findings include: Resident 1 was readmitted to the facility in 11/2022, with diagnoses including above the knee amputation of both legs, diabetes, and dementia. A facility Incident Report dated 8/4/23, indicated Resident 1 had a witnessed non-injury fall while being propelled in the shower chair in the shower room. The CNA who assisted the resident stated she was backing up with the resident in the shower chair. The wheel of the chair dropped down into the recessed floor drain and the chair flipped over backwards. The CNA was able to lower the resident to the floor. The root cause of the fall was determined to be related to the resident's absence of legs which made the resident top heavy in the shower chair. When the chair wheel dropped in the drain area the chair became unstable and flipped backwards. The care plan was updated following the fall to include two staff to assist resident while in the shower chair. Resident 1's care plan revised 8/8/23 indicated the resident had an ADL self-care performance deficit with impaired balance related to bilateral amputations. The resident required two staff to move her/him to and from the shower while in the shower chair, with an additional intervention for staff which stated, DO NOT move shower chair alone. Resident 1's 4/14/24 Annual MDS CAA for Falls indicated the resident had a fall with an injury in the last quarter. The resident suffered a T8 (toward the lower end of the twelve thoracic vertebrae within the central, torso section of the spine) fracture. The facility's investigation of Resident 1's fall on 3/19/24 indicated she/he was sent to the emergency department following the fall. On 3/21/24 a CT scan (computed tomography) was completed for Resident 1 which documented a fracture in the thoracic region of the spine. The facility's investigation concluded Resident 1 was only assisted by one staff member during a shower chair transfer instead of two staff members as required by Resident 1's care plan. On 7/19/24 at 1:20 PM, an observation of the facility shower room was conducted. There were four shower chairs stored in the room. The floor drain was located between a far wall where the shower head was located and the door. The shower chairs would pass over the drain to get to the shower area. The flooring around the circumference of the drain sloped downward into the drain. Two of the shower chairs were tested for performance rolling across the drain area by the surveyor and Staff 4 (CNA) and Staff 5 (NA). The two chairs both had a wheel leave the ground when pushed across the drain area. The wheels which left the ground caused the chair to pitch forward or back depending on the way the chair was pushed. On 7/19/24 at 10:18 AM, Staff 3 (CNA) stated on 3/19/24 at approximately 7:20 AM she pushed Resident 1 by the front of the shower chair into the shower room when something stopped the chair and it flipped backwards and the resident fell and hit her/his head. Staff 3 stated she had transferred the resident by herself and knew the resident was supposed to have two staff when using the shower chair. Staff 3 stated she was aware of the resident's previous fall while in the shower chair. Staff stated she forgot about the two-person transfer and it was not a staffing issue as there was staff available to assist at the time. On 7/19/24 at 11:02 AM, Staff 4 (CNA) and Staff 5 (NA) were asked about the shower drain and the shower chairs. Staff 5 indicated the smallest shower chair was an issue and they had to push residents on a path along the right wall to avoid the drain area for safety. Staff 5 (NA) stated the bigger chairs had a wider base and could handle the drain area better. Both staff indicated they were aware the drain area could cause problems with the shower chairs. On 3/19/24 at 11:27 PM, Staff 1 (Administrator) and Staff 2 (DNS) acknowledged the fall in the shower room resulted in a fractured back for Resident 1 and Staff 3 did not follow the resident's care plan related to transfers in the shower chair.

Based on observation and interview it was determined the facility failed to assess and develop a water management plan and failed to perform laundry in a sanitary manner for 1 of 1 facility. This placed residents at risk for infections. Findings include: 1. On 12/14/23 at 8:25 AM Staff 7 (Maintenance Director) stated he worked at the facility for multiple years and was not aware of a water management plan related to Legionella (water-borne pathogen). On 12/14/23 at 9:00 AM Staff 1 (Administrator) stated she had the facility's water flow map. A request was made to Staff 1 to provide documentation the facility identified where water-borne pathogens could grow, measures to prevent the growth of the pathogens and how the facility would monitor the measures they had in place. No additional information was provided. 2. On 12/14/23 at 7:41 AM Staff 8 (CNA) stated the night shift staff brought residents' dirty laundry in plastic bins and lined the bins up against the wall in the clean laundry area until the washing machine was available, which was behind a locked door next to the clean laundry room. Staff 8 stated there was no other area to store the dirty linens. The clean laundry area was observed to have mechanical lift slings and dirty gowns in plastic bins under the table where clean linens were folded. The bins had dried feces on them. The room smelled of feces. Staff 8 stated dirty slings were placed under the tables until they were able to be washed on the night shift. On 12/14/23 at 7:47 AM Staff 2 (DNS) observed the the clean laundry area with the dirty bins, linens and dried feces. Staff 2 stated dirty linen was not to be in the clean laundry area.

Based on interview and record review it was determined the facility failed to revise care plan interventions for 5 of 6 sampled residents (#s 7, 8, 12, 13, and 19) reviewed for accidents, nutrition, dignity, activities, and medications. This placed residents at risk for unmet needs. Findings include: 1. Resident 7 was admitted to the facility in 2019 with a diagnosis of diabetes. Progress notes revealed the following: -11/5/23 Resident 7 choked on food and was sent to the emergency room for evaluation and treatment. -11/30/23 Resident 7 choked in bed. Resident 7 was aware of her/his need to eat meals out of bed. -12/4/23 Resident 7 was found flat in bed and was choking. A 11/30/23 RD assessment indicated the resident had recent choking events and it was likely related to position and the resident did not have swallowing issues. The note indicated the RD agreed with the plan to provide all meals for the resident out of bed. On 12/11/23 during lunch observation, Resident 7 did not eat in the dining room. On 12/11/23 at 2:25 PM Resident 7 was observed in bed with her/his head of the bed at a 45 degree angle and was observed to eat food and drinks were within reach. The resident was not observed to choke or cough. On 12/12/23 at 3:21 PM Staff 2 (DNS) stated Resident 7's care plan was not updated to include the resident was to be up for all meals due to her/his history of choking. The resident did not have swallowing issues and did not need to be supervised, but it was best for the resident to eat in the dining room. 2. Resident 8 was admitted to the facility in 2021 with a diagnosis of heart failure. An 10/10/23 Annual MDS and associated CAAs revealed the resident required extensive assistance for most ADLs and the medications the resident was administered contributed to her/his fall risk. Staff were to monitor the resident for increased confusion and agitation. The CAA also indicated the resident had several falls in the past and one fall resulted in a fracture. A care plan last updated 10/26/23 revealed the resident was a high risk for falls and did not have a history of falls. On 12/13/23 at 2:34 PM Staff 2 (DNS) acknowledged Resident 8's care plan was not updated to reflect the resident had falls including one with an injury. 3. Resident 12 was admitted to the facility in 2021 with a diagnosis of dementia. An 8/31/23 quarterly MDS revealed Resident 12 attended some activities, but only participated for a short period of time. Resident 12 liked to observe her/his peers during the activity. The MDS note indicated she/he also liked to watch television, participate in balloon toss and board games. A care plan last updated 7/2023 revealed Resident 12 depended on others for her/his decision making. There were no resident specific interventions related to activities. Resident 12's 11/1/23 through 12/8/23 activity log revealed the resident participated in coloring, people watching, movies, and was provided a fidget blanket (provided sensory stimulation when touching different textures). On 12/13/23 at 11:16 PM Staff 5 (Activity Director) stated Resident 12 had dementia and her/his participation level varied day to day. All staff had access to activity supplies when Staff 5 was not in the facility. Staff 5 acknowledged Resident 12's care plan was not updated with resident specific interventions related to activities. 4. Resident 19 was admitted to the facility in 2023 with a diagnosis of dementia and was on hospice services. An 10/22/23 admission MDS and associated CAAs revealed Resident 12 had little interest in activities and staff would familiarize the resident with available activity supplies. A care plan last revised on 11/14/23 did not include activities staff should try to provide to Resident 19. On 12/13/23 at 10:08 AM Witness 2 (Hospice RN) stated when Resident 19 first arrived at the facility the resident wanted to stay in bed. Now, when Witness 2 visited Resident 19, the resident was observed to be sitting in her/his wheel chair with magazines by the nurses station. Witness 2 stated overall the resident was more engaged. On 12/13/23 at 11:16 PM Staff 5 (Activity Director) stated after staff provided Resident 19 a shower the resident participated in activities. The resident liked happy hour and karaoke. The resident participated as long as she/he was able to tolerate being in her/his wheelchair. Staff 5 stated she did not have very much information about Resident 19 when the resident was admitted to the facility and Staff 5 did not update the care plan once she learned what the resident liked to do. 35855 5. Resident 13 was admitted to the facility in 9/2022 with a diagnosis of a fractured leg. A 9/21/23 care plan indicated Resident 13 tested positive for COVID-19 on 9/13/23 with interventions which included placing the resident on transmission-based precautions with personal protective equipment provided at the entrance of her/his room. From 12/11/23 through 12/14/23 no transmission-based precautions were observed at the entrance of Resident 13's room. On 12/14/23 at 9:30 AM Staff 2 (DNS) and Staff 3 (RN Consultant) confirmed Resident 13's care plan was outdated, and COVID-19 precautions needed to be removed.

Based on interview, it was determined the facility failed to have a system in place to deliver mail on Saturdays. This placed residents at risk for lack of timely written communication. Findings include: On 12/13/23 at 9:56 AM during the Resident Council meeting Staff 5 (Activities Director) stated the mail was not delivered to the residents on Saturdays because she did not work on Saturdays. On 12/13/23 at 12:02 PM Staff 5 stated the mail was delivered to the facility on Saturdays, there was no one available to distribute it to the residents. Staff 5 further stated she would deliver the Saturday mail on Mondays.

Based on observation, interview, and record review, it was determined the facility failed to clean filters on the heater air-conditioning equipment for 1 of 1 facility reviewed for environment. This placed residents at risk for unclean and unhomelike environment. Findings include: No documentation was found related to cleaning of the heater air-conditioning equipment. A 12/7/23 Resident Council minutes indicated the heaters needed cleaned. On 12/11/23 at 12:51 PM Resident 14 stated she/he accidently dislodged the dining room heater air-conditioning face plate and the filter was covered in a layer of dust and dirt. Resident 14 stated she/he reported the dirty filters to Staff 1 (Administrator), but the filters were still not cleaned after several weeks. On 12/14/23 at 8:11 AM, in the presence of Staff 21 (Assistant Environment Services Manager) the heater air-conditioner equipment in room [ROOM NUMBER] was observed. Staff 21 stated he did not know how long it was since it was last cleaned. Staff 21 further stated he did not think it was recorded when maintenance completed the cleaning. The filter was observed covered in a layer of dust. On top of the heater air conditioner there were debris particles and dust. Staff 7 (Environment Services Director) stated he was not surprised by the look of the equipment being dirty as items often got spilled on the equipment. Staff 7 further stated that the amount of dust on the filter depended on what was going on in the room, which would determine how much accumulation would occur.

Based on interview and record review, it was determined the facility failed to implement its abuse prevention program policy and procedure for screening for 1 of 5 sampled staff members (#16) reviewed for facility personnel. This placed residents at risk for abuse and neglect of care. Findings include: The Abuse Prevention Program Policy and Procedure, dated 10/2/19, indicated as part of the resident abuse prevention, the administrator or their designee would conduct employee background checks. A New Hire List from 8/12/23 through 12/12/23 revealed Staff 16 was hired on 9/22/23. An Application Report (background check) from 9/1/23 through 10/31/23 revealed Staff 16's application status was closed because her fingerprints were not obtained. A Person Summary revealed Staff 16's training period was completed on 10/28/23 and she started assisting residents without supervision. No documentation was found in Staff 16's personnel folder indicating she was supervised from 10/28/23 through 12/13/23. On 12/14/23 at 8:37 AM Staff 1 (Administrator) stated she was not aware Staff 16's fingerprints were not completed, and her application was closed.

Based on observation, interview, and record review it was determined the facility failed to maintain cleanliness for 1 of 1 Kitchen and 1 of 1 dining room. This placed residents at risk for cross contamination. Findings include: 1. On [DATE], during initial kitchen tour, the dry storage area fan above the door, which moves air from the kitchen into the dry storage area, was observed to be covered in black chunks of dirt and debris. The door from the outside into the kitchen was open, with screen door closed. The screen door was covered in a layer of dust. On [DATE] at 10:12 AM Staff 6 (Dietary Manager) stated he did not have a scheduled time to clean the fan and screen door. Staff 6 stated he would assign a staff member to clean them when he noticed they needed cleaned and confirmed they needed cleaned. 2. A ,d+[DATE] Refrigerator Temperature Log for the dining room revealed for the month of ,d+[DATE] the refrigerator temperature was not checked 19 out of 30 days. On [DATE] at 7:02 AM, in the main dining room, the resident snack refrigerator was observed to contain a slice of pizza dated [DATE], a store-bought cake with two dates (one [DATE] and a second of [DATE]), and an orange with green mold on the bottom. Staff 11 (CNA) confirmed the pizza, store-bought cake and orange should be discarded. Staff 11 did not know about the temperature log for the refrigerator and did not know who was responsible for documenting the temperature. A ,d+[DATE] Refrigerator Temperature Log for the dining room revealed from [DATE] through [DATE] the refrigerator temperature was not checked six out of 12 days. On [DATE] at 10:12 AM Staff 6 (Dietary Manager) stated it was expected for the CNAs to log the temperatures for the dining room refrigerator, and for both the dietary staff and the CNAs to remove expired items from the dining room refrigerator.

Based on interview and record review it was determined the facility failed to developed care plans for 2 of 2 sampled residents (#s 12 and 18) reviewed for activities. This placed residents at risk for lack of social engagement. Findings include: 1. Resident 12 was admitted to the facility in 2021 with a diagnosis of dementia. A 11/28/23 Activities Participation Review form revealed Resident 12 liked to observe other residents during group activities more than participating and reported to staff she/he wanted to color. Review of the comprehensive care plan last updated 10/16/23 revealed there was no activity focus with goals and interventions. On 12/12/23 at 2:22 PM and 12/13/23 at 11:16 PM Staff 5 (Activities Director) stated Resident 12 had dementia and her/his activity involvement fluctuated but she/he liked to color, watch movies, listen to music and watch her/his peers while they participated in an activity. Staff 5 acknowledged Resident 12 did not have a care plan related to activities. 35855 2. Resident 18 was admitted to the facility in 9/2023 with a diagnosis of dementia. An 10/6/23 Admission MDS indicated Resident 18 was cognitively intact. Resident 18 felt it was not very important to have items to read, listen to music and keep up with news. It was very important to be around animals and engage in her/his favorite activities. It was somewhat important for Resident 18 to do things with groups of people and go outside when weather was good. A review of Resident 18's comprehensive care plan revealed no information about her/his activity interests. On 12/14/23 at 9:30 AM Staff 2 (DNS) and Staff 3 (RN Consultant) stated they would review the care plan regarding Resident 18's activity interests. No additional information was provided.

Based on observation, interview and record review it was determined the facility failed to ensure a resident's nails were trimmed for 1 of 1 sampled resident (#8) reviewed for ADLs. This placed residents at risk for lack of hygiene. Findings include: Resident 8 was admitted to the facility in 2021 with diagnoses including heart disease and diabetes. An 10/10/23 annual MDS and CAAs revealed Resident 8 required extensive assist with ADLs. A care plan last revised on 10/26/23 revealed Resident 8 was dependent on staff for cares including showers. Resident 8 was to receive showers every Monday and Thursday. 11/2023 and 12/2023 TARs revealed Resident 8 was to receive diabetic nail care every Monday evening and she/he refused on on 11/27/23, 12/4/23, and 12/11/23. No documentation was found the staff reapproached the resident after refusals. On 12/11/23 at 1:07 PM Resident 8 was observed with long fingernails with brown debris underneath the nails. The resident stated she/he was not able to independently cut her/his nails. On 12/13/23 at 12:37 PM Staff 11 (CNA) stated if a resident was not diabetic the CNAs provided nail care on shower days. If a resident was diabetic then the nurse provided nail care. Staff 11 observed Resident's 8's nails to be long. The brown debris was no longer under the nails. Staff 11 stated she cleaned under the nails with a wash cloth. Resident 8 stated she hated her/his nails because they were too long. On 12/13/23 at 12:42 PM Staff 22 (LPN) stated the resident should have been provided nail care on 12/11/23. On 12/14/23 at 2:00 PM a request was made to Staff 2 (DNS) to provide documentation Resident 8 was provided nail care. No additional information was provided.

Based on interview and record review it was determined the facility failed to review a consent for medications with a resident's representative for 1 of 5 sampled residents (#12) reviewed for medications. This placed residents at risk for unnecessary medications. Findings include: Resident 12 was admitted to the facility in 2021 with a diagnosis of dementia. A 11/26/21 facility admission documentation revealed Witness 1 (Family) signed the resident's paperwork as Resident 12's responsible party. An Informed Consent for Psychotropic Drugs dated 10/20/23 revealed Resident 12 was administered mirtazapine (antidepressant) and olanzapine (antipsychotic). The consent was signed by two staff and not Witness 1. On 12/12/23 at 2:50 PM Staff 2 (DNS) stated, annually, the facility reviewed and obtained new consents for residents' psychotropic medication administration. Staff 2 acknowledged Resident 12's consent was signed by two staff members and not Witness 1 and stated she was not sure if the resident's family was called in regards to the resident's current medication dose. No additional information was provided to indicate family consented to Resident 12's current use of psychotropic medications.

Based on interview and record review it was determined the facility failed to assist a resident with completing an advance directive for 1 of 4 sampled residents (#2) reviewed for advance directives. This placed residents at risk for end of life choices not being honored. Findings include: Resident 2 was admitted to the facility in 2021 with diagnoses of stroke and diabetes. A 4/26/23 Care Plan revealed Resident 2 had blindness in both eyes from diabetes. A 5/24/23 Care Conference meeting form revealed Resident 2 requested a staff member read the advance directive to her/him to see if she/he would like help filling it out. A 9/26/23 Annual BIMS revealed Resident 2 was cognitively intact. Resident 2's record did not reveal staff reviewed the advance directive with her/him. On 12/13/23 at 11:15 AM Staff 3 (RN Consultant) stated she would look to see if staff reviewed the advance directive with the resident. No additional information was provided.

Based on interview and record review it was determined the facility failed to provided a two day notice prior to the ending of skilled services for 1 of 3 sampled residents (#71) reviewed for beneficiary notifications. This placed residents at risk for lack of timely appeals. Findings include: Resident 71 was admitted to the facility in 2023 with a diagnosis of liver disease. Resident 71's Notice of Medicare Non-Coverage form revealed her/his services ended on 10/31/23. The notice was provided on 10/30/23. On 12/13/23 at 3:09 PM Staff 5 (Activities Director) stated she was trained the two day notice included the day the resident was discharged from the facility and not when the services ended. Staff 5 acknowledged the resident discharged on [DATE] and the notice was given on 10/30/23, one day before services ended.

Based on interview and record review, it was determined the facility failed to provide the risks and benefits for the use of psychotropic medications prior to administration for 1 of 5 sampled residents (#18) reviewed for medications. This placed residents at risk for lack of informed consent. Findings include: Resident 18 was admitted to the facility in 9/2023 with a diagnosis of dementia. A 11/2023 signed physician orders instructed staff to administer sertraline (a medication used to treat depression) once a day for dementia, and anxiety starting on 9/27/23. A review of clinical records found Resident 18 was not provided the risk and benefits of taking sertraline. On 12/14/23 at 9:32 AM Staff 2 (DNS) and Staff 3 (RN Consultant) confirmed Resident 18's risk and benefits for sertraline was not completed timely.

Based on interview and record review, it was determined the facility failed to ensure CNA staff annual performance reviews were completed for 3 of 5 sampled CNA staff (#s 8, 11, and 12) reviewed for staffing. This placed residents at risk for a lack of competent staff. Findings include: A review of personnel records on 12/13/23 indicated the following employees did not receive their annual performance evaluations: -Staff 12 (CNA), hired on 6/1/78, no evaluation on file for 6/1/22 through 12/13/23. -Staff 11 (CNA), hired on 7/29/19, no evaluation on file for 7/29/22 through 12/13/23. -Staff 8 (CNA), hired on 11/9/17, no evaluation on file for 11/9/22 through 12/13/23. On 12/14/23 at 9:04 AM Staff 2 (DNS) stated she did not find annual performance reviews for the above listed staff.

Based on observations, interviews and record reviews, it was determined the facility failed to maintain acceptable parameters of nutritional status for 2 of 3 sampled residents (#s 1 & 2). Resident 1 experienced a 8.9% severe weight loss in less than one month. Resident 2 experienced a 5.8% severe weight loss in less than one month. Findings include: 1. Resident 1 was admitted to the facility in the last month with [DIAGNOSES REDACTED]. Review of the physician's admission orders [REDACTED]. Orders were received for a mechanical soft diet with thin liquids. Medication orders included [MEDICATION NAME] OTC 20 mg every day. [MEDICATION NAME] OTC is a gastrointestinal drug used to treat Gastro-[MEDICAL CONDITION] Reflux Disease (GERD) and ulcers. Review of the Admission Nursing Assessment, dated 2/28/11, revealed the resident's weight was 189.4 pounds. The resident was assessed to require supervision with eating. The resident was assessed as alert and oriented on admission, but when the family left, the resident became moderately confused to time, place and situation. According to the NN dated 3/6/11 at 6:00 am the resident had "poor intake of food." On 3/7/11 at 7:00 am the resident "only has a fair appetite." Review of the Registered Dietician's (RD) initial assessment, dated 3/7/11, revealed the resident had "inadequate protein stores" related to [MEDICAL CONDITION], dysphagia "as evidenced by [MEDICATION NAME] level of 3.1." According to the Merck Manual Eighteenth Edition, [MEDICATION NAME] measures the protein in the bloodstream. As undernutrition progresses, [MEDICATION NAME] decreases slowly. Normal [MEDICATION NAME] levels are 3.5 to 5.0. The RD's recommendation included Nutritionally Enhanced Meals (NEM) and monitor the resident's weight and meal percentages. On 3/7/11 the resident's diet was changed to include NEM. Review of the February 2011 and March 2011 MARs revealed the [MEDICATION NAME] OTC was scheduled to be given at 5:00 pm. According to the MARs the [MEDICATION NAME] OTC had not been administered as ordered from 2/28/11 through 3/9/11. There was no documentation on the back of the MARs to indicate why the [MEDICATION NAME] OTC had not been administered. Review of the NN dated 3/10/11 at 1:45 pm revealed when the resident was questioned about acid indigestion she/he responded "all the time." The NN indicated it was noted that doses of the [MEDICATION NAME] OTC had not been given "when the med (medication) was not available & usually takes in AM." The NN indicated the time was changed to be given every morning instead of 5:00 pm. According to the Vital Signs & Weights Record on 3/10/11 the resident's weight was documented at 176.0 pounds, a 7.0% severe weight loss in 10 days. Further review of the NN dated 3/10/11 at 1:45 pm revealed the resident was to be weighed weekly and referred to the RD. The resident's physician was notified of the weight loss. Review of the Nutrition Committee Review notes, dated 3/11/11 and signed by Staff 3 (DNS) and Staff 10 (Dietary Manager), revealed NEM began on 3/7/11; the [MEDICATION NAME] was not available for several days and was given in the evenings; the time was changed for the [MEDICATION NAME] to be given every morning; the resident complained of heartburn; orange juice was discontinued and cranberry juice was to be given instead; supplements offered if the resident ate less than 75% of meals and weekly weights were to be continued. According to the NN dated 3/11/11 at 10:45 am the resident complained of upper abdominal pain "indigestion". The resident's physician was notified and the [MEDICATION NAME] OTC was increased to 20 mg BID. On 3/13/11 at 7:00 am the NN indicated the resident had a poor appetite, ate 5% to 20% and "does not drink well, either." Review of the Complete Metabolic Panel (CMP) lab results dated 3/14/11 revealed the resident's [MEDICATION NAME] level was 2.9. On 3/16/11 the resident's weight was documented at 172.4 pounds, a 8.9% severe weight loss from 2/28/11 to 3/16/11. On 3/23/11 the resident's weight was documented at 172.4 pounds. Review of the Meal Monitor for 3/1/11 through 3/28/11 revealed 10 different meals when the resident ate less than 75%. There was no documentation to indicate a nutritional supplement was offered. No documentation could be located to indicated the RD had been notified of the resident's 8.9% severe weight loss. No assessment could be located regarding the resident's continued weight loss. Continuous observations of the resident on 3/29/11 from 11:35 am to 1:35 pm revealed the resident was cued and assisted with lunch frequently. From 12:08 pm to 12:15 pm the resident was observed pick up the fork and feed her/himself without assistance or cueing. At 12:28 pm the resident was asked if she/he wanted strawberries and whipped cream. At 12:35 pm the resident fed himself the desert. At 12:37 pm Staff 11 (RN) asked the resident about eating only 50% of lunch. The resident was offered something different or a nutritional supplement, the resident refused. From 12:45 pm to 1:35 pm the resident was in an activity with eight other residents. The resident was given juice to drink. On 3/30/11 at 7:40 am the resident was observed in the dining room adding pepper to the poached egg. The resident began eating without cueing or assistance from the staff. The resident ate approximately 80% of breakfast. In an interview on 3/30/11 at 8:20 am Staff 2 (CMA) stated the [MEDICATION NAME] OTC had been ordered from the pharmacy on admission to the facility. Staff 2 indicated the medication was not administered from 2/28/11 through 3/9/11 due to a problem at the pharmacy. In an interview on 3/30/11 at 12:45 pm Staff 4 (CNA) stated the resident would eat and take fluids without cueing or assistance at times, and other times required extensive assistance to eat. In an interview on 3/30/11 at 1:20 pm Staff 6 (RN) stated the resident had refused to eat or drink. Staff 6 indicated the [MEDICATION NAME] had not been given because it wasn't available when first admitted ." Staff 6 stated the resident had experienced at least a 10 to 12 pound weight loss since admission. The continued weight loss was discussed with Staff 3 (DNS) and Staff 9 (Administrator) on 3/31/11 at 3:00 pm. No new information was provided. 2. Resident 2, a long time resident of the facility, was admitted with [DIAGNOSES REDACTED]. Review of the February 2011 and March 2011 MARs revealed the resident's medications, with side effects including drowsiness, lethargy and somnolence included, [MEDICATION NAME], an anti-[MEDICAL CONDITION] medication; [MEDICATION NAME], a decongestant; medications for behaviors including [MEDICATION NAME] and [MEDICATION NAME]. According to the Annual Nursing Assessment, dated 3/4/11, the resident required limited assistance with eating. Review of the Nutrition Committee Review, dated 1/11/11 and signed by a RN, revealed the resident received a puree texture diet and had experienced a weight loss in September and October 2010, but had stabilized in December 2010. The resident's weight was documented at 223 pounds on 12/21/10. A Speech Therapy (ST) evaluation was requested. On 1/12/11 the ST recommended the resident's diet be upgraded to dysphagia mechanical soft diet with extra sauce and gravy. On 1/19/11 the resident's diet was changed as per the recommendation. Review of the RD's annual assessment dated [DATE] revealed the resident's weight was 217.8 pounds. The assessment indicated the resident had lost 10% over the last six months; the resident remained above her/his desirable weight range and the plan was to continue with the current diet. Review of the NN revealed the following: On 2/12/11 at 9:30 am the resident ate a late breakfast, only ate 50%, was sleepy,"slept in chair this am." At 1:00 pm on 2/12/11 the resident ate 50% of lunch and took 120 cc of a supplement, "continues sleepy, letting food & fluids fall out of mouth when done." On 2/20/11 the resident was "not wanting to rouse for lunch." On 3/4/11 at 11:00 am the resident was "unable to arouse this am for foods or fluids." A supplement was given at 10:30 am with a snack. On 3/8/11 the resident was "up by 9:15 am" and was "too sleepy to get up @ breakfast." Review of the Annual Nursing Assessment, dated 3/4/11, revealed the resident had a significant weight loss that was "addressed in previous quarter, sometimes skips meals if too sleepy to eat." According to the Vital Signs & Weight Record, on 3/1/11 the resident's weight was documented at 214.6 pounds. On 3/22/11 the resident's weight was documented at 202.0 pounds, a 5.8% severe weight loss in less that one month. No documentation could be located to indicate the resident's 5.8% severe weight loss had been assessed. No new interventions had been implemented. Observations of the resident on 3/30 11 at 12:15 pm to 12:30 pm revealed the resident was sleepy with eyes closed. The lunch meal was on the table, the resident was not eating. At 12:17 pm a staff member sat next to the resident and cued the resident. The resident began eating with staff assistance. At 12:20 pm the staff member left the resident's side and the resident's eyes closed. The resident had eaten approximately 80% of the lunch meal. On 3/31/11 at 7:45 am the resident was observed in the dining room with eyes closed and her/his mouth open. The resident's breakfast was on the table and the resident was not eating. In an interview on 3/30/11 at 12:45 pm Staff 4 (CNA) stated the resident required assistance and cueing to eat and usually would eat if assistance was provided. Staff 4 indicated at times the resident had to be woken up to eat at meals. In an interview on 3/30/11 at 2:30 pm Staff 6 (RN) stated the resident had behaviors that escalate in the evenings and due to the [MEDICAL CONDITION] medications, the resident was sleepy during the day. Staff 6 indicated when sleepy, the resident would not eat well and required assistance and cueing. On 3/31/11 at 3:00 pm the resident's weight loss was discussed with Staff 3 (DNS) and Staff 9 (Administrator). No new information was provided.

Based on observations, interviews and record review, it was determined the facility failed to ensure a drug regimen was free from unnecessary drugs for 1 of 1 sampled residents (#2). Resident 2 was observed to be drowsy, lethargic and somnolent at times. Findings include: Resident 2, a long time resident of the facility, was admitted with [DIAGNOSES REDACTED]. Review of the February 2011 MAR indicated [REDACTED] 2 mg to 8 mg intramuscularly (IM), PRN, ordered 1/16/10. According to the Federal Regulation, the daily dose threshold for [MEDICATION NAME] is 2 mg. The daily dose threshold for [MEDICATION NAME] is 50 mg. Review of the pain assessment, dated 7/2/10 revealed the resident had pain in the left elbow at times. Sports cream was "attempted." On 8/22/10 the pain assessment was updated. The resident had pain in the knees and hip when rolled onto the left side, "does not ask for pain medication, sports cream is applied at times." The update indicated the resident had received Tylenol three times in the last three months. According to the Resident Activity Assessment, dated 7/19/10, in the past, the resident enjoyed baseball, bull riding, cowboy music, audio books, fishing and movies. Review of the care plan for mood stabilizers, not signed or dated, revealed the goal was the resident would be able to be up in the dining room for meals without becoming agitated and uncontrollable. The approaches included approach calmly and try to re-direct; remove from the area and allow to vent frustrations. Review of the NN dated 2/19/11 from 11:00 am through 4:45 pm revealed the resident was agitated, attempting ambulation, "have to get myself to work," exit seeking, running into objects and residents, shaking door handles and setting off alarms. The documentation indicated at 2:05 pm "encouraged exercise at hall rail bars, pt (patient) continues attempt self ambulation." Review of the MAR for 2/19/11 revealed the resident received [MEDICATION NAME] 25 mg at 1:30 pm; [MEDICATION NAME] 2 mg PO at 3:00 pm and 4:45 pm and [MEDICATION NAME] 25 mg at 8:00 pm No documentation could be located to indicate the resident had been assessed for pain as a possible cause for the agitation and no other non-pharmacological interventions were attempted. According to the February 2011 MAR, the resident received PRN Tylenol three times; [MEDICATION NAME] 2 mg PO PRN three times; [MEDICATION NAME] 25 mg PO PRN 13 times and [MEDICATION NAME] 2.5 mg IM twice and [MEDICATION NAME] 5 mg IM twice. Review of the NN dated 3/4/11 at 11:00 am revealed the resident was "unable to arouse this am for food or fluids." According to the March 2011 MAR, the resident received 6 mg of [MEDICATION NAME] PO PRN on 3/2/11. On 3/4/11 the resident received [MEDICATION NAME] 25 mg PO PRN at 5:30 pm and [MEDICATION NAME] 2 mg PO PRN at 8:00 pm. No documentation could be located to indicate the resident had been assessed for pain as a possible cause for the agitation and no other non-pharmacological interventions were attempted. According to the 3/4/11 Annual Nursing Assessment Cognitive Status section, "plan to try Tylenol for pain relief if starts to escalate to see if this may help." Review of the NN dated 3/8/11 at 10:30 am revealed the resident was "too sleepy to get up @ breakfast." According to the MAR, on 3/16/11 the resident received Tylenol PO PRN at 8:25 am; [MEDICATION NAME] 4 mg PO PRN at 12:00 am; [MEDICATION NAME] 25 mg PO PRN at 5:20 pm and [MEDICATION NAME] 4 mg PO PRN at 7:50 pm. On 3/17/11 the resident received Tylenol PO PRN at 6:30 am; [MEDICATION NAME] 25 mg PO PRN at 8:30 am and at 4:45 pm and [MEDICATION NAME] 4 mg at 7:00 pm. No Tylenol PO PRN had been administered before the PRN [MEDICATION NAME] and [MEDICATION NAME]. No documentation could be located to indicate non-pharmacological interventions were attempted. Review of the physician progress notes [REDACTED]. The previous year the resident reported visual hallucinations of worms, "these reports have declined over the past year." The progress note indicated the resident was placed on low dose [MEDICATION NAME] in late 2009, "which when taken daily caused sedation." The [MEDICATION NAME] was decreased to 2.5 mg every other day. Orders were received on 3/20/11 to increase the [MEDICATION NAME] to 125 mg PO TID. Review of the NN for 3/1/11 through 3/28/11 revealed no indication the resident had experienced any hallucinations. According to the 2/1/11 quarterly MDS, there were no hallucinations or [MEDICAL CONDITION]. Review of the MAR for 3/1/11 through 3/28/11 revealed the resident received 16 doses Tylenol; seven doses of [MEDICATION NAME] 4 mg PO PRN; two doses of [MEDICATION NAME] 6 mg PO PRN; one dose of [MEDICATION NAME] 2 mg PO PRN and 11 doses of [MEDICATION NAME] 25 mg PO PRN. No documentation could be located to indicate Gradual Dose Reductions (GDRs) had been attempted; no assessment of the effectiveness of the PRN Tylenol; no routine pain medication had been attempted and there was no implementation of different non-pharmacological interventions before administration of the PRN antipsychotic medications. Observations of the resident on 3/30/11 at 9:15 am revealed the resident sitting in the dining room with eyes closed and head down. At 12:15 pm lunch was on the table, the resident had eyes closed and was not touching the food. At 3:00 pm the resident was awake in the hallway. The resident was observed to attempt to talk to various staff members. On 3/31/11 at 7:45 am the resident was observed in the dining room not eating breakfast. The resident's head was back and mouth open with closed eyes. At 8:45 am the resident was awake, with a distressed look on her/his face, mouth open, moaning loudly. In an interview on 3/30/11 at 8:20 am Staff 2 (CMA) stated the resident seemed "a little more sleepy" since the [MEDICATION NAME] had been increased. In an interview on 3/30/11 at 2:30 pm Staff 6 (RN) stated the resident could be intrusive in to other resident's rooms. Staff 6 indicated the resident's behaviors increased in the evenings, and due to the [MEDICAL CONDITION] medications, the resident was sleepy during the day. Staff 6 stated they try re-direction, but "that only works so long." In an interview on 3/30/11 at 3:15 pm Staff 1 (RN) stated no mental health or psychiatric evaluation had been attempted. In an interview on 3/31/11 at 9:40 am Staff 7 (CNA) stated the resident had pain in the elbows and the CNAs had to be careful when dressing the resident. In an interview on 3/31/11 at 9:55 am Staff 8 (CMA/CNA) stated the resident had pain in the elbows, shoulders and knees. Staff 8 indicated PRN Tylenol was given and "sometimes it helps, sometimes it doesn't." Staff 8 stated the resident had a distressed look and moaning "quite a bit." In an interview on 3/31/11 at 10:12 am Staff 6 stated early on 3/31/11 the resident was restless, attempting to stand frequently. Staff 6 indicated Staff 5 (Activity Director) took the resident in the hall and assisted the resident to stand and sit down several times. Staff 5 took the resident back to the dining room with toast and juice. The resident fell asleep. On 3/31/11 at 3:00 pm the resident's antipsychotic medications, GDRs, pain and non-pharmacological interventions were discussed with Staff 3 (DNS) and Staff 9 (Administrator). No additional information was provided.

Based on observations, interviews and record review, it was determined the facility failed to provide sufficient fluid intake to maintain proper hydration for 1 of 4 sampled residents (#1). Resident 1 experienced dehydration and required intravenous fluids (IV). Findings include: Resident 1 was admitted to the facility in the last month with [DIAGNOSES REDACTED]. According to the Admission Nursing Assessment, dated 2/28/11, the resident was assessed to require supervision with eating. Review of the admission physician's orders [REDACTED]. [MEDICATION NAME] OTC is a gastrointestinal drug used to treat Gastro-[MEDICAL CONDITION] Reflux Disease (GERD) and ulcers. Review of the February and March 2011 MARs revealed the [MEDICATION NAME] OTC was scheduled to be given at 5:00 pm. According to the MARs the [MEDICATION NAME] OTC had not been administered as ordered from 2/28/11 through 3/9/11. There was no documentation on the back of the MARs to indicate why the [MEDICATION NAME] OTC had not been administered. Review of the Meal Monitor from 3/1/11 through 3/5/11 revealed the resident's documented fluids taken at meals averaged from 560 cc to 960 cc for 24 hours. No documentation could be located to indicate the amount of fluids the resident consumed between meals. Review of the Meal Monitor from 3/6/11 through 3/12/11 revealed the resident's documented fluids taken at meals averaged from 480 cc to 780 cc for 24 hours. No documentation could be located to indicate the amount of fluids the resident consumed between meals. Review of the NN dated 3/10/11 at 1:45 pm revealed when the resident was questioned about acid indigestion she/he responded "all the time." The NN indicated it was noted that doses of the [MEDICATION NAME] OTC had not been given "when the med (medication) was not available & usually takes in AM." The NN indicated the time was changed to be given every morning instead of 5:00 pm. According to the NN dated 3/13/11 at 6:00 pm, the resident's temperature was documented at 100.1. The on-call physician was contacted and orders were received for a urinalysis and Culture and Sensitivity (C & S) if indicated. At 6:45 pm the NN indicated the urinalysis results were reported to the on-call physician. Orders were received to repeat the urinalysis in two days and "push fluids." On 3/14/11 at 6:45 pm the NN indicated the resident's temperature was 102.8. Witness 2 (Resident 1's physician) came to the facility and orders were received for intravenous fluids (IV). Review of the physician's Progress Note, after his visit to the facility on [DATE] revealed the resident had been "lethargic, decreasing oral intake, and decreasing urine output in the last 24 hours." The assessment indicated "Decreasing oral intake/Anorexia/Dehydration." The plan included IV fluids, one L [MEDICATION NAME] over one hour, then normal saline 100 cc per hour IV continued; intake and output every six hours; encourage oral hydration, taper IV down and wean off IV fluid if tolerating oral intake and drinking well more than 2 L within 24 hours. Physician orders [REDACTED]." Review of the NN dated 3/15/11 at 11:30 am revealed the resident was taking fluids well. The physician was contacted and orders were received to decrease the IV fluids to 75 cc per hour. On 3/16/11 the NN indicated the resident was taking fluids well. On 3/17/11 the IV fluids were discontinued. Review of the 24 Hour Intake and Output Record from 3/14/11 through 3/18/11 revealed the resident's 24 hour fluid intake was documented at 870 cc to 2000 cc (2 L) on 3/16/11. Review of the Meal Monitor from 3/19/11 through 3/28/11 revealed the resident's documented fluids taken at meals averaged from 270 cc to 1220 cc for 24 hours. No documentation could be located to indicate the amount of fluids the resident consumed between meals. Continuous observations of the resident on 3/29/11 from 11:35 am to 1:35 pm revealed the resident was cued and assisted with lunch frequently. From 12:08 pm to 12:15 pm the resident was observed pick up the fork and feed her/himself without assistance or cueing. At 12:28 pm the resident was asked if she/he wanted strawberries and whipped cream. At 12:35 pm the resident fed her/himself the desert. The resident required frequent cueing to drink fluids. At 12:37 pm Staff 11 (RN) asked the resident about eating only 50% of lunch. The resident was offered something different or a nutritional supplement. The resident refused. From 12:45 pm to 1:35 pm the resident was in an activity with eight other residents. The resident was given juice to drink. On 3/30/11 at 7:40 am the resident was observed in the dining room adding pepper to the poached egg. The resident began eating without cueing or assistance from the staff. The resident ate approximately 80% of breakfast, but required frequent cueing to drink fluids. In an interview on 3/29/11 at 3:40 pm Staff 1 (RN) stated the resident had poor food and fluid intake, became dehydrated and required IV fluids. Staff 1 indicated the resident "seems better, at baseline now." In an interview on 3/30/11 at 8:20 am Staff 2 (CMA) stated the [MEDICATION NAME] OTC had been ordered from the pharmacy on admission to the facility. Staff 2 indicated the medication was not administered from 2/28/11 through 3/9/11 due to a problem at the pharmacy. In an interview on 3/30/11 at 10:30 am the 24 hour fluid totals on the Meal Monitor were discussed with Staff 3 (DNS). Staff 3 indicated the totals on the Meal Monitor were only the amount of fluids consumed at meals. No documentation could be located to indicate there was a system to monitor the amount of fluids the resident consumed between meals to ensure the resident's fluid intake remained 2 L in 24 hours as per the physician's orders [REDACTED]. On 3/31/11 at 3:00 pm the resident's dehydration and fluid consumption was discussed with Staff 3 and Staff 9 (Administrator). No additional information was provided.

Based on interviews and record review, it was determined the facility failed to administer a medication per the physician's order for 1 of 4 sampled residents (#1). Resident 1 experienced a 8.9% severe weight loss in less than one month and dehydration and required IV fluids. Findings include: Resident 1 was admitted to the facility in the last month with [DIAGNOSES REDACTED]. Review of the admission physician's orders dated 2/28/11 revealed orders for the medication [MEDICATION NAME] OTC 20 mg daily. [MEDICATION NAME] OTC is a gastrointestinal drug used to treat Gastro-[MEDICAL CONDITION] Reflux Disease (GERD) and ulcers. Review of the February 2011 and March 2011 MARs revealed the [MEDICATION NAME] OTC was scheduled to be given at 5:00 pm. According to the MARs the [MEDICATION NAME] OTC had not been administered as ordered from 2/28/11 through 3/9/11. There was no documentation on the back of the MARs to indicate why the [MEDICATION NAME] OTC had not been administered. Review of the NN dated 3/10/11 at 1:45 pm revealed when the resident was questioned about acid indigestion she/he responded "all the time." The NN indicated it was noted that doses of the [MEDICATION NAME] OTC had not been given "when the med (medication) was not available & usually takes in AM." The NN indicated the time was changed to be given every morning instead of 5:00 pm. In an interview on 3/30/11 at 8:20 am Staff 2 (CMA) stated the [MEDICATION NAME] OTC had been ordered from the pharmacy on admission to the facility. Staff 2 indicated the medication was not administered from 2/28/11 through 3/9/11 due to a problem at the pharmacy. On 3/31/11 at 3:00 pm the [MEDICATION NAME] OTC was discussed with Staff 3 (DNS) and Staff 9 (Administrator). No new information was provided. Refer to F-325, example 1 and F-327.