Every finding on record at Anaheim Healthcare Center, LLC

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for three sampled residents (Residents 1, 2, and 3) reviewed for ADL care. * The facility failed to ensure a care plan were develop when Residents 1, 2, and 3 refused showers on their scheduled shower days. In addition, the facility failed to document interventions and notify the responsible party of Resident 1, 2, and 3's refusals. * The facility failed to complete Resident 3's shower skin inspection sheets. These failures had the potential for the residents' need not to be met and for the residents to experience physical discomfort.Findings: Review of the facility's P&P titled Activities of Daily Living (ADLs) revised on 12/19/22, showed the following:- the facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services may consist of the following ADLs such as bathing, dressing, grooming, and oral care;- refusal of care and treatment by the resident or his/her representative to maintain functional abilities after efforts by the facility to inform and educate about the risks and benefits of the proposed care and treatment, counsel and/or offer alternatives to the resident or representative;- a resident who is unable to carry out activities of daily living will receive necessary services to maintain good nutrition, grooming, personal, and oral hygiene; and- the facility will maintain individual objectives of the care plan and periodic review and evaluation. Review of the facility's P&P titled Comprehensive Care Plans revised on 12/19/22, showed the comprehensive care plan will describe at a minimum the following:- the services that are to be furnished to attain or maintain the residents' highest practicable physical, mental, and psychological well-being; and- any services that would otherwise be furnished but are not provided due to the residents' right to refuse treatment. 1. Medical record review for Resident 1 was initiated on 7/29/26. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 1's MDS assessment dated [DATE], showed Resident 1 had a BIMS score of nine, indicating moderate cognitive impairment. Review of Resident 1's H&P examination dated 7/20/26, showed Resident 1 had the capacity to understand and make decisions. On 7/29/26 at 0905 hours, an observation and concurrent interview was conducted with Family Member 1 for Resident 1. Resident 1 was observed lying in bed, awake and oriented to person and forgetful. Family Member 1 showed rashes present on Resident 1' back. On 7/30/26 at 0824 hours, an interview and concurrent medical record review was conducted with ADON 2. Review of Resident 1's shower schedule showed the showers were every Monday and Thursday during the morning shift (0700-1500 hours). Review of Resident 1's July 2026 shower documentation showed Resident 1 refused showers on 7/2, 7/6, 7/9, 7/16, and 7/23/26. ADON 2 verified the findings and verified Resident 1's medical record did not contain documentation of interventions, development of a care plan or notification of the responsible party related to Resident 1's refusals. On 7/30/26 at 1414 hours, an interview and concurrent medical record review was conducted with LVN 5. Review of Resident 1's Order Summary dated 7/30/26, showed a physician's order dated 7/23/26, for clobetasol Propionate External Cream 0.05 % (super-high-potency topical corticosteroid used to treat severe inflammatory and pruritic (itchy) skin conditions) to apply to affected area topically every day shift and as needed for generalized body rash. LVN 5 verified the findings. 2. Medical record review for Resident 2 was initiated on 7/29/26. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's MDS assessment dated [DATE], showed Resident 2 had a BIMS score of three, indicating severe cognitive impairment. Review of Resident 2's Order Summary Report dated 7/30/26, showed a physician's order dated 7/23/26, for triamcinolone Acetonide External cream 0.1% (a medium-to-strong prescription topical corticosteroid used to relieve skin redness, itching, swelling, and discomfort caused by conditions like eczema, dermatitis, and psoriasis) to apply to generalized body topically every day shift and as needed for rash. On 7/29/26 at 0943 hours, an observation and concurrent interview was conducted with LVN 5. Resident 2 was observed sitting up in bed, awake and oriented to person and forgetful. LVN 5 showed rashes on Resident 2's back and stated Resident 2 had a treatment ordered for the rash. On 7/29/26 at 1422 hours, an interview and concurrent medical record review was conducted with LVN 1. Review of Resident 2's shower schedule showed the showers were scheduled every Wednesday and Saturday during the morning shift. Review of Resident 2's medical record failed to show shower skin inspection sheet for 7/25/26. LVN 1 verified the findings. LVN 1 stated CNAs were responsible for completing the shower skin inspection sheet after each shower, submitting them to the licensed nurse, and reporting any skin observations or shower refusals to the assigned LVNs. LVN 1 stated the LVNs were responsible to check if the CNAs completed the scheduled showers and the associated shower skin inspection sheets. On 7/29/26 at 1655 hours, an interview and concurrent medical record review was conducted with ADON 1. Review of Resident 2's July 2026 shower showed refusals of showers on 7/4, 7/8, and 7/11/26. ADON 1 verified the findings. On 7/30/26 at 0824 hours, an interview and concurrent medical record review was conducted with ADON 2. ADON 2 verified Resident 2's medical record did not show documentation of interventions, a care plan, and notification of the responsible party related to Resident 2's refusals. 3. Medical record review for Resident 3 was initiated on 7/299/26. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's H&P examination dated 7/7/26, showed Resident 3 had no capacity to understand and make decisions. Review of Resident 3's Order Summary Report dated 7/30/26, showed physician's order dated 7/23/26, for hydrocortisone External Cream 1 % (a mild topical steroid medication used to reduce skin inflammation, redness, swelling, and itching) to apply to right upper chest topically every day shift for rash. On 7/29/26 at 1430 hours, an interview and concurrent medical record review was conducted with LVN 1. Review of Resident 3's shower schedule showed the showers were scheduled every Monday and Thursday during the morning shift. Review of Nurse Station A's shower binder showed missing shower skin inspection sheets for 7/9, 7/13, 7/16, 7/20, 7/23, and 7/27/26 for Resident 3. LVN 1 verified the findings. On 7/30/26 at 1222 hours, an interview was conducted with the DSD. The DSD stated the CNAs must complete the shower skin inspection sheets after providing scheduled showers. If a resident refused the scheduled shower, the CNA must still complete the shower skin inspection sheet, document the refusal and notify the licensed nurse. The DSD stated the purpose of the shower skin inspection sheet was for the CNAs to document the observation of residents' skin and nails. The DSD stated for Nurse Station A, the CNAs must file the completed shower skin inspection sheets in the shower binder; missing shower skin inspection sheets indicated they were not completed. On 7/30/26 at 0824 hours, an interview was conducted with ADON 2. ADON 2 stated after two refusals in month of any resident care, including showering or bathing, the licensed nurses must offer alternatives and educate the resident about the risks and benefits and if refusals continue, notify the physician and responsible party, completed a change of condition documentation and develop a care plan. On 7/30/26 at 1540 hours, an interview was conducted with the Administrator, ADON 1, ADON 2, DSD, and IP nurse. The Administrator, ADON 1, ADON 2, DSD, and IP nurse were informed and acknowledged the above findings.

Based on observation, interview, and facility document review, the facility failed to maintain the essential equipment in safe operating condition when the ice machine manufacturer guidelines for sanitizing the ice machine and ice storage bin were not followed. This failure created the potential for the residents to receive ice from the kitchen that was not adequately clean for safe consumption.Findings: Review of Scotsman Ice Systems model number C1030 manufacture guidelines showed: 14. Create a solution of sanitizer by mixing a 1 gallon or 4-liter solution of locally approved sanitizer and clean, warm water. Use an EPA approved food equipment sanitizer at the solution mix recommended by the sanitizer manufacturer. Scotsman offers Stera Sheen [NAME] Label sanitizer, part number 14-0382-01. And 20. Pour the sanitizing solution into the reservoir until it is full. The unit will circulate the sanitizer, then drain and flush it. This will take 35 minutes, then the machine will stop and the display will show 0. Further reviews of the manufacture guidelines showed: Ice storage Bin 3. Mix a solution of sanitizer and thoroughly wash all interior surfaces of the ice storage bin. Pour excess sanitizer solution into the bin's drain. On 6/1/26 at 0939 hours, an interview and product manufacture guideline review was conducted with the Maintenance Director. The Maintenance Director stated the ice machine was cleaned monthly. When the Maintenance Director was asked how the ice machine was cleaned, the Maintenance Director stated he used Scotsman Clear 1 Scale Remover to clean the ice machine by mixing one ounce of Scotsman Clear 1 and 32 ounces of water then pressed the clean cycle on the ice machine. When asked how the ice machine was sanitized, the Maintenance Director stated he used Scotsman Clear 1 scale remover for the ice machine by mixing one ounce of Scotsman Clear 1 and 32 ounces of water and poured the mixed solution into the ice machine's reservoir and the ice machine would go through the sanitizing cycle. When asked how the ice storage bin was sanitized, the Maintenance Director stated he used Scotsman Clear 1 scale remover to sanitize the ice machine storage bin by mixing one ounce of Scotsman Clear 1 and 32 ounces of water. The manufacturer guidelines were reviewed with the Maintenance Director. The Maintenance Director stated he thought the Scotsman Clear 1 was to be used for both cleaning and sanitizing the ice machine. The Maintenance Director verified the ice machine, and the ice storage bin were not being sanitized per the manufacture's guidelines. On 6/4/26 at 1450 hours, an interview was conducted with the LRD and Administrator. The LRD and Administrator were informed and acknowledged the above findings.

Based on interview, document review, and medical record review, the facility failed to ensure the residents or their representatives were informed in advance of the proposed treatment regarding the use of psychotropic for two of five residents (Residents 6 and 13) reviewed for unnecessary medications and three of 35 final sampled residents (Residents 10, 214, and 238). * The facility failed to ensure Resident 6's informed consents for the trazodone (antidepressant) medication included the indication for use and duration of use, and for the Buspar (antianxiety) medication included the duration of use. In addition, the facility failed to obtain informed consent for the use of the PRN lorazepam (antianxiety) medication for Resident 6. * The facility failed to ensure the informed consents for the paroxetine (antidepressant) medication included the behavior manifestation and for the trazadone (antidepressant) medication included the correct diagnosis and behavior manifestation for Resident 10. * The facility failed to ensure Resident 13's informed consent for Ativan (antianxiety) medication included the behavior manifestation. * The facility failed to ensure the informed consents for trazodone medication included the diagnosis for Resident 214. * The facility failed to ensure Resident 238's informed consent for the olanzapine (antipsychotic medication) was verified by two licensed nurses when the resident's representative gave consent via telephone. These failures had the potential for the residents' and residents' representative to not be aware of their rights and to be fully informed regarding the psychotropic medication in order to make an informed decision. Findings: Review of the facility's P&P titled Psychotropic Medication Use/Informed Consent dated 3/2024 showed the following: - Before prescribing a psychotherapeutic drug, the prescriber must personally examine the resident and obtained informed written consent signed by the resident or resident's representative along with the signature of the healthcare professional declaring the required material information has been provided . The personal exam and signatures of the prescriber, resident or representative can be completed and signed using remote technology; and - Before initiating treatment with psychotherapeutic drugs, the facility staff must verify that the resident's health record contains written informed consent with the required signatures. Review of the facility's P&P titled Informed Consent revised date 3/25/24, showed the following: - For psychotherapeutic medications, prior to initiating the administration of a psychotherapeutic medication or physical restraint or a device, licensed nursing staff shall verify with the resident or surrogate decision maker that he/she has given informed consent for the proposed psychotherapeutic medication or physical restraint or device to the prescriber. Psychotherapeutic medications may not be administered until informed consent has been verified; and - Licensed nursing staff shall document either 1) in the order for the psychotherapeutic medication or physical restraint or device, when the order is given by the physician, that informed consent was obtained by the physician and the name/or relationship of the individual to the resident giving informed consent, or, 2) on a separate verification form; and - If a form is used to document that informed consent was verified, the licensed nursing staff will complete the Verification of Informed Consent Form and place it under the consent section in the clinical record. Review of the AFL 25-38.1 titled Notice of Release of Psychotherapeutic Drug Informed Consent Form dated 2/3/26, showed the facilities may use the CDPH (California Department of Public Health) Psychotherapeutic Drug Informed Consent Form or use their own in-house form as long as the in-house form contains all the data elements on the CDPH form. The form must be in use by January 1, 2026, for new residents, residents being prescribed a new psychotherapeutic drug, and residents having a psychotherapeutic drug dosage change. Review of the CDPH 9168 document titled Psychotherapeutic Drug Informed Consent Form dated 12/2025 showed to include the following psychotherapeutic drug information: drug category, drug name, dosage prescribed, frequency, duration, administration method, caution and warning summary, reason for use of the psychotherapeutic drug and benefits, the probable side effects and significant risks associated with the use of the psychotherapeutic drug, and the reasonable alternative mode(s) of treatment or possible non-pharmacological approaches that could address the resident's needs. 1. Medical record review for Resident 6 was initiated on 6/1/26. Resident 6 was admitted to the facility on [DATE]. Review of Resident 6's H&P examination dated 4/11/26, showed Resident 6 had no capacity to understand or make decisions. Review of Resident 6's MAR for May 2026, showed the following: - Resident 6 was administered the buspirone 5 mg, one tablet via GT every eight hours for anxiety as manifested by physical restlessness from 5/1 to 5/21/26 at 0600, 1400, and 2100 hours; and - Resident 6 was administered trazodone 50 mg, one tablet via GT at bedtime for depression as manifested by inability to sleep. a. Review of Resident 6's Psychotherapeutic Drug Informed Consent Form dated 4/9/26, showed for the trazodone medication use, Resident 6 's responsible party was informed. However, further review of the form failed to show the documentation of the duration of use and the indication for the use of the trazodone medication. b. Review of Resident 6's Psychotherapeutic Drug Informed Consent Form dated 4/9/26, showed for the buspirone medication use, Resident 6 's responsible party was informed. However, further review of the form failed to show the documentation of the duration of use for the buspirone medication. c. Review of Resident 6's Order Summary Report dated 6/2/26, showed a physician's order dated 5/24/26, to administer Ativan (lorazepam) 1 mg, give one tablet via GT every six hours as needed for anxiety as manifested by yelling out, for 14 days. Review of Resident 6's medical record failed to show the documentation if the informed consent was obtained for the use of the Ativan medication as needed every six hours for anxiety as manifested by yelling out for 14 days. On 6/3/26 at 1603 hours, an interview and concurrent medical record review for Resident 6 was conducted with LVN 1. LVN 1 stated Resident 6 was routinely administered the trazodone medication for depression and buspirone medication for anxiety. LVN 1 further stated Resident 6 was also administered the Ativan medication as needed for anxiety. LVN 1 reviewed Resident 6's informed consents for the buspirone, trazodone, and Ativan medications and verified the above findings. On 6/4/26 at 0905 hours, an interview and concurrent medical record review for Resident 6 was conducted with ADON 2. ADON 2 reviewed Resident 6's medical records and stated she did not see the informed consent for the Ativan medication for 5/24/26. On 6/4/26 at 1122 hours, an interview was conducted with the DON. The DON stated for the residents prescribed with psychotropic medications, an informed consent should be obtained and the informed consent should include the type of medication, name, dose, route, frequency, duration, indications, and manifested behaviors. On 6/4/26 at 1150 hours, a follow-up interview was conducted with the DON. The DON was informed and acknowledged the above findings. 2. Medical record review for Resident 238 was initiated on 6/1/26. Resident 238 was readmitted to the facility on [DATE]. Review of Resident 238's Order Summary Report showed a physician's order dated 5/16/26, to administer olanzapine 5 mg one tablet by mouth at bedtime for psychotic disorder as manifested by physical aggressions. Review of Resident 238's MAR for May and June 2026 showed Resident 238 was administered the olanzapine medication from 5/16 to 5/18/26, and from 5/21 to 6/1/26 at 2100 hours. Review of Resident 238's Psychotherapeutic Drug Informed Consent Form dated 5/16/26, showed for the olanzapine medication, the informed consent was given by the resident's representative via telephone. Further review of the informed consent form only one licensed nurse verified the informed consent. On 6/3/26 at 0845 hours, an interview and concurrent medical record review for Resident 238 was conducted with RN 4. RN 4 verified the informed consent form for the olanzapine medication showed the resident's representative gave the informed consent via telephone; however, only one licensed nurse verified the informed consent. RN 4 stated two licensed nurses were supposed to verify the informed consent when the consent was given via telephone. On 6/3/26 at 1453 hours, an interview for Resident 283 was conducted with the DON. The DON was informed and acknowledged the above findings. 3. Medical record review for Resident 13 was initiated on 6/1/26. Resident 13 was readmitted to the facility on [DATE]. Review of Resident 13's Order Summary Report showed a physician's order dated 3/17/26, to administer Ativan 0.5 mg one tablet by mouth every 12 hours for anxiety as manifested by verbalization of feeling anxious. Review of Resident 13's Psychotherapeutic Drug Informed Consent Form dated 3/16/26, for Ativan medication, under the Reason for Use of Psychotherapeutic Drug and Benefits section, showed a handwritten note showing anxiety. The form did not include the behavior manifestation of the verbalization of feeling anxious related to the use of the Ativan medication. Review of Resident 13's MAR for May and June 2026 showed Resident 13 was administered the Ativan medication on 5/1 to 6/2/26 at 0900 and 2100 hours, and on 6/3/26 at 0900 hours. On 6/3/26 at 0958 hours, an interview and concurrent medical record review for Resident 13 was conducted with RN 4. RN 4 verified the informed consent form for the Ativan medication for Resident 13 did not show the behavior manifestation of verbalization of feeling anxious related to the use of the Ativan medication. On 6/3/26 at 1522 hours, an interview for Resident 13 was conducted with the DON. The DON was informed and acknowledged the above findings. 4. Medical record review for Resident 10 was initiated on 6/1/26. Resident 10 was readmitted to the facility on [DATE]. Review of Resident 10's H&P examination dated 4/24/26, showed Resident 10 had the capacity to understand and make decisions. Review of Resident 10's Order Summary Report showed the following physician's orders: - dated 4/19/26, to administer paroxetine hydrochloride 20 mg one tablet by mouth one time a day for depression as manifested by verbalization of sadness; and - dated 4/20/26, to administer trazadone hydrochloride 50 mg one and a half tablets by mouth at bedtime for depression as manifested by inability to sleep. a. Review of Resident 10's Psychotherapeutic Drug Informed Consent Form dated 4/19/26, for the paroxetine medication, under the Reason for Use of Psychotherapeutic Drug and Benefits section, showed a typewritten note of Depression. The form did not include the behavior manifestation of verbalization of sadness related to the use of paroxetine. b. Review of Resident 10's Psychotherapeutic Drug Informed Consent Form dated 4/19/26, for trazadone medication, under the Reason for Use of Psychotherapeutic Drug and Benefits section, showed a typewritten note of Insomnia. The form did not show the correct diagnosis and behavior manifestation of inability to sleep related to the use of trazadone. Review of Resident 10's MAR for May and June 2026 showed Resident 10 was administered with the following medications: - paroxetine medication on 5/1 to 5/31/26 at 0900 hours, and 6/1 to 6/3/26 at 0900 hours; and - trazadone medication on 5/1 to 5/31/26 at 2100 hours, and 6/1 to 6/2/26 at 2100 hours. On 6/3/26 at 1256 hours, an interview and concurrent medical record review for Resident 10 was conducted with ADON 1. ADON 1 verified the informed consent form for the paroxetine medication did not show the behavior manifestation related to the use of the paroxetine medication and the informed consent form for the trazadone medication did not show the correct diagnosis and behavior manifestation related to the use of the trazadone medication for Resident 10. ADON 1 stated the psychotropic informed consent should reflect the diagnosis and manifested behavior related to the use of the medication as per physician's order. 5. Medical record review for Resident 214 was initiated on 6/1/26. Resident 214 was readmitted to the facility on [DATE]. Review of Resident 214's H&P examination dated 3/13/26, showed Resident 214 was alert, verbal, and oriented times three (to person/place/time). Review of Resident 214's Order Summary Report showed a physician's order dated 3/9/26, to administer trazadone hydrochloride 50 mg one tablet by mouth at bedtime for insomnia as manifested by inability to sleep. Review of Resident 214's Psychotherapeutic Drug Informed Consent Form dated 3/9/26, for trazadone medication, under the Reason for Use of Psychotherapeutic Drug and Benefits section, showed a handwritten note of inability to sleep. The form did not include the diagnosis related to the use of the trazadone medication. Review of Resident 214's MAR for May and June 2026 showed Resident 214 was administered trazadone medication on 5/1 to 5/31/26 at 2100 hours, and 6/1 to 6/2/26 at 2100 hours. On 6/3/26 at 1615 hours, an interview and concurrent medical record review for Resident 214 was conducted with ADON 1. ADON 1 verified the informed consent form for the trazadone medication did not show the diagnosis related to the use of the trazadone medication for Resident 214. ADON 1 stated the psychotropic informed consent should reflect the diagnosis for the use of the medication as per physician's order. On 6/4/26 at 1433 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings for Residents 10 and 214.

Based on observation, interview, medical record review, and P&P review, the facility failed to maintain a safe, clean, and homelike environment for three of 35 final sampled residents (Residents 5, 6, and 14) and two nonsampled residents (Resident 26 and 171). * The facility failed to ensure a homelike environment was provided for Residents 5 and 26 who were residing in Room A. Resident 5's closet door was observed in disrepair with peeled paint and the bottom left corner of the closet door was observed chipped and missing. Additionally, the wall behind Resident 26's bed was observed with chipped paint. * The facility failed to ensure a homelike environment was provided for Residents 6 and 171 who were residing in Room B. The wall between Resident 6's head of the bed and the bedside drawer was observed with multiple areas of chipped and peeled paint and the edges of Resident 6's bedside drawer were observed chipped. Additionally, the wall behind Resident 171's bed was observed with chipped and peeled paint. * The facility failed to protect and initiate an investigation for Resident 14, as per the facility's P&P. These failures had the potential to negatively impact the residents' quality of life. Findings: Review of the facility's P&P titled Safe, and Homelike Environment revised 12/19/22, showed in accordance with residents' rights, the facility will provide a safe, clean, comfortable, and homelike environment allowing the resident to use his or her personal belongings to the extent possible. 1. On 6/1/26 at 0913 hours, an observation was conducted for Room A. Residents 5 and 26 were observed lying in bed and the following were observed: - Resident 5's closet door was observed in disrepair, with chipped/peeled paint, and the bottom left corner of the closet door was observed missing; and - The wall behind Resident 26's (Resident 6's roommate) bed was observed with multiple areas of chipped paint. a. Medical record review for Resident 5 was initiated on 6/1/26. Resident 5 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 5's MDS assessment dated [DATE], showed Resident 5 was cognitively intact. b. Medical record review for Resident 26 was initiated on 6/1/26. Resident 26 was admitted to the facility on [DATE]. Review of Resident 26's H&P examination dated 5/22/26, showed Resident 26 had no capacity to understand and make medical decisions. 2. On 6/2/26 at 1010 hours, the following were observed inside Room B: - Resident 6 was observed lying in bed. The wall between Resident 6's bed and the bedside drawer was observed in disrepair with multiple areas of chipped and peeled paint. The edges of Resident 6's bedside drawer was also observed with chipped paint. - The wall behind Resident 171's (Resident 6's roommate) bed was observed with chipped and peeling paint. a. Medical record review for Resident 6 was initiated on 6/1/26. Resident 6 was admitted to the facility on [DATE]. Review of Resident 6's H&P examination dated 4/11/26, showed Resident 6 lacked the capacity for medical decision-making. b. Medical record review for Resident 171 was initiated on 6/2/26. Resident 171 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 171's H&P examination dated 12/30/25, showed Resident 171 could make his needs known but could not make medical decisions. On 6/4/26 at 1000 hours, an interview and concurrent observation inside Rooms A and B was conducted with ADON 2. ADON 2 stated the facility should ensure a homelike environment for the residents residing at the facility. ADON 2 verified the above findings in Rooms A and B. On 6/4/26 at 1122 hours, an interview was conducted with the DON. The DON stated the residents residing at the facility should be provided with a homelike environment. The DON further stated the walls with chipped paint or closets in disrepair should be addressed. 3. Review of the facility's P&P titled Theft and Loss Program revised date 12/19/22, showed the following; - The facility has a Theft and Loss Program to ensure that residents' property is safeguarded; - When a personal property is reported missing, the staff should immediately begin a search for the missing property. The facility staff should ask the resident when he/she last saw the property if he/she has any idea where it may be at this time; - If the property is not found, a Theft and Loss report is to be completed. Theft and Loss reports are available at the nurse's station in the Social Services Communication Book; - Social Services will continue the search and investigation of the loss to determine if the property can be found, or how the loss will be resolved; - The Individual Theft and Loss reports shall include, but not be limited to the following information: description of the missing item(s), an estimated value of the item, the date and time the theft or loss was discovered, the date and time of the theft or loss, if able to determine; and action taken; and - The facility will review the documentation of the incidents and efforts to control Theft and Loss, including investigative procedures and results of the investigations by the Administrator, and when feasible, the resident council, on a quarterly basis On 6/1/26 at 1000 hours, an interview was conducted with Resident 14. Resident 14 had expressed concerns about his personal items being misplaced in the facility. Resident 14 stated when he was admitted to the facility, he brought his heart monitor and bought his own mattress and a pair of tennis shoes. Resident 14 stated his mattress and tennis shoes disappeared when he was transferred to the hospital. Resident 14 further stated his heart monitor was also misplaced. When asked if he reported the missing items to the staff, Resident 14 stated they all knew about it, but did not do anything about it. Resident 14 was observed laying on a therapeutic mattress. When asked if the therapeutic mattress he was on was the mattress that was missing, Resident 14 did not know if this was the mattress he bought. Medical record review for Resident 14 was initiated on 6/1/26. Resident 14 was readmitted on [DATE]. Review of Resident 14's H&P examination dated 5/20/26, showed Resident 14 had the capacity to understand and make decisions. On 6/2/26 at 1110 hours, an interview and concurrent facility document review for Resident 14 was conducted with the SSA, with the SSD present. When asked about Resident 14's report of missing items, the SSA stated they were aware of the missing mattress. The SSA stated she and another social worker delivered the mattress to Resident 14 when the resident was readmitted to the facility. When asked about the Theft and Loss Report or any documentation about investigating and returning the missing mattress, the SSA failed to show documented evidence regarding the missing mattress. When asked about Resident 14's report of a missing heart monitor, the SSD stated the missing heart monitor was already investigated, and replaced, to which she showed a Theft and Loss Report. Review of the Theft and Loss Report for Resident 14's heart monitor dated 5/20/26, showed the social services borrowed the heart monitor from the cardiologist until Medtronic can come to replace. When asked if the social services department followed up with Medtronic regarding the replacement of Resident 14's heart monitor, the SSA answered no. When asked about the missing tennis shoes, the SSA stated she was not aware of the missing tennis shoes but will start a Theft and Loss report today. When asked if there were other reports of Resident 14's missing items, the SSA answered no. On 6/3/26 at 0950 hours, an interview and concurrent facility document review for Resident 14 was conducted with RN 4. When asked if Resident 14 had reported any missing items to the nursing department, RN 4 stated Resident 14 informed him of a missing back brace, money, and a pair of tennis shoes. RN 4 stated she reported Resident 14's missing back brace, money, and a pair of tennis shoes to the SSA about a week ago. When asked about any documentation about investigating or reporting the missing items to the SSA, RN 4 stated she did not document but she reported it to the SSA and they were already aware. On 6/3/26 at 1516 hours, an interview for Resident 14 was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the residents were free from unnecessary psychotropic drugs for two of five residents (Residents 3 and 152) reviewed for unnecessary medication and three of 35 final sampled residents (Residents 15, 212, and 214). * The facility failed to ensure the behaviors related to the use of quetiapine fumarate (antipsychotic), fluphenazine (antipsychotic), and sertraline (antidepressant) medications were monitored for Resident 3. In addition, the facility failed to ensure nonpharmacological interventions were provided prior to the use of sertraline medication for the resident. * The facility failed to ensure non-pharmacological interventions were provided prior to the use of olanzapine (antipsychotic) medication for Resident 15. * The facility failed to ensure Resident 152's orthostatic hypotensive blood pressure (blood pressure for the lying and sitting positions) were accurately monitored and the BP readings for lying and sitting were the same. Resident 152 was on Risperdal (antipsychotic) medication. * The facility failed to ensure Resident 212 was monitored for side effects such as dry mouth, constipation, blurred vision, disorientation, confusion, difficulty urinating, hypertension, dark urine, yellow skin, nausea and vomiting, lethargy, drooling was conducted for the use of escitalopram (antidepressant) medication. * The facility failed to ensure the behaviors related to the use of trazadone (antidepressant) medication were monitored for Resident 214. These failures had the potential for adverse effects from the psychotropic medications, not providing the correct data to the prescriber to adjust the dosage of the medications and to negatively impact the residents' well-being. Findings: Review of the facility's P&P titled Use of Psychotropic Medication(s) revised 3/17/25, the Policy Explanations and Compliance Guidelines sections showed:- Non-pharmacological interventions must be attempted unless clinically contraindicated to minimize the need for psychotropic medications, use the lowest possible dose, or discontinue the medication;- The resident's medical record shall include documentation of this evaluation and the rationale for chosen treatment options. This includes any indicated documentation of rationale for prescribing multiple psychotropic medications or switching from one type of psychotropic medication, specifically an antipsychotic medication, to another category of psychotropic medication;- The effect of psychotropic medication on a resident's physical, mental, and psychosocial wellbeing will be evaluated on an ongoing basis, in accordance with the nurse assessments and medication monitoring parameters consistent with clinical standards of practice, manufacturer's specifications, and the resident's comprehensive care plan; and- The resident's response to the medication(s), including progress towards the goal and presence/absence of adverse consequences, shall be documented in the resident's medical record. 1. Medical review for Resident 3 was initiated on 6/1/26. Resident 3 was readmitted to the facility on [DATE]. Review of Resident 3's H&P examination dated 2/12/26, showed Resident 3 had the capacity to understand and make decisions. Review of Resident 3's Order Summary Report showed a physician's orders dated 2/11/26 for the following:- to administer quetiapine fumarate 50 mg one tablet by mouth in the evening for schizophrenia (mental health condition that affects how people think, feel and behave) as manifested by hallucinations;- to administer fluphenazine hydrochloride 5 mg one tablet by mouth at bedtime for schizophrenia delusions;- to administer sertraline hydrochloride 25 mg one tablet by mouth one time a day for depression as manifested by feeling sad;- to monitor behaviors of schizophrenia every shift and record the number of episodes: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior and negative symptoms every shift;- to monitor depression as manifested by verbalization of feeling sad. Record number of times the behavior was exhibited every shift; and- nonpharmacological approach attempted prior to administration of psychotropic medication: 1. Encourage to verbalize feelings (needs/concern); 2. Encourage family to participate in care; 3. Encourage to attend daily activities; 4. Provide a calm and quiet environment with diversion (i.e. listening to music, watching TV); 5. Teach relaxation techniques or deep breathing exercises; 6. Redirect and provide gentle reality orientation; 7. Other every shift for Sertraline use. Review of Resident 3's MAR and Monitoring Record for April 2026 showed the following:a. Resident 3 received quetiapine fumarate 50 mg on 4/15, 4/16, and 4/21/26 at 1800 hours; however, review of Resident 3's Monitor Record failed to show the episodes of hallucinations were monitored and documented on 4/15, 4/16, and 4/21/26 during the AM shift.b. Resident 3 received fluphenazine 5 mg on 4/15, 4/16, and 4/21/26 at 2100 hours; however, review of Resident 3's Monitor Record failed to show the episodes of delusions were monitored and documented on 4/15, 4/16, and 4/21/26 during the AM shift.c. Resident 3 received sertraline 25 mg on 4/15, 4/16, and 4/21/26 at 0900 hours; however, review of Resident 3's Monitor Record failed to show the episodes verbalization of feeling sad were monitored and documented on 4/15, 4/16, and 4/21/26 during the AM shift. In addition, the nonpharmacological interventions were not provided to Resident 3 before the administration of sertraline medications on the above dates and times. On 6/3/26 at 1256 hours, an interview and concurrent medical record review for Resident 3 was conducted with ADON 1. ADON 1 verified the above findings. ADON 1 stated the manifested behaviors should be accurately documented to determine if the resident was getting better or worse and it would also assist in determining whether the medication should be continued or not. ADON 1 further stated the manifested behavior should be addressed by providing the nonpharmacological interventions first and if not effective, administer the prescribed medications. 2. Medical record review for Resident 15 was conducted on 6/1/26. Resident 15 was readmitted to the facility on [DATE]. Review of Resident 15's H&P examination dated 6/30/25, showed Resident 15 had decision making capacity. Review of Resident 15's Order Summary Report showed the following physician's orders:- dated 6/24/25, nonpharmacological approach attempted prior to administration of psychotropic medication: 1. Encourage to verbalize feelings (needs/concern); 2. Encourage family to participate in care; 3. Encourage to attend daily activities; 4. Provide a calm and quiet environment with diversion (i.e. listening to music, watching TV); 5. Teach relaxation techniques or deep breathing exercises; 6. Redirect and provide gentle reality orientation; 7. Other every shift for the olanzapine medication.- dated 2/3/26, to administer olanzapine 5 mg one tablet by mouth every 12 hours for schizophrenia bipolar type; and- dated 5/22/26, to administer olanzapine 5 mg one tablet by mouth at bedtime for schizophrenia bipolar type. Review of Resident 15's MAR for May and June 2026, showed Resident 3 received olanzapine 5 mg on the following dates and times:- dated 5/1 to 5/4/26 at 2100 hour;- dated 5/5/26 at 0900 hour;- dated 5/9/26 at 0900 and 2100 hours;- dated 5/11 and 5/13 to 5/16/26 at 2100 hour;- dated 5/18/26 at 0900 hour;- dated 5/26, 5/27, and 5/31/26 at 2100 hour; and- dated 6/2/26 at 2100 hour. Review of Resident 15's Monitor Record for May and June 2026 showed for the above dates and times, the nonpharmacological intervention for olanzapine medication section showed or marked with 0. On 6/4/26 at 0901 hours, an interview and concurrent medical record review for Resident 15 was conducted with ADON 1. ADON 1 verified the above findings. ADON 1 stated the nurses should be using the codes for which nonpharmacological interventions were provided as per physician's order. ADON 1 further stated the 0 could mean no nonpharmacological interventions were provided prior to the administration of the olanzapine medication to Resident 15. 3. Medical record review for Resident 214 was initiated on 6/1/26. Resident 214 was readmitted to the facility on [DATE]. Review of Resident 214's H&P examination dated 3/13/26, showed Resident 214 was alert, verbal, and oriented times three (to person/place/time). Review of Resident 214's Order Summary Report showed the following physician's orders:- dated 3/9/26, to administer trazadone hydrochloride 50 mg one tablet by mouth at bedtime for insomnia as manifested by inability to sleep, and monitor the hours of sleep every evening and night shift for the trazadone medication use; and- dated 3/10/26, to monitor for insomnia as manifested by inability to sleep every evening and night shift for the trazadone medication use. Review of Resident 214's MAR for May 2026 showed Resident 214 received trazadone 50 mg on 5/15/26 at 2100 hour. Review of Resident 214's Monitor Record for May 2026 failed to show the hours of sleep and inability to sleep were monitored and documented on 5/15/26, for the night shift. On 6/3/26 at 1615 hours, an interview and concurrent medical record review for Resident 214 was conducted with ADON 1. ADON 1 verified the above findings for Resident 214. On 6/4/26 at 1433 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings for Residents 3, 15, and 214. 4. Medical record review for Resident 212 was initiated on 6/3/26. Resident 212 was admitted to the facility on [DATE]. Review of Resident 212's Order Summary Report showed the following orders: - dated 4/28/26, to administered Escitalopram Oxalate 5 mg, give 1 tablet via PEG-tube one time a day for depression manifested by verbalizing sadness; and - dated 4/28/26, to monitor for dry mouth, constipation, blurred vision, disorientation, confusion, difficulty urinating, hypertension, dark urine, yellow skin, nausea and vomiting, lethargy and drooling. Enter Y (Yes) if side effect is observed, otherwise enter N (No), every shift for escitalopram use. Review of Resident 212's H&P examination dated 4/30/26, showed the resident had capacity to make decisions and had a diagnosis of depression. Review of Resident 212's Monitoring Record for May 2026 failed to show documented evidence the resident was monitored for the side effects of the escitalopram medication on the following dates and shifts: - on 5/2/26, during the 0700 to 1500 hours shift; - on 5/19/26, during the 0700 to 1500 hours shift; - on 5/21/26, during the 1500 to 2300 hours shift; and - on 5/22/26, during the 0700 to 1500 hours shift. On 6/3/26 at 1301 hours, an interview and concurrent medical record review for Resident 212 was conducted with ADON 2. ADON 2 verified the above findings and stated the facility should monitor the side-effects of the escitalopram medication and document on the monitoring record. On 6/4/26 at 1036 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. 5. Medical record review for Resident 152 was initiated on 6/1/26. Resident 152 was admitted to the facility on [DATE]. Review of Resident 152's H&P examination dated 1/17/26, showed Resident 152 had no capacity to understand and make decisions. Review of Resident 152's Order Summary Report showed the following physician's orders: - dated 7/17/25, to monitor orthostatic BP while lying weekly every day shift on Fridays; and - dated 7/17/25, to monitor orthostatic BP while sitting weekly every day shift on Fridays. Review of Resident 152's MAR for May 2026 showed the following: - on 5/1/26, the BP readings were 120/74 mmHg for the sitting and lying position; - on 5/8/26, the BP readings were 122/74 mmHg for the sitting and lying position; - on 5/15/26, the BP readings were 124/79 mmHg for the sitting and lying position; and - on 5/22/26, the BP readings were 126/70 mmHg for the sitting and lying position. On 6/3/26 at 1005 hours, an interview and concurrent medical record review for Resident 152 was conducted with ADON 1. ADON 1 stated the orthostatic hypotension BP was checked weekly in lying and sitting position every Friday. ADON 1 verified the orthostatic hypotension BP readings for lying and sitting were not accurate and should expect a difference in the BP readings. On 6/4/26 at 1350 hours, an interview and concurrent medical record review for Resident 152 was conducted with the DON. The DON verified the above findings. The DON acknowledged Resident 152's MAR showed the resident's orthostatic hypotension BP readings for both lying and sitting were the same values. The DON stated the BP readings were not accurate and stated the BP readings for lying and sitting would have some differences in the BP readings. On 6/4/26 at 1408 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Based on interview, medical record review, and P&P review, the facility failed to revise the comprehensive care plan for four of 35 final sampled residents (Residents 10, 80, 174, and 238). * The facility failed to ensure Resident 10's care plan for pain and use of pain medication was revised to address the use of nonpharmacological interventions prior to the administration of the pain medications. * The facility failed to ensure Resident 80's care plan was revised to reflect the resident's use of oxygen. * The facility failed to ensure Resident 174's comprehensive care plan was revised to reflect Resident 174's current fluid restriction of 1200 ml per day. * The facility failed to ensure Resident 238's care plan intervention for the mirtazapine (antidepressant) medication was revised to show the correct behavior manifestation. These failures posed the risk of not providing appropriate, consistent and individualized care for Residents 10, 80, 174, and 238. Findings: Review of the facility's P&P titled Comprehensive Care Plans revised date 12/19/22, showed the comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment, and the comprehensive care plan will describe, at a minimum, the following: resident specific interventions that reflect the resident's needs. 1. Medical record review for Resident 174 was initiated on 6/1/26. Resident 174 was readmitted to the facility on [DATE]. Review of Resident 174's Order Summary Report showed a physician's order dated 4/8/25, for fluid restriction of 1200 ml per day. Review of Resident 174's Care Plan Report showed a care plan problem revised on 5/8/26, to address hemodialysis and fluid restriction of 1200 ml per day. However, the interventions included a fluid restriction of 1000 ml per day, which was initiated on 12/25/24. On 6/3/26 at 0936 hours, an interview and concurrent medical record review for Resident 174 was conducted with RN 4. RN 4 verified the intervention in Resident 174's plan of care was not revised to reflect the current fluid restriction of 1200 ml per day. On 6/3/26 at 1511 hours, an interview for Resident 174 was conducted with the DON. The DON was informed and acknowledged the above findings: 2. Medical record review for Resident 238 was initiated on 6/1/26. Resident 238 was readmitted to the facility on [DATE]. Review of Resident 238's Order Summary Report showed a physician's order dated 5/16/26, to administer mirtazapine 15 mg one tablet via PEG-tube at bedtime for depression as manifested by sad affect. Review of Resident 238's Care Plan Report showed a care plan problem revised date 4/2/26, to address Resident 238's use of the mirtazapine medication as manifested by poor oral intake. The interventions included to monitor meal intake every breakfast, lunch, dinner, and record percentage. On 6/3/26 at 0845 hours, an interview and concurrent medical record review for Resident 238 was conducted with RN 4. RN 4 verified the care plan problem and intervention in Resident 238's plan of care was not revised to reflect the correct behavior manifestation related to the use of the mirtazapine medication. On 6/3/26 at 1453 hours, an interview for Resident 238 was conducted with the DON. The DON was informed and acknowledged the above findings: 3. Medical record review for Resident 80 was initiated on 6/1/26. Resident 80 was admitted to the facility on [DATE], and readmitted on [DATE] Review of Resident 80's H&P examination dated 1/21/25, showed Resident 80 was diagnosed with pneumonia, and had the capacity to understand and make medical decisions. On 6/1/26 at 0757 hours, an observation was conducted of Resident 80. Resident 80 was observed lying in bed. An oxygen concentrator was observed adjacent to Resident 80's bed. The oxygen concentrator was set to administer a continuous oxygen at a rate of 4 liters per minute. Review of Resident 80's Care Plan Report showed a care plan problem initiated on 1/29/26 and revised on 3/23/26, to address Resident 80's oxygen use. The interventions included oxygen; however, it was not updated specifically to the amount of oxygen the resident was currently on. On 6/1/26 at 1059 hours, an interview and concurrent medical record review for Resident 80 was conducted with RN 1. RN 1 verified the above findings and stated Resident 80's current plan of care for oxygen should be specific to the resident's current status. On 6/4/26 at 1040 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. The DON stated the care plan should be updated to reflect the resident's current status. 4. Medical record review for Resident 10 was initiated on 6/1/26. Resident 10 was readmitted to the facility on [DATE]. Review of Resident 10's Order Summary Report showed a physician's order dated 4/20/26, to administer hydrocodone-acetaminophen (pain medication) 5-325 mg one tablet by mouth every six hours as needed for pain rate of 5-10 (scale of 0 to 10, 0 = no pain and 10 = severe pain). NPI (nonpharmacological interventions): 1-Relaxation; 2-Redirect/Reapproach; 3-Repositioning; 4-Heat/Cold Therapy; 5-Gentle Massage; 6-Distraction | NPIO:1-Better; 2-Same; 3-Worsened. Review of Resident 10's Care plan Report revised 4/28/26, showed a care plan problem to address Resident 10's pain and use of pain medication. The interventions did not include the nonpharmacological interventions for pain as ordered by the physician. On 6/3/26 at 1256 hours, an interview and concurrent medical record review for Resident 10 was conducted with ADON 1. ADON 1 stated Resident 10's current plan of care for pain and use of pain medication should reflect the nonpharmacological interventions as one of the interventions. ADON 1 verified the care plan for Resident 10 was not updated or revised to show or include the nonpharmacological interventions as one of the interventions for pain and to initiate prior to administering the pain medication. ADON 1 further stated the plan of care needed to be reviewed and updated to reflect current or ongoing problems with the interventions because it's the guide for the resident's treatment. On 6/4/26 at 1433 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings for Resident 10.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary quality of care and services were provided for three of 35 final sampled residents (Residents 6, 11, and 15). * The facility failed to ensure the injection sites for the insulin (medication to control blood glucose levels) administration were rotated for Residents 6 and 11. These failures had the risk for lipodystrophy (buildup of fatty lumps) and decreased insulin absorption. * The facility failed to ensure Resident 15 was continuously monitored when the resident had a change in condition related to weight loss. These failures had the potential for the residents to not receive the necessary care and services and negatively affect the residents' well-being. Findings: 1. Review of the facility's P&P titled Administration of Injections revised 12/19/22, showed injections are administered by licensed nurses as ordered by the physician and in accordance with professional standards of practice. Under the section: Procedure for subcutaneous injections, showed to identify the injection site (usually abdomen, upper hips, or lateral upper arms and thighs), and clean the injection site with an alcohol pad. For repeated injections, rotate the injection site. To document the procedure in the MAR, including the location of the injection site. a. Medical record review for Resident 6 was initiated on 6/1/26. Resident 6 was admitted to the facility on [DATE], with the diagnosis of type 2 diabetes mellitus (DM). Review of Resident 6's H&P examination dated 4/11/26, showed Resident 6 had no capacity to understand or make decisions. Review of Resident 6's MAR for May 2026 showed the following physician's order: * dated 4/9/26, to administer lispro insulin (rapid acting insulin, used to manage blood sugar) subcutaneously before meals and at bedtime for DM, as per the sliding scale, if the blood sugar was: - 0 to 150 mg/dl: administer zero (0) units; - 151 to 200 mg/dl: administer one unit; - 201 to 250 mg/dl: administer two units; - 251 to 300 mg/dl: administer three units; - 301 to 350 mg/dl: administer four units; - 351 to 400 mg/dl: administer five units; and - if BS >400 mg/dl: administer six units and call the physician; and * dated 4/11/26, for the administration of the insulin glargine (long-acting insulin used to treat type 1 and 2 diabetes) pen-injector 100 units/ ml, to inject eight units subcutaneously at bedtime for diabetes mellitus, to rotate the injections sites. Further review of Resident 6's MAR for May 2026 showed the documentation when the injection sites were not rotated for the following insulin medications: * Resident 6 was administered the insulin glargine medication at the left lower quadrant of the abdomen on the following dates and times: - dated 5/23/26 at 2000 hours, - dated 5/24/26 at 2119 hours, - dated 5/25/26 at 2146 hours, - dated 5/26/26 at 2106 hours, - dated 5/27/26 at 2153 hours, - dated 5/30 at 2127 hours, and - dated 5/31/26 at 2151 hours. * Resident 6 was administered the lispro insulin medication at the left lower quadrant of the abdomen on the following dates and times: - dated 5/25/26 at 1646 hours, and - dated 5/26/26 at 1605 hours. On 6/2/26 at 1620 hours, an interview and concurrent medical record review for Resident 6 was conducted with LVN 1. LVN 1 stated for the administration of the insulin injections, prior to administering the insulin, the licensed nurse should review the MAR to determine the previous injection site. LVN 1 further stated the insulin injection site should be rotated. LVN 1 reviewed Resident 6's MAR for May 2026 and verified the above findings. 2. Medical record review for Resident 11 was initiated on 6/1/26. Resident 11 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 11's Order Summary Report dated 6/2/26, showed a physician's orders dated 2/20/26, to administer regular human insulin (short-acting insulin, used to manage blood sugar) 100 units/ml as per the sliding scale, subcutaneously every six hours for diabetes mellitus (DM), and administer insulin glargine 100 unit/ml, 10 units subcutaneously at bedtime for DM. Further review of Resident 11's MAR for May 2026 showed the documentation when the injection sites were not rotated for the following insulin medications: * Resident 11 was administered the insulin glargine medication at the left lower quadrant of the abdomen on the following dates and times: - dated 5/1/26 at 2136 hours - dated 5/2/26 at 2056 hours, - dated 5/3/26 at 2102 hours, - dated 5/12/26 at 2051 hours, - dated 5/13/26 at 2045 hours, - dated 5/14/26 at 2138 hours, - dated 5/15/26 at 2045 hours, - dated 5/24/26 at 2118 hours, and - dated 5/25/26 at 2113 hours. * Resident 11 was administered the regular huma insulin medication at the left lower quadrant of the abdomen on the following dates and times: - dated 5/1/26 at 0057 and 1836 hours, - dated 5/2/26 at 0047, 1233, and 1856 hours, - dated 5/3/26 at 1803 hours, - dated 5/12/26 at 1851 hours, - dated 5/13/26 at 1845 hours, - dated 5/14/26 at 1837 hours, and - dated 5/15/26 at 1844 hours. On 6/2/26 at 1634 hours, an interview and concurrent medical record review for Resident 11 was conducted with LVN 1. LVN 1 reviewed Resident 11's MAR for May 2026 and verified the above findings. On 6/4/26 at 1122 hours, an interview was conducted with the DON. The DON stated for the administration of insulin injections, the injection sites should be rotated to prevent skin complication related to repeated injections at the same site. The DON further stated prior to the insulin injection, the licensed nurse should review the MAR for the previously injected site and administer the insulin injection at a different site. On 6/4/26 at 1150 hours, a follow-up interview was conducted with the DON. The DON was informed and acknowledged the above findings. 3. Review of the facility's P&P titled Weight Management Policy revised 11/1/24, showed significant changes in weight (loss or gain) or insidious weight changes (unintended loss or gain over a duration of time) may indicate a nutritional problem. Interventions will be identified, implemented, monitored, and modified (as appropriate), consistent with the resident's assessed needs, choices, preferences, goals and current professional standards to maintain acceptable parameters of nutritional status. Medical record review for Resident 15 was conducted on 6/1/26. Resident 15 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 15's H&P examination dated 6/30/25, showed Resident 15 had decision making capacity. Review of Resident 15's eInteract Change in Condition Evaluation dated 5/7/26 at 1719 hours, showed the physician was notified of Resident 15's weight loss of -7 lbs. in one month; the RD was aware and no new physician's order. Review of Resident 15's Care Plan Report showed a care plan problem revised on 5/7/26, to address Resident 15's unplanned/unexpected weight loss. The interventions included to monitor and evaluate any weight loss. Review of Resident 15's Progress Notes dated 5/7 to 5/10/26, failed to show documented evidence of the continued monitoring related to the resident's unplanned weight loss. On 6/4/26 at 0901 hours, an interview and concurrent medical record review was conducted with ADON 1. ADON 1 stated any weight loss whether it's significant or non-significant was considered a change in the resident's condition. ADON 1 stated for any change in condition, the resident would be assessed and monitored related to the change in condition every shift for 72 hours and may extend depending on the severity of the condition. ADON 1 verified Resident 15 was not monitored continuously related to Resident 15's unplanned/unexpected weight loss. On 6/4/26 at 1433 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings for Resident 15. Cross reference to F692, example #2.

Based on observation, interview, medical record review, facility document review, and P&P review, the facility failed to ensure three of four final sampled residents (Residents 1, 4, and 15) received the appropriate services needed to maintain acceptable parameters of nutritional status. * The facility failed to implement a systematic approach to ensure effective monitoring of acceptable parameters of nutritional status when Resident 1 experienced severe weight loss. The severe weight loss of -24 lbs. was not assessed and monitored by the IDT. In addition, the facility failed to ensure the physician was notified and the resident's centered plan of care was revised related to Resident 1's severe weight loss. Resident 1 who had severe weight loss and poor PO intake ultimately received a GT placement. * The facility failed to ensure the RD's recommendations for Resident 15 were carried out when the resident had a weight loss of seven pounds in one month. * The facility failed to ensure the fluid restriction for 2000 ml per 24 hours was followed as per the physician's order for Resident 4. These failures had the potential for adverse nutritional outcomes and negatively affect the residents' well-being. Findings: A professional reference review of the National Library of Medicine titled, An approach to the management of unintentional weight loss in elderly people dated 3/15/05, showed in part, Unintentional weight loss, or the involuntary decline in total body weight over time, is common among elderly people who live at home. Weight loss in elderly people can have a deleterious effect on the ability to function and on quality of life and is associated with an increase in mortality over a 12-month period .Unintentional weight loss is the involuntary decline in total body weight over time. In clinical practice, it is encountered in up to 8% of all adult outpatients and 27% of frail people 65 years and older. Weight loss is an important risk factor in elderly patients. It is associated with increased mortality, which can range from 9% to as high as 38% within 1 to 2.5 years after weight loss has occurred .Weight loss of 4%-5% or more of body weight within 1 year, or 10% or more over 5-10 years or longer, is associated with increased mortality or morbidity or both. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC552892/ Review of the facility's P&P titled Weight Management Policy revised 11/1/24, showed based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise. The facility will utilize a systematic approach to optimize a resident's nutritional status. This process includes: a. Identifying and assessing each resident's nutritional status and risk factors; b. Evaluating/analyzing the assessment information; c. Developing and consistently implementing pertinent approaches; d. Monitoring the effectiveness of interventions and revising them as necessary. Information gathered from the nutritional assessment and current dietary standards of practice are used to develop and initiate an individualized care plan to address the resident's specific nutritional; concerns and preferences. Weight analysis: the newly recorded resident weight should be compared to the previous recorded weight. Pursuant to the Resident Assessment Instrument (RAI) Manual, a significant change in weight is defined as 5% change in weight in one month (30 days) or 10% change in weight in 6 months (180 days). The RD will consult residents with significant weight changes as ordered by the attending physician. The documentation of significant weight changes shall be completed in accordance with the facility's documentation policies and procedures and acceptable standards of practice. 1. Review of the facility's P&P titled Notification of Changes revised 12/19/22, showed the facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representatives when there is a change requiring such notification. Circumstances requiring notification include: significant changes in the resident's physical, mental or psychosocial condition such as deterioration in health, mental, or psychosocial status. Medical record review for Resident 1 was conducted on 6/1/26. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE] with the diagnosis of unspecified severe protein-calorie malnutrition. Review of Resident 1's H&P (History and Physical) examination dated 5/25/26, showed Resident 1 had fluctuating capacity. a. Review of Resident 1's Weights and Vitals Summary from 11/1/25 through 6/30/26, showed the following weights and comparisons for Resident 1: - on 11/19/25, weight = 149 lb., - on 12/2/25, weight = 145 lbs., - on 4/1/26, weight = 121 lbs., a -10.0% change (compared to weight on 11/19/25 of 149 lbs., -18.0%, -28 lbs.) Review of Resident 1's Nutrition - Amount Eaten for March 2026 showed the following documentation: - dated 3/5/26, for the lunch meal: Resident 1 at 30% of the meal and resident refused the alternative meal, - dated 3/6/26, for the dinner meal: Resident 1 ate 20% of the meal and ate 26-50% of the alternative meal, - dated 3/9/26, for the breakfast meal: Resident 1 ate 40% of the meal, and response not required was documented for the alternative meal, - dated 3/9/26, for the lunch meal: Resident 1 ate 30% of the meal, and response not required was documented for the alternative meal, - dated 3/13/26, for the dinner meal: Resident 1 ate 25% of the meal, and refused the alternative meal, - dated 3/14/26, for the breakfast meal: Resident 1 ate 30% of the meal and ate 26-50% of the alternative meal, - dated 3/15/26, for the lunch meal: Resident 1 ate 40% of the meal and ate 0-25% of the alternative meal, - dated 3/16/26, for the breakfast meal: Resident 1 ate 45% of the meal, and refused the alternative meal, - dated 3/16/26, for the lunch meal: Resident 1 ate 35% of the meal, and refused the alternative meal, - dated 3/17/26, for the breakfast meal: Resident 1 ate 45% of the meal, and refused the alternative meal, - dated 3/17/26, for the lunch meal: Resident 1 ate 45% of the meal, and refused the alternative meal, - dated 3/18/26, for the lunch meal: Resident 1 ate 30% of the meal, and refused the alternative meal, - dated 3/22/26, for the breakfast meal: Resident 1 ate 25% of the meal, and refused the alternative meal, - dated 3/22/26, for the lunch meal: Resident 1 ate 30% of the meal, and refused the alternative meal, - dated 3/24/26, for the dinner meal: Resident 1 ate 25% of the meal and refused the alternative meal, and - dated 3/27/26, for the dinner meal: Resident 1 ate 0% of the meal and ate 0-25% of the alternative meal. Review of Resident 1's Quarterly Nutritional Assessment by the RD dated 3/29/26 , showed the following documentation: - Resident 1 weighed 145 lbs., with the usual body weight (UBW) of 145 to 152 lbs. and the goal weight was the UBW range; - Recent weight change, indicated no; - Average percentage of meal eaten indicated 61% for two weeks. The nutritional assessment further showed Resident 1 had been refusing weights for three months. Resident 1 was eating fairly, about 61% average intake of meals with snacks ordered daily. The RD recommended to increase snacks to three times daily. The RD visited the resident at bedside this afternoon, resident reported disliking some food items. The RD encouraged resident to provide food preferences, resident declined. The RD encouraged resident to provide additional snack ideas, resident requesting to add yogurt and cottage cheese, kitchen was notified. The RD encouraged the resident to agree to monthly weigh-in next week, resident agreeable. The RD will continue to monitor the PO intake, skin, weight, labs as available as needed per protocol. Further review of Resident 1's medical record failed to show any documentation to address Resident 1's poor PO intake in the month of March 2026. Resident 1's intake had less than or equal to 50%, including the two meals that were refused for 32 of the 90 meals recorded. Resident 1 was also not seen by the RD until 3/29/26. b. Review of Resident 1's Weights and Vitals Summary from 11/1/25 through 6/30/26, showed the following weights and comparisons for Resident 1: - on 11/19/25, weight = 149 lb., - dated 12/2/25, weight = 145 lbs.; and - dated 4/1/26, weight = 121 lbs., a -10.0% change (compared to weight on 11/19/25 of 149 lbs., -18.0%, -28 lbs.); and - dated 4/24/26, weight = 117 lbs. a -10.0% change (comparison weight 11/19/25 of 149 lbs., -21.5%, -32 lbs.) Review of Resident 1's eInteract Change in Condition Evaluation dated 4/1/26, showed the physician was notified of Resident 1's poor PO intake. The licensed nurse documented Resident 1 was noted with PO intake less than 50% with the last three meals. Under most recent weight the licensed nurse documented the weight of 145 lbs. obtained on 12/2/25. Further review of the Change in Condition Evaluation showed the physician was informed with recommendations to continue monitoring Resident 1 for 72 hours, encourage PO and fluid intake, offer substitutions, assist Resident 1 with meals, and offer Boost and high-calorie shakes. However, further review of the Change in Condition Evaluation failed to show the documentation if the physician was informed of Resident 1's current weight of 121 lbs. (a weight loss of 24 lbs. from 12/2/25 to 4/1/26, or a weight loss of 28 lbs. from 11/19/25). Resident 1 was also not seen by the RD until 4/28/26 when Resident 1 was readmitted to the facility on [DATE]. c. Review of Resident 1's Weights and Vitals Summary from 11/1/25 through 6/30/26, showed the following weights and comparisons for Resident 1:- dated 4/1/26, weight = 121 lbs., a -10.0% change (compared to weight on 11/19/25 of 149 lbs., -18.0%, -28 lbs.); and - dated 4/24/26, weight = 117 lbs. a -10.0% change (comparison weight 11/19/25 of 149 lbs., -21.5%, -32 lbs.) Review of Resident 1's Nutritional Assessment by the RD dated 4/28/26 for readmission, showed the following documentation: - Resident 1 weighed 117 lbs. on 4/27/26, usual body weight 120 lbs., - BMI (Body Mass Index) of 18.3, the goal weight range indicated gradual weight gain towards BMI 23.0 to 29.9, - Recent weight change indicated no - Average of meal percentage eaten indicated 64% for four days. The nutritional assessment further showed Resident 1's PO intake did not meet 100% of the estimated needs. Resident 1 was currently on a therapeutic diet and on 1:1 feeding assist. The resident may benefit from liberalization of diet to help promote PO intake/meet increased needs. The RD will continue to monitor the PO intake, skin, weight, labs as available as needed per protocol. Further review of the RD's nutritional assessment failed to show the documentation if the RD acknowledged Resident 1's weight loss of 24 lbs. from 12/2/25 to 4/1/26. In addition, Resident 1's Usual Body Weight was changed to 120 lbs. from 145 - 152 lbs. as documented in the nutritional assessment dated [DATE]. On 6/4/26 at 0919 hours, an interview and concurrent medical record review for Resident 1 was conducted with ADON 2. ADON 2 stated for any weight variances of 3% loss in one week, 5 % loss in one month, or 10% weight loss in three months, ADON 2 stated the physician would be notified, a change in condition evaluation would be completed to monitor the resident's weight loss and PO intake, the resident would be reevaluated by the RD, and an IDT meeting would be conducted to discuss the resident's weight variance. When asked about Resident 1's documented weight loss on 4/1/26, ADON 2 reviewed Resident 1's medical record and stated there was no documentation if the physician was informed of Resident 1's weight loss of 24 lbs (16.55%), a severe weight loss since 12/2/25, no IDT meeting was conducted to discuss Resident 1's weight variance, or an RD evaluation was conducted following the documented weight loss on 4/1/26. Additionally, ADON 2 verified Resident 1's care plan problem was not updated to address Resident 1's weight loss. On 6/4/26 at 1032 hours, an interview and concurrent medical record review for Resident 1 was conducted with the Lead Registered Dietician (LRD). The LRD reviewed Resident 1's medical record and verified Resident 1 had a severe weight loss of 24 lbs. (16.55%) in four months from 12/2/25 to 4/1/26, and 28 lbs. (18.8%) in six months from 11/19/25 to 5/19/26. The LRD reviewed Resident 1's MDS assessment dated [DATE], and stated Resident 1 had a weight loss of more than 10% in six months and the coding for weight loss was inaccurate. The LRD verified there were no documented evidence Resident 1 was reevaluated by the RD following the weight loss on 4/1/26, until 4/28/26, when Resident 1's was readmitted to the facility. The LRD reviewed Resident 1's Nutritional Assessments dated 3/29/26 and 4/28/26, and verified the difference in the documentation of Resident 1's usual body weight from 145-152 lbs. to 120 lbs. When asked about the difference in the documentation of Resident 1's usual body weight, the LRD stated the RD who completed the assessment may have changed the weight based on the resident's current weight to provide a more accurate baseline. The LRD reviewed the nutritional assessment dated [DATE], and verified Resident 1's weight loss of 24 lbs. from 12/2/25 to 4/1/26 was not documented in the nutritional assessment. The LRD stated the weight loss should have been addressed as soon as possible. On 6/4/26 at 1122 hours, an interview was conducted with the DON. The DON stated, after inputting the weight, the unit manager/desk nurse was responsible for reviewing the resident's weights for any significant or severe weight changes. If a weight variance of 5% in one month, or 10% in six months was noted or identified, the unit manager/desk nurse was expected to initiate the Change in Condition evaluation, inform the physician/responsible party, and notify the RD for reassessment, and the IDT weight variance review should be conducted as soon possible for nutritional reassessment and interventions. On 6/4/26 at 1534 hours, an interview and concurrent medical record review for Resident 1 was conducted with LVN 1. LVN 1 stated Resident 1's meal intake was dependent on his mood. LVN 1 stated Resident 1's average meal intake was 40-60% and Resident 1 needed encouragement and assistance with his meals. LVN 1 stated poor PO intake was when the resident would eat less than 50% of the meal for three meals. LVN 1 further stated if the resident's PO intake was less than 50% for three days, the desk nurse would be notified to inform the physician and initiate a change in condition evaluation. On 6/4/36 at 1556 hours, a follow-up interview and concurrent medical record review for Resident 1 was conducted with the DON. The DON acknowledged the facility did not follow the facility's protocol for weight loss. When asked, the DON stated the CNAs were responsible for the documentation of the residents' meal intakes. The DON stated if the resident had less than 50% of the meal intake, the licensed nurse was responsible for communicating with the oncoming nurses the resident's poor PO intake. The DON stated if the resident had poor PO intake of less than 50% for three days or three consecutive meals, the licensed nurse should initiate a Change in Condition Evaluation and inform the physician to obtain orders. The DON reviewed Resident 1's meal intake records from 3/1 to 3/31/26, and verified Resident 1 had poor PO intake. The DON further reviewed Resident 1's medical record and verified a Change in Condition evaluation related to Resident 1's poor PO intake was not completed for Resident 1 during the month of March 2026, until 4/2/26. The DON verified a change of condition evaluation was not initiated, the physician and responsible party were not informed, an RD evaluation or IDT meeting was not conducted when Resident 1 had been refusing to be weighed for three months and had poor PO intake to evaluate Resident 1's nutritional status. The DON also verified the physician was not notified and there were no weight variance meeting conducted nor Resident 1 was seen by the RD when Resident 1 weighed only 121 lbs. on 4/1/26 (a weight loss of - 28 lbs. from 11/19/25). d. Review of the facility's P&P titled Comprehensive Care Plans revised 12/19/22, showed the comprehensive care plan will be reviewed and revised by the IDT team after each comprehensive and quarterly MDS assessment. The comprehensive care plan will include measurable objectives and timeframes to meet the resident' needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monito the resident's progress. Alternative interventions will be documented as needed. Review of Resident 1's Care Plan Report showed the following care plan problems: - dated 2/2/25, addressing Resident 1's resistive to care: refusal of meals and meal substitute. The interventions included allowing the resident to make decisions, educating the resident of the possible outcomes, encourage participation/interaction during care, praise the resident when behavior is appropriate. However, further review of the interventions failed to include specific interventions or monitoring related to Resident 1's refusal of meals and meal substitute; and - dated 5/7/26, addressing Resident 1's nutritional problem or potential nutritional problem showed on 3/29/26: quarterly review- resident refusing weights for three months, and on 5/27/26: - 5 lbs. weight loss in one month, and 33 lbs. weight loss in six months. The intervention included to monitor/record/report to the physician as needed for signs and symptoms of malnutrition: muscle wasting, significant weight loss: >5 % in one month, >7.5% in three months, >10% in six months). On 6/4/26 at 0919 hours, an interview and concurrent medical record review for Resident 1 was conducted with ADON 2. ADON 2 stated the resident weights were compared at one, three, and six-months intervals. When asked about Resident 1's documented weight loss on 4/1/26, ADON 2 reviewed Resident 1's medical record and verified the weight loss was not included in Resident 1's care plan. ADON 2 verified Resident 1's care plan problem was not revised to include Resident 1's weight loss of 24 lbs. (16.55%), a severe weight loss since 12/2/25. On 6/4/36 at 1556 hours, an interview and concurrent medical record review for Resident 1 was conducted with the DON. The DON verified Resident 1's care plan addressing Resident 1's refusal of meals or meal substitutes failed to include any specific monitoring/interventions related to Resident 1's weight loss. The DON was informed and acknowledged the above findings. 2. Medical record review for Resident 15 was conducted on 6/1/26. Resident 15 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident 15's H&P examination dated 6/30/25, showed Resident 15 had decision making capacity. The H&P further showed the documentation Resident 15 was at high risk for life-threatening deterioration. Review of Resident 15's Weight Change Progress Note dated 5/5/26 at 1733 hours, showed Resident 15 was seen by the RD for weight change of (-) seven lbs./3.2% in one month; unplanned and non-significant. The resident was currently on therapeutic diet and modified diet texture, and the oral intake was desirable. The note further showed when the RD visited, the resident stated he was not aware of the weight loss and wanted to maintain current weight. The noted also showed the cause of weight loss was unknown, and the resident stated he had been eating well. The RD recommended snacks in between meals and the resident was agreeable. RD recommended snacks BID and weekly weights for two weeks. The RD would continue to monitor po, skin, weight, labs as available as needed per protocol. Review of Resident 15's Weights and Vitals Summary from 4/1/26 through 5/31/26, showed the following weights recorded: - dated 4/2/26, weight = 166 lbs.; and - dated 5/4/26, weight = 159 lbs. Further review of Resident 15's medical record did not show documented evidence Resident 15 was being monitored for weekly weights for two weeks and the RD's recommendation for snacks BID was not ordered until 5/30/26 as per the review of the resident's Order Summary Report. Review of Resident 15's 1's eInteract Change in Condition Evaluation dated 5/7/26 at 1719 hours, showed the physician was notified of Resident 15's weight loss of (-) seven pounds in one month, the RD was aware and no new physician's order. Review of Resident 15's IDT Care Conference for Weight Variance dated 5/7/26 at 1724 hours, showed the following documentation: Reason for review was for monthly weight. Resident 15's average percentage of meals eaten was 90-100%, the most recent weight was 159 lbs.; the significant weight loss/gain: +/- five lbs in one month; indicate how much weight loss: (-) seven lbs. The recommendations showed to continue to monitor the oral intake, continue with dietary regimen as ordered by the RD follow up, and notify the physician for any significant changes. On 6/1/26 at 1407 hours, an observation and interview was conducted with Resident 15. Resident 15 stated he just felt sleepy. Resident 15 stated he was eating ok but sometimes he just did not have an appetite. Resident 15 stated he was recently receiving snacks between meals, and it was ok. Resident 15 stated he remembered he was informed of his weight loss last month. Resident 15 further stated he did not know how much he weighs now because he was not weighed recently. On 6/4/26 at 0901 hours, an interview and concurrent medical record and facility document review for Resident 15 was conducted with ADON 1 and RN 5. ADON 1 verified Resident 15 had a weight loss of seven pounds in one month last May 2026. ADON 1 stated the RD was usually in the facility daily and following up with the residents. RN 5 stated the RD would fill up the Clinical Recommendation Form and would give to the nurse at the end of the day, the nurse would review and notify the physician of the RD's recommendations, and the nurse would carry out the order when the physician approved the recommendations within 72 hours. RN 5 further stated the nurse would document the communication with the physician. Review of the facility document titled Clinical Recommendation Form revised 11/27 for the month of May 2026 did not show documentation of the RD's noted weight loss for Resident 15 on 5/4/26. However, on 5/29/26, the following documentation showed: Resident 15's Problem/Concern: Resident's preference; Recommendations: add snacks BID (two times a day); and the Nursing & Dietary Sections were blank. ADON 1 verified the RD's recommendations on 5/7/26 were not communicated to the physician and carried out until 5/29/26. On 6/4/26 at 1200 hours, an interview was conducted with the LRD. The LRD stated the RD would communicate the recommendations to nursing by writing in the Clinical Recommendation Form and would also send email to the DON, medical record or Administrator as necessary. The LRD stated when the RD had recommendations, he/she needed to communicate it to the nursing preferably on that day or at least within 72 hours. The LRD was informed and acknowledged the above findings for Resident 15. On 6/4/26 at 1433 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings for Resident 15. Cross reference to F684, example #3. 3. Review of the facility's P&P titled Fluid Restriction revised 5/18/26, the Compliance Guidelines section showed the following: - The fluid restriction distribution will take into consideration the amount of fluid to be given at mealtimes, snacks, and medication passes; - The food and nutrition department will be notified by facility communication methods of the fluid restriction; and - Water will not be provided at the bedside unless calculated into the daily total fluid restriction. On 6/1/26 at 1117 hours, during the initial tour of the facility, Resident 4 was observed awake and lying on the bed. Resident 4 stated he could drink water if the water container was on his table and if there was none, he would call and ask for it. Resident 4 stated he drank enough water, but he was swollen now. Resident 4's bilateral hands and arms were observed swollen with tightness of the skin. Medical record review for Resident 4 was initiated on 6/1/26. Resident 4 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 4's H&P examination dated 6/30/25, showed Resident 15 had the capacity to understand and make medical decisions. Review of Resident 4's Order Summary Report showed a physician's order dated 5/15/26, for fluid restriction of 2000 ml/24 hours as follows: * Total for Dietary: 960 ml - 360 ml at breakfast; - 360 ml at lunch; and - 240 ml at dinner. * Total for Nursing: 1040 ml - 240 ml for the 2300 to 0700 hours shift; - 400 ml for the 0700 to 1500 hours shift; and - 400 ml for the 1500 to 2300 hours shift. On 6/2/26 at 1136 hours, an interview for Resident 4 was conducted with CNA 2. CNA 2 stated Resident 4 could eat and drink by himself. CNA 2 stated he was familiar with Resident 4. CNA 2 stated during the morning huddle, the nurse would inform the CNAs if there were special orders for the resident like fluid restriction. CNA 2 stated he was not documenting the fluid intake of the residents but would report to the nurse after breakfast and lunch meal. CNA 2 stated he would report to the nurse the residents' food and fluid intake after he took out all the food trays. CNA 2 verified Resident 4 had a fluid restriction but did not know how much and there was no visible sign at Resident 4's room regarding the resident's fluid retraction for 24 hours. CNA 2 stated he would usually place a whole water pitcher at Resident 4's bedside which may be about 800-900 ml. CNA 2 further stated Resident 4 would tell him if the resident did not drink the water in the pitcher. CNA 2 stated he already reported to the nurse this morning the amount of fluid Resident 4 had for breakfast, but he could not recall it anymore when asked how much fluid the resident had for breakfast. On 6/2/26 at 1201 hours, an interview and concurrent medical record review for Resident 4 was conducted with LVN 2. LVN 2 stated if the resident had a fluid restriction, a signage of how much fluid restriction in a day would be posted in the resident's room and the nurses would communicate to the CNAs not to place a water pitcher in the resident's room. LVN 2 stated she would inform the CNA how much fluid restriction in the dietary intake and nursing intake. LVN 2 stated the dietary intake would be from the kitchen like coffee, milk or juice which were in the food tray. LVN 2 stated the nursing intake would be the water or juice which were given during medication administration and the water from the bedside which was given by the nurse or CNA. LVN 2 stated the CNAs would report to the nurses the resident's fluid intake after each meal. LVN 2 stated the fluid restriction intake was recorded in the Monitor Record. Review of Resident 4's Monitor Record for May and June 2026 showed the fluid intake record for the following dates and shifts: - dated 5/15 and 5/16 for the 0700 to 1500 hours shift, the recorded fluid intake was 1120 ml; - dated 5/16 and 5/17 for the 1500 to 2300 hours shift, the recorded fluid intake was 1120 ml; - dated 5/22 for the 0700 to 1500 hours shift, the recorded fluid intake was 1120 ml; - dated 5/24 for the 0700 to 1500 hours shift, the recorded fluid intake was 720 ml; - dated 5/25 for the 1500 to 2300 hours shift, the recorded fluid intake was 600 ml; - dated 5/29 and 5/30/26 for the 0700 to 1500 hours shift, the recorded fluid intake was 720 ml; and - dated 6/2/26 for the 0700 to 1500 shift, the recorded fluid intake was 640 ml. LVN 2 stated there was no report received from CNA 2 regarding the resident 4's fluid intake for breakfast. LVN 2 stated the fluid intake recorded in the Monitor Record was only from the nursing department and not the dietary intake. LVN 2 was asked about the documentation of fluid intake coming from the dietary. Further review of Resident 4's medical record failed to show documented evidence of the fluid intake from the dietary to provide 960 ml of fluids in 24 hours. LVN 2 verified the findings. In addition, Resident 4 received more than the fluid restriction as per the physician's order for the above dates for May and June 2026. On 6/4/26 at 1433 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings for Resident 4. Cross Reference to F580.

Based on observation, interview, medical record review, and P&P review, the facility failed to provide the necessary care and services related to GT feeding for four of four final sampled residents (Residents 6, 11, 130, and 238) reviewed for tube feedings. * The facility failed to ensure Residents 6, 11, and 238 were administered the complete dose of the GT enteral feeding and water flushes as per the physician's order. * The facility failed to ensure Resident 130 was administered the complete dose of GT enteral feeding and water flushes as per the physician's order. In addition, the facility failed to follow the RD recommendations to increase the GT enteral feeding. These failures had the potential to not meeting the residents' nutritional needs and put the residents at risk for weight loss and/or dehydration. Findings: Review of the facility's P&P titled Appropriate Use of Feeding Tubes revised 12/19/22, showed it is a policy of the facility to ensure that a resident maintains acceptable parameters of nutritional and hydration status. A resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal- pharyngeal ulcers. 1. On 6/1/26 at 0908 hours, Resident 6 was observed in bed. A feeding pump was observed hanging on the pole; however, there was no enteral feeding formula observed. Medical record review for Resident 6 was initiated on 6/1/26. Resident 6 was admitted to the facility on [DATE]. Review of Resident 6's Order Summary Report showed the following physician's orders dated 4/18/26, to administer the following: - continuous enteral feeding Glucerna (enteral feeding formula) 1.5 at 55 ml per hour for 20 hours, to provide 1100 ml total, a total of 1650 kcal to start at 1100 hours until 1100 ml has infused; and - continuous water flushing via the GT at 50 ml per hour for 20 hours, to provide 1000 ml, to start the water flushing at 1100 hours until a total of 1000 ml has infused. On 6/4/26 at 0805 hours, a follow-up observation was conducted for Resident 6. Resident 6 was observed lying in bed without any GT feeding. On 6/4/26 at 0840 hours, an observation for Resident 6 and concurrent interview and medical record review was conducted with RN 7. RN 7 was asked to check Resident 6's GT feeding pump. The feeding pump showed feeding incomplete. RN 7 was then asked to check the GT feeding history. The feeding pump showed 1002 ml fed and 900 ml flushed. RN 7 reviewed Resident 6's medical records and verified Resident 6 was not administered the prescribed enteral feeding dose of 1100 ml, and was not administered the prescribed water flushes of 1000 ml. 2. On 6/1/26 at 0856 hours, Resident 11 was observed in bed. A feeding pump was observed hanging on the pole; however, there were no enteral feeding formula observed. Medical record review for Resident 11 was initiated on 6/1/26. Resident 11 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 11's MDS assessment dated [DATE], showed Resident 11 had severely impaired cognitive skills for daily decision making. Review of Resident 11's Order Summary Report showed the following physician's orders: - dated 2/25/26, to administer continuous enteral feeding Glucerna 1.5 at 55 ml per hour for 20 hours, to start at 1100 hours until 1100 ml has infused, to provide 1100 ml total ; and - dated 4/28/26, to administer continuous water flushing via the GT at 25 ml per hour for 20 hours, to provide 500 ml. On 6/2/26 at 1023 hours and 6/4/26 at 0800 hours, a follow-up observation was conducted for Resident 11. Resident 11 was observed lying in bed, without any GT feeding being administered. On 6/4/26 at 0845 hours, an observation for Resident 11 and concurrent interview and medical record review was conducted with RN 7. RN 7 was asked to check Resident11's GT feeding pump. The feeding pump showed feeding incomplete. RN 7 was then asked to check the GT feeding history. The feeding pump showed 1024 ml fed and 450 ml flushed. RN 7 reviewed Resident 11's medical records and verified Resident 11 was not administered the prescribed enteral feeding dose of 1100 ml and was not administered the prescribed water flushes of 500 ml. RN 7 stated the residents should be fed the ordered volume of enteral feeding and water flushes to ensure the residents received the full nutrients. On 6/4/26 at 1122 hours, an interview was conducted with the DON. The DON stated all enteral feedings and water flushes should be administered as per the physician's order. The DON further stated if the enteral feedings and water flushes were not completely administered, there would be the potential risk of weight loss or dehydration. On 6/4/26 at 1150 hours, an follow-up interview was conducted with the DON. The DON was informed and acknowledged the above findings. 3. Medical record review for Resident 130 was initiated on 6/1/26. Resident 130 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 130's H&P examination dated 5/22/26, showed Resident 130 had no capacity to understand and make medical decisions. Review of Resident 130's MDS assessment dated [DATE], showed Resident 130 had a feeding tube and medical diagnosis of dysphagia (difficulty swallowing). Review of Resident 130's Order Summary Report dated 6/4/25, showed the following orders dated 5/20/26, to administer Fibersource HN (enteral feeding formula) at 40 ml/hr for 20 hours to provide 800ml per day and administer water for 20 ml/hr for 20 hours to provide 400ml per day. Further review of Resident 130 Nutritional assessment dated [DATE], showed a recommendation to increase the enteral feeding of Fibersource HN (enteral feeding formula) to 50 ml/hr for 20 hours to provide 1000 ml/1200 kcal, for Resident 130 was noted with gradual weight loss for 90 days. On 6/4/26 at 0754 hours, an observation and concurrent interview for Resident 130 was conducted with LVN 4. Resident 130 was observed in bed with no GT enteral feeding hanging. LVN 4 verified Resident 130 was not connected with GT enteral feeding. When LVN was asked to check Resident 130's GT feeding pump, the feeding pump showed feeding incomplete. The pump feeding history showed 73 ml left, and 37 ml flushed. LVN 4 verified Resident 130 did not receive the prescribed dose of 800 ml of enteral feeding, and was not provided with the prescribed water flushes of 400 ml. On 6/4/26 at 1148 hours, an interview and concurrent medical record review was conducted for Resident 130 with ADON 1. ADON 1 verified the RD recommendation to increase the enteral feeding was not follow up with the physician. On 6/4/26 at 1408 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings. 4. On 6/1/26 at 0938 hours, Resident 238 was observed in bed. Resident 238's GT feeding of Fibersource was observed hanging and connected via a feeding pump. The feeding pump was observed beeping, and the screen showed feeding complete. Medical record review for Resident 238 was initiated on 6/1/26. Resident 238 was admitted to the facility on [DATE]. Review of Resident 238's Order Summary Report showed a physician's order dated 5/16/26, to administer the following: - continuous enteral feeding formula Fibersource at 80 ml per hour for 20 hours, to start at 1100 hours until 1000 ml has infused; and - continuous enteral flushing with water at 24 ml per hour for 20 hours until 480 ml has infused. On 6/2/26 at 1001 hours, a follow-up observation was conducted for Resident 238. Resident 238 was observed in bed without any GT feeding. On 6/2/26 at 1047 hours, an observation for Resident 238 and concurrent interview and medical record review was conducted with RN 6. RN 6 verified Resident 238 was not connected with GT feeding. When RN 6 was asked to check Resident 238's GT feeding pump, the feeding pump showed feeding incomplete. RN 6 was then asked to check the GT feeding history, and the feeding pump showed 967 ml fed, and 456 ml flushed. RN 6 verified Resident 238 did not receive the prescribed dose of 1000 ml of enteral feeding, and was not provided with the prescribed water flushes of 480 ml. On 6/3/26 at 1453 hours, an interview for Resident 238 was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on observation, interview, medical record review and facility P&P review, the facility failed to provide the necessary pain management care and services for four of 35 final sampled residents (Residents 3, 22, 152, and 214) reviewed for pain management. * The facility failed to ensure the nonpharmacological interventions were provided and documented to Residents 3 and 214 prior to administering the pain medications. * The facility failed to accurately document the pain level as ordered by the physician when pain medication was administered to Resident 22. * The facility failed to ensure pain medication was administered as per physician's order for Resident 152's complaint of 9/10 pain. In addition, the facility failed to ensure the non-pharmacological pain interventions were implemented and documented before the resident was administered pain medication. These failures posed the risk for the residents not to receive the appropriate and necessary interventions to manage the residents' pain. Findings: Review of the facility's P&P titled Pain Management revised 3/17/25, showed the facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. The Pain Management and Treatment section showed: a. Non-pharmacological interventions will include but are not limited to: - Environmental comfort measures (e.g., adjusting room temperature, smoothing linens, comfortable seating, assistive devices or pressure redistributing mattress and positioning); - Loosening any constrictive bandage, clothing or device; - Applying splinting (e.g., pillow or folded blanket); - Physical modalities (e.g., cold compress, warm shower/bath, massage, turning and repositioning); - Exercises to address stiffness and prevent contractures as well as restorative nursing programs to maintain joint mobility; and - Cognitive/behavioral interventions ( e.g., music, relaxation techniques, activities, diversions, spiritual and comfort support, teaching the resident coping techniques and education about pain). b. Pharmacological interventions will follow a systematic approach for selecting medications and doses to treat pain. 1. On 6/1/26 at 1011 hours, during the initial tour of the facility, Resident 3 was observed awake and sitting on the bed. Resident 3 was observed with right BKA (below the knee amputation). Resident 3 stated she had pain in her right leg all the time. Resident 3 stated she received pain medication when she needed it. Medical record review for Resident 3 was initiated on 6/1/26. Resident 3 was readmitted to the facility on [DATE]. Review of Resident 3's H&P examination dated 2/12/26, showed Resident 3 had the capacity to understand and make decisions. Review of Resident 3's Order Summary Report showed a physician's order dated 2/11/26, to administer hydrocodone-acetaminophen (pain medication) 5-325 mg one tablet by mouth every six hours as needed for 5-7 pain rate (in a scale of 0-10, 0 = no and 10 = severe pain). Review of Resident 3's Care Plan Report showed a care plan dated 6/13/25, addressing the resident's risk for pain related to diabetic neuropathy and status post right BKA. The interventions included to provide non-pharmacological intervention to alleviate pain (specify: provide warm blanket when cold, provide cool drink when hot, provide extra snack when hungry, provide quiet environment to sleep when tired). Review of Resident 3's MAR for May and June 2026 showed Resident 3 received hydrocodone-acetaminophen 5-325 mg medication on the following dates and times: - dated 5/11 at 1226 hour; - dated 5/13 at 1215 hour; - dated 5/14 at 1335 hour; and - dated 6/2/26 at 0720 hour. Further review of Resident 3's medical record failed to show any documented evidence of the nonpharmacological interventions provided to Resident 3 prior to the administration of the pain medication. On 6/3/26 at 1256 hours, an interview and concurrent medical record review for Residents 3 was conducted with ADON 1. ADON 1 stated the nonpharmacological interventions such as massage, providing quiet and calm environment, music, distraction, diversion or relaxation techniques should be used when the resident was experiencing pain. ADON 1 stated the nonpharmacological interventions should be provided prior to the administration of pain medications because this could minimize the use of medications and its side effects and prevent any episodes of over sedation or dependence due to the use of the medications. ADON 1 verified Resident 3 received pain medication on the days and times listed above and was not provided with any nonpharmacological interventions prior to the administration of the pain medication. 2. On 6/1/26 at 0815 hours, during the initial tour of the facility, Resident 214 was observed awake and sitting in the wheelchair inside the room. Resident 214 stated he had pain in his right shoulder most of the time. Resident 214 stated the pain was like at number 5 or moderate pain. Resident 214 stated he received pain medication when he asked for it. Medical record review for Resident 214 was initiated on 6/1/26. Resident 214 was readmitted to the facility on [DATE]. Review of Resident 214's Order Summary Report showed a physician's order dated 3/9/26, to administer tramadol hydrochloride 50 mg one tablet by mouth every eight hours as needed for moderate (5-7) to severe (8-10) pain. Review of Resident 214's H&P examination dated 3/13/26, showed Resident 214 was alert, verbal, and oriented times three (to person/place/time). Review of Resident 214's MAR for May 2026 showed Resident 214 received tramadol 50 mg on 5/23 at 1735 hours, and 5/27/26 at 0953 hours. Further review of Resident 214's medical record failed to show any documented evidence of the nonpharmacological interventions provided to Resident 214 prior to the administration of the pain medication. On 6/2/26 at 1634 hours, an interview and concurrent medical record review for Residents 214 was conducted with ADON 1. ADON 1 verified Resident 214 received pain medication on the days and times listed above and was not provided with any nonpharmacological interventions prior to the administration of the pain medication. On 6/4/26 at 1433 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings for Residents 3 and 214. 4. Medical record review for Resident 22 was initiated on 6/2/26. Resident 22 was admitted to the facility on [DATE]. Review of Resident 22's H&P examination dated 5/8/26, showed Resident 22 has fluctuating capacity to understand and make decisions. Review of Resident 22's Order Summary Report showed a physician's order dated 5/8/26, to administer Hydrocodone-Acetaminophen (Norco) (pain medication) tablet 5-325 mg, give one tablet by mouth every four hours as needed for severe pain level of 8-10. Review of Resident 22's MAR for May 2026 showed the resident was administered the Norco medication on the following dates and times: - dated 5/24/26 at 0900 hours for a pain level of 6; and - dated 5/28/26 at 0800 hours, for a pain level of 6. On 6/2/26 at 0952 hours, an interview and concurrent medical record review for Resident 22 was conducted with ADON 2. ADON 2 stated for the residents who reported pain, the licensed nurse would assess the resident pain level prior to the administration of the pain medications. ADON 2 further stated the pain medication would be administered as per the physician's order and within the ordered parameters. ADON 2 stated for the pain level of 6, the licensed nurse should not give Norco because the order for Norco was for a pain level of 8-10. ADON 2 reviewed Resident 22's medical record and verified the above findings. On 6/4/26 at 1031 hours, an interview was conducted with the DON. The DON stated she expected the licensed nurses to accurately document the resident's pain level and give the pain medication as the physician ordered. The DON was informed and acknowledged above findings. 3. Medical record review for Resident 152 was initiated on 6/1/26. Resident 152 was admitted to the facility on [DATE]. Review of Resident 152's H&P examination dated 1/17/26, showed Resident 152 had no capacity to understand and make decisions. Review of Resident 152's Order Summary Report showed a physician's order dated 7/17/25, to give for acetaminophen 325 mg (pain medication) give two tablets by mouth every four hours as needed for numerical pain scale 1-4. Review of Resident 152's MAR for May 2026 showed the resident received acetaminophen pain medication as needed on 5/18/26 at 1318 hours for a pain level of 9. On 6/3/26 at 1005 hours, an interview and concurrent medical record review for Resident 152 was conducted with ADON 1. ADON 1 verified the above findings and stated Resident 152's pain level of nine dated 5/18/26 was considered severe pain. ADON 1 verified Resident 152 did not have a pain medication ordered for severe pain, and the PRN acetaminophen order was for mild pain. ADON 1 further stated no non-pharmacological interventions were documented prior to administering the medication. ADON 1 stated the physician should have been contacted to obtain a different pain medication order to address Resident 152's severe pain. On 6/4/26 at 1408 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for three of three final sampled residents reviewed for hemodialysis (Residents 8, 158, and 174). * The facility failed to ensure Resident 8 and 158's fluid intake were monitored accurately. In addition, the facility failed to ensure Resident 8 and 158's hemodialysis access were monitored accurately * The facility failed to ensure Resident 174 was monitored for any extra fluids at bedside, and the appropriate emergency kit was provided for the resident who has a Permacath. These failures had the potential to result in accurate assessment of fluid status, complications associated with fluid overload, and delayed intervention in the event of a dialysis access emergency.Findings: Review of the facility's P&P titled Hemodialysis revised date 6/5/23, showed the following;- The facility will assure that each resident receives care and services for the provision of hemodialysis and/or peritoneal dialysis consistent with professional standards of practice. This includes the ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility, and ongoing assessment and oversight of the resident before, during and after dialysis treatments, including monitoring of the resident's condition during treatments, monitoring for complications, implementation of appropriate interventions, and using appropriate infection control;- The licensed nurse will communicate to the dialysis facility via telephonic communication or written format, such as dialysis communication form or other form, that will include, but not limited to, nutritional/ fluid management including documentation of weights, resident compliance with food/ fluid restrictions or provision of meals before, during and/or after dialysis and monitoring intake and output measurements as ordered, and dialysis adverse reactions/ complications and/or recommendations for follow up observations and monitoring, and/or concerns related to the vascular access site;- The nurse will monitor and document the status of the resident's access site(s) upon return from the dialysis treatment to observe for bleeding or other complications; and- The nurse will ensure that the dialysis access site is checked before and after dialysis treatments and every shift for patency by auscultating for a bruit and palpating for a thrill. If absent, the nurse will immediately notify the attending physician, dialysis facility and/or nephrologist. Review of the facility's P&P titled Fluid Restriction revised date 5/18/26, showed the following:- The facility will ensure fluid restrictions will be followed in accordance with physician's orders;- The fluid restriction distribution will take into consideration the amount of fluid to be given at mealtimes, snacks and medication passes; and- Water will not be provided at the bedside unless calculated into the daily total fluid restriction. 1.a. On 6/3/26 at 0850 hours, Resident 8 was observed in bed, with a bottle of cranberry juice on the nightstand. Medical record review for Resident 8 was initiated on 6/1/26. Resident 8 was readmitted to the facility on [DATE]. Review of Resident 8's Order Summary Report showed the following physician's orders:- dated 8/11/25, for hemodialysis access site monitoring of AVF on the left forearm for bruit and thrill. Document P if present, and A if absent every shift;- dated 8/11/25, for hemodialysis access monitoring of AVF on the left forearm for R for redness, S for swelling, B for bleeding, and P for pain;- dated 8/12/25, for hemodialysis days on Monday, Wednesday, and Friday; and- dated 2/18/26, for fluid restriction of 1200 ml per day. The fluid intake limit for nursing was 600 ml, which was broken down to 240 ml for 0700 to 1500 hours shift, 240 ml for 1500 to 2300 hours shift, and 120 ml for 2300 to 0700 hours shift. The fluid intake limit for dietary was 600 ml, which was broken down to 240 ml for breakfast, 120 ml for lunch, and 240 ml for dinner. b. Review of Resident 8's fluid intake as per the CNA and licensed nurses' documentation showed inconsistency. In addition, the CNA documentation of Resident 8's fluid intake have also exceeded the amount documented by the licensed nurses documentation in the Monitor Record. For example: Review of Resident 8's Follow Up Questions Report for May and June 2026 showed the following Resident 8's fluid intake from dietary/ meals as per the CNA documentation:- dated 5/2/26, there was no documentation of the resident's fluid intake during dinner;- dated 5/3/26 at 2252 hours, the fluid intake was 550 ml;- dated 5/8/26 at 0626 hours, the fluid intake was 120 ml;- dated 5/9/26 at 0545 hours, the fluid intake was 120 ml;- dated 5/11/26 at 1933 hours, the fluid intake was 200 ml;- dated 5/12/26 at 2037 hours, the fluid intake was 200 ml;- dated 5/13/26 at 0344 hours, the fluid intake was 120 ml;- dated 5/13/26, there was no documentation of the resident's fluid intake during dinner;- dated 5/22/26 at 0659 hours, the fluid intake was 4 ml;- dated 5/22/26 at 2118 hours, the fluid intake was 550 ml;- dated 5/24/26 at 1916 hours, the fluid intake was 200 ml;- dated 5/24/26, there was no documentation of the resident's fluid intake during breakfast and lunch;- dated 5/25/26 at 0505 hours, the fluid intake was 120 ml;- dated 5/26/26 at 1450 hours, the fluid intake was 360 ml;- dated 5/26/26 at 2222 hours, the fluid intake was 8 ml;- dated 5/27/26, there was no documentation of the resident's fluid intake during dinner;- dated 5/30/26 at 1212 hours, the fluid intake was 240 ml;- dated 5/30/26, there was no documentation of the resident's fluid intake during dinner;- dated 5/31/26 at 1444 hours, the fluid intake was 240 ml;- dated 6/1/26, there was no documentation of the resident's fluid intake during dinner; and- dated 6/2/26 at 2259 hours, the fluid intake was 600 ml. Review of Resident 8's Monitor Record for May and June 2026 showed the following Resident 8's fluid intake as per the licensed nurses' documentation:- dated 5/3/26 at 1500 to 2300 hours shift, the fluid intake was 480 ml;- dated 5/8/26 at 2300 to 0700 hours shift, the fluid intake was 100 ml;- dated 5/9/26 at 2300 to 0700 hours shift, the fluid intake was 100 ml;- dated 5/11/26 at 1500 to 2300 hours shift, the fluid intake was 200 ml;- dated 5/13/26 at 2300 to 0700 hours, the fluid intake was 100 ml;- dated 5/22/26 at 1500 to 2300 hours shift, the fluid intake was 240 ml;- dated 5/24/26 at 1500 to 2300 hours shift, the fluid intake was 100 ml;- dated 5/25/26 at 2300 to 0700 hours shift, the fluid intake was 100 ml;- dated 5/26/26 at 1500 to 2300 hours shift, the fluid intake was 220 ml;- dated 5/28/26 at 0700 to 1500 hours shift, there was no documentation of the resident's fluid intake;- dated 5/30/26 at 0700 to 1500 hours shift, the fluid intake was 220 ml;- dated 5/31/26 at 0700 to 1500 hours shift, the fluid intake was 220 ml; and- dated 6/2/26 at 2300 to 0700 hours shift, the fluid intake was 100 ml. c. Further review of Resident 8's Monitor Record for May and June 2026 showed Resident 8's hemodialysis access site was not monitored consistently and accurately. For example:- Under the monitoring for bruit and thrill of the AVF on the left forearm, and to document P if present, and A if absent every shift, the licensed nurses documented N on 5/22/26 at 1500 to 2300 shift, and on 5/9 and 5/22/26 at 2300 to 0700 shift. In addition, there was no documentation on 5/28/26 at 0700 to 1500 hours shift; and- Under the hemodialysis access, Resident 8 was documented to have pain ( P) on 5/11 and 5/17/26 at 0700 to 1500 hours shift, on 5/11, 5/12, 5/14, 5/17, 5/18, 5/20, 5/22, 5/23, 5/24, and 5/26/26 at 1500 to 2300 hours shift, and on 5/2, 5/3, 5/4, 5/8, 5/10, 5/11, 5/12, 5/14, 5/15, 5/16, 5/17, 5/18, 5/20, 5/23, and 5/24/26 at 2300 to 0700 shift. In addition, there was no documentation on 5/28/26 at 0700 to 1500 hours shift. Further review of Resident 8's medical record did not show the licensed nurses notified the attending physician, dialysis facility and/or nephrologist of Resident 8's fluid intake, absence of bruit and thrill, and consistent complaint of pain. On 6/3/26 at 0900 hours, an interview and concurrent medical record review for Resident 8 was conducted with RN 4. RN 4 stated the resident's fluid intake from the dietary/ meals were documented by the CNAs on the Task (Follow-Up Questions Report). RN 4 stated the licensed nurses' documentation of the resident's fluid intake in the Monitor Record included the resident's fluid intake from the nursing and dietary/meals. RN 4 stated the licensed nurses would refer to the Task documentation to calculate the total amount of fluid intake by the resident. When asked about the monitoring of Resident 8's fluid intake, RN 4 stated the fluid intake for nursing and dietary was documented in the Monitor Record. RN 4 verified the resident's fluid intake from the dietary/meals under the Task (Follow-Up Question Report) was inconsistent and exceeded the fluid intake documented in the Monitor Record, which should have been the total fluid intake from the nursing and dietary. When asked about the hemodialysis access monitoring, RN 4 verified the licensed nurses documented N on the monitoring for bruit and thrill, and Resident 8 was documented to have pain on the hemodialysis access but there was no documentation if the physician or nephrologist nor the dialysis facility was notified. On 6/3/26 at 1010 hours, an observation of Resident 8 and concurrent interview was conducted with RN 4. RN 4 verified Resident 8 was lying in bed with a bottle of cranberry juice at bedside. RN 4 stated there should be no extra fluids at bedside. On 6/3/26 at 1433 hours, an interview for Resident 8 was conducted with the DON. When asked about residents on fluid restriction, the DON stated the facility has a protocol for the residents on fluid restriction to not have a water pitcher or extra fluids at bedside, and the resident's fluid intake from nursing and dietary will be documented by the licensed nurses in the Monitor Record. The DON was informed and acknowledged the above findings. 2. Medical record review for Resident 158 was initiated on 6/1/26. Resident 158 was admitted to the facility on [DATE]. Review of Resident 174's Order Summary Report showed the following physician's orders:- dated 5/16/24, for hemodialysis days on Tuesday, Thursday, and Saturday;- dated 2/18/26, for fluid restriction of 1000 ml per day. The fluid intake limit for nursing was 520 ml, which was broken down to 200 ml for 0700 to 1500 hours shift, 200 ml for 1500 to 2300 hours shift, and 120 ml for 2300 to 0700 hours shift. The fluid intake limit for dietary was 480 ml, which was broken down to 240 ml for breakfast, 120 ml for lunch, and 120 ml for dinner.- dated 4/15/26, for hemodialysis access site monitoring of AV shunt on the left forearm for bruit and thrill. Document P if present, and A if absent every shift; and- dated 4/15/26, for hemodialysis access monitoring of AV shunt on the left forearm for R for redness, S for swelling, B for bleeding, and P for pain. Review of Resident 158's Monitor Record for May and June 2026 showed the following:- Under the monitor for Resident 158's fluid restriction, Resident 158's total fluid intake on 5/15/26, was 1040 ml;- Under the monitoring for bruit and thrill of Resident 158's AV shunt on the left forearm, and to document P if present, and A if absent every shift, the licensed nurses documented N on 5/22/26 at 1500 to 2300 hours shift, and on 5/1, 5/6, 5/7, 5/9, and 5/22/26 at 2300 to 0700 hours shift. The licensed nurses also documented 0 on 5/2/26 at 1500 to 2300 hours shift. In addition, there was no documentation on 5/16 and 5/28/26 at 0700 to 1500 hours shift, 5/19/26 at 1500 to 2300 hours shift; and- Under the hemodialysis access, Resident 158 was documented to have pain ( P) on 5/11 and 5/17/26 at 0700 to 1500 hours shift, on 5/11, 5/12, 5/14, 5/17, 5/18, 5/20, 5/23, 5/24, and 5/26/26 at 1500 to 2300 hours shift, and on 5/3, 5/4, 5/5, 5/8, 5/10, 5/11, 5/12, 5/14, 5/15, 5/16, 5/17, 5/18, 5/20, 5/23, 5/24, and 5/29/26 at 2300 to 0700 shift. In addition, there was no documentation on 5/16 and 5/28/26 at 0700 to 1500 hours shift, 5/19/26 at 1500 to 2300 hours shift. Further review of Resident 8's medical record did not show the licensed nurses notified the attending physician, dialysis facility and/or nephrologist of Resident 8's fluid intake, absence of bruit and thrill, and consistent complaint of pain. On 6/3/26 at 0916 hours, an interview and concurrent medical record review for Resident 158 was conducted with RN 4. RN 4 verified there was no CNA documentation of Resident 158's fluid intake under Task. RN 4 also verified Resident 158's fluid intake on 5/15/26, exceeded the allowed daily fluid limit. RN 4 further verified the licensed nurses documented N on the monitoring for bruit and thrill, and Resident 158 was documented to have pain on the hemodialysis access but there was no documentation if the physician or nephrologist nor the dialysis facility was notified. On 6/3/26 at 1506 hours, an interview for Resident 158 was conducted with the DON. The DON was informed and acknowledged the above findings. The DON stated she did not know why the licensed nurses documented 0 or N for the monitoring of bruit and thrill on Resident 158's AV shunt. The DON further stated the licensed nurses should have done nursing interventions when Resident 158 complained of pain on the hemodialysis access site. 3. On 6/1/26 at 0930 hours, during the initial tour of the facility, Resident 174 was observed awake in bed. A transparent bag marked with the resident's name and dialysis torniquet kit was observed hanging on the wall. Resident 174 stated she goes to hemodialysis treatment, and her hemodialysis access was a permacath on the left shoulder. Resident 174 expressed concern that the emergency kit did not apply to her but applies to residents with an AV shunt hemodialysis access. On 6/3/26 at 0758 hours, Resident 174 was observed asleep in bed. A half-consumed bottle of soda, and a cup of water were observed at the bedside table. On 6/3/26 at 0759 hours, an observation of Resident 174 and concurrent interview was conducted with CNA 3. CNA 3 verified a half-consumed bottle of soda and a cup of water were observed at Resident 174's bedside table. CNA 3 stated Resident 174 was on fluid restriction, and the CNAs document the fluids consumed by the resident from the meal tray. When asked if the CNAs report to the licensed nurses about the resident's fluid intake from the meal tray, CNA 3 answered no. CNA 3 further stated the nurses knew the resident takes 240 ml for breakfast, and for lunch, it depends, sometimes 120 ml in the morning, or 120 ml in the afternoon. Medical record review for Resident 174 was initiated on 6/1/26. Resident 174 was readmitted to the facility on [DATE]. Review of Resident 174's Order Summary Report showed the following physician's orders:- dated 9/25/24, for hemodialysis days on Tuesday, Thursday, and Saturday;- dated 9/25/24, for hemodialysis access monitoring of central catheter on the left chest. Permacath site dressing changes at dialysis and as needed. To monitor access site for signs and symptoms of infection every shift; and- dated 4/8/26, for fluid restriction of 1200 ml per day. The fluid intake limit for nursing was 600 ml, which was broken down to 240 ml for 0700 to 1500 hours shift, 240 ml for 1500 to 2300 hours shift, and 120 ml for 2300 to 0700 hours shift. The fluid intake limit for dietary was 600 ml, which was broken down to 240 ml for breakfast, 120 ml for lunch, and 240 ml for dinner. Further review of Resident 174's medical record did not show CNA documentation of Resident 174's fluid intake under Task. On 6/3/26 at 0814 hours, an observation for Resident 174 and concurrent interview was conducted with LVN 2. LVN 2 verified a half bottle of soda, and a cup of water were observed at Resident 174's bedside table. LVN 2 further verified a transparent bag marked with the resident's name and dialysis torniquet kit was observed hanging on the wall inside Resident 174's room. LVN 2 verified the transparent bag contained a roll of stretch bandage, bordered gauze, T-drain sponges, rolls of paper tape, and a roll of a blue torniquet. LVN 2 stated in case of emergency involving Resident 174's hemodialysis access, they would use the emergency supplies inside the transparent bag. LVN 2 verified the transparent bag did not contain plastic clamps, and the torniquet would not be appropriate for the residents with Permacath hemodialysis access. When asked about Resident 174's fluid intake, LVN 2 stated Resident 174 was on fluid restriction, and the licensed nurses document the fluid intake from the nursing and dietary in the Monitor Record. LVN 2 further stated the fluid intake from the medication administration would be under the nursing department, and the fluid intake from the meal trays would be under the dietary department. LVN 2 stated they would have to add the extra amount of fluid from the half bottle of soda found on Resident 174's bedside. On 6/3/26 at 0936 hours, an interview and concurrent medical record review for Resident 174 was conducted with RN 4. RN 4 verified there was no CNA documentation of Resident 174's fluid intake under Task. On 6/3/26 at 1511 hours, an interview for Resident 174 was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the kitchen employees had the appropriate competencies and skill sets to carry out the functions of the food and nutrition services department. 1. Two of 32 kitchen employees (DAs 1 and 2) failed to follow proper manual ware washing procedures. 2. One of 32 kitchen employees (Cook 2) failed to show competency in checking the sanitizing solution concentration. 3. Two of 32 kitchen employees (DA 1 and [NAME] 1) failed to perform proper hand hygiene. These failures had the potential for cross contamination and food preparation equipment, dishware, and utensils not to be cleaned and sanitized correctly.Findings: 1. According to the USDA Food Code 2022, 4-301.12 Manual Ware washing, Sink Compartment Requirements. The 3-compartment requirement allows for proper execution of the 3-step manual ware washing procedure. If properly used, the 3 compartments reduce the chance of contaminating the sanitizing water and therefore diluting the strength and efficacy of the chemical sanitizer that may be used. Alternative manual ware washing equipment, allowed under certain circumstances and conditions, must provide for accomplishment of the same 3 steps: 1. Application of cleaners and the removal of soil; 2. Removal of any abrasive and removal or dilution of cleaning chemicals; and 3. Sanitization. According to the USDA Food Code 2022 4-603.16 Rinsing Procedures. Washed utensils and equipment shall be rinsed so that abrasives are removed and cleaning chemicals are removed or diluted through the use of water or a detergent-sanitizer solution by using one of the following procedures: Use of a distinct, separate water rinse after washing and before sanitizing if using: (3) A 3-step washing, rinsing, and sanitizing procedure in a ware washing system. It is important to rinse off detergents, abrasive, and food debris after the wash step to avoid diluting or inactivating the sanitizer. Review of the facility's P&P titled Manual Warewashing-2 or 3 Compartment Sink revised 12/19/22, showed to prevent the spread of bacteria that may cause food borne illness, this facility washes, rinses, and sanitizes pots, pans, and other utensils using a 2 or 3 compartment sink in accordance with current standards for food safety. a. Review of the facility's document titled Dietary Aide- Job Descriptions signed and dated 8/1/22 by DA 1, showed the Dietary Aide position was responsible to perform dishwashing/cleaning procedures. Assure that utensils, etc., are readily available for next meal. Review of the facility's document titled Employee Performance Evaluation signed by DA 1 on 3/21/25, showed DA 1 was above average on job performance - a. knowledge of job. On 6/1/26 at 0854 hours, an observation of the manual ware washing process using a two-compartment sink was observed with DA 1. DA 1 was observed scrubbing soiled pans in compartment one of the manual ware washing sink with hot soapy water. Then, using the sink faucet, DA 1 rinsed the pan allowing the water to run into compartment one of the manual ware washing sink diluting the cleaning solution. Next, DA 1 was observed submerging the dish pan in compartment two of the ware washing sink with a sanitizing solution. b. Review of the facility's document titled Dietary Aide- Job Descriptions signed by DA 2 on 10/25/23, showed the Dietary Aide position was responsible to perform dishwashing/cleaning procedures. Assure that utensils, etc., are readily available for next meal. Review of the facility's document titled Employee Performance Review (Dietary Aide) signed by DA 2 on 2/1/25, showed DA 2 was average on wash and clean utensils as directed. On 6/2/26 at 0930 hours, an observation and interview was conducted with DA 2. DA 2 was observed cutting cantaloupes on a food preparation table using a knife and a cutting board. After DA 2 finished, DA 2 gathered the knives and the cutting board and walked to the two-compartment manual ware washing station. Without washing the knives in the first compartment of the manual ware washing sink, DA 2 rinsed the two knives using the faucet, then placed the two knives into the clean knife holder inside the dry storage room. DA 2 acknowledged she did not follow the manual ware washing procedure to clean the two knives. On 6/3/26 at 1008 hours, an interview was conducted with the LRD. The LRD stated the facility's policy did not specify how to use a two-compartment manual ware washing sink. The LRD further stated compartment one of a manual ware washing sink was used for both washing and rinsing. The LRD stated the water in compartment one of a manual ware washing sink should be emptied after washing the pots and pans then filled with fresh water to rinse the pots and pans. The washed and rinsed pots and pans are then submerged in a sanitizing solution in compartment two of the manual ware washing sink. The LRD acknowledged DAs 1 and 2 did not follow the proper manual ware washing procedure. On 6/4/26 at 1653 hours, a follow-up interview was conducted with the LRD. The LRD stated there was no evidence the facility provided in-service training on manual ware washing for food service staff in the past year. 2. According to the USDA Food Code 2022 4-501.116 Ware washing Equipment, Determining Chemical Sanitizer Concentration. Concentration of the sanitizing solution shall be accurately determined by using a test kit or other device. Review of Manufacturer's guidelines on Micro Essential Lab QT- 10 Hydrion QT Test Quaternary Ammonia Check Test Paper Dispenser showed test paper should be held motionless in solution for ten seconds and results should be read immediately. Review of the facility's document titled Employee Performance Evaluation signed by [NAME] 2 on 8/26/25, showed superior on Job Performance - a. knowledge of job. On 6/2/26 at 1003 hours, an observation and interview was conducted with [NAME] 2. [NAME] 2 was observed testing the sanitizer concentration used for sanitizing food preparation surfaces. [NAME] 2 was observed dipping the test strip into the sanitizing solution for six seconds. [NAME] 2 removed the sanitizing test strip, looked at the sanitizing test strip then put the sanitizing test strip back in the sanitizing solution. [NAME] 2 stirred the sanitizing test strip in the sanitizing solution then without comparing the sanitizing test strip with the color chart located on the sanitizing test strip container, [NAME] 2 stated the sanitizing solution was less than 200 ppm. [NAME] 2 stated the sanitizing solution was changed every two hours or when it was visually dirty it should be changed. On 6/4/26 at 1653 hours, an interview was conducted with the LRD. The LRD stated there was no evidence the facility provided in-service training on properly testing the sanitizing solution for food service staff in the past year. On 6/4/26 at 1450 hours, an interview was conducted with the LRD and the Administrator. The LRD and Administrator were informed and acknowledged [NAME] 2 did not check sanitizing solution correctly. 3. Review of the facility's P&P titled Hand Hygiene revised dated 12/19/22, showed the staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. a. Review of the facility's document titled Dietary Aide- Job Descriptions signed by DA 1 on 8/1/22, showed to follow established Infection Control Precautions policies and procedures when performing daily tasks. Review of the facility's document titled Employee Performance Evaluation signed by DA 1 on 3/21/25, showed DA 1 was above average on job performance- a. knowledge of job. On 6/1/26 at 0830 hours, an observation of the manual ware washing process was conducted with DA 1. DA 1 wore gloves as she manually washed the soiled pans. DA 1 used the two compartment manual ware washing sink to wash the pans. DA 1 was observed scrubbing soiled pans in the first sink compartment. DA 1 then rinsed the pans using the faucet, then placed the pans in the sanitizing solution in sink two. Next, DA 1 was observed removing her gloves then rinsed her hands using the faucet over the first sink compartment. Finally, DA 1 was observed picking up the clean pans without performing hand hygiene and storing the clean pans in the dry storage room. b. Review of the facility's document titled Cook- Job Descriptions signed and dated 10/15/25 by [NAME] 1, showed h. Follow defined safety codes while performing all duties. Follow defined Infection Control procedures Review of the facility's document titled Employee Performance Review (Cook) signed and dated 2/27/26 by [NAME] 1, showed Strongly agree on follow established Infection Control Precautions policies and procedures when performing daily tasks. On 6/2/26 at 1031 hours, an observation was conducted with [NAME] 1. [NAME] 1 wore a black hat and gloves while he was thawing raw chicken in a sink. Using his gloved hands, [NAME] 1 touched the raw chicken then touched his hat. Next, [NAME] 1 removed his gloves and donned a new pair of gloves without performing hand hygiene. On 6/1/26 at 0854 hours, an interview was conducted with the LRD. The LRD was informed and acknowledged the above findings and stated the kitchen staff should wash their hands using the hand washing station. On 6/4/26 at 1653 hours, an interview was conducted with the LRD. The LRD stated there was no evidence the facility provided in-service training on hand washing for food service staff in the past year. On 6/4/26 at 1450 hours, an interview was conducted with the LRD and Administrator. The LRD and Administrator were informed and acknowledged the above findings.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure food safety and sanitation guidelines were followed when: 1. The cool down process for time, temperature control for safety (TCS) food, food that needs to be kept at specific temperatures to prevent bacteria growth and foodborne illnesses, was not monitored.2. Two of 32 kitchen employees failed to perform proper hand hygiene.3. The thawing process for fish and meat was not followed.4. The manual ware washing process was not followed.5. The kitchen utensils and equipment were not clean and were not stored in a sanitary manner.6. One of 32 kitchen employees failed to don an appropriate hair restraint.7. Food service equipment was not air-dried.8. Five cutting boards were heavily marred, and one was not clean.9. Two can opener blades were heavily worn and were not clean. These failures posed the risk for food borne illnesses in highly susceptible resident population of 187 facility residents who received food prepared in the kitchen.Findings: Review of the facility's Matrix dated 6/1/26, showed 187 of 217 residents consumed food prepared in the kitchen. 1. According to the USDA Food Code 2022, Section 3-501.14 Cooling. (A) Cooked time/temperature control for safety food shall be cooled: (1) Within 2 hours from135 Fahrenheit (F) to 70 F and (2) Within a total of 6 hours from 135 F to 41 F or less. (B) Time/Temperature Control for Safety Food shall be cooled within 4 (four) hours to 41 degrees Fahrenheit (F) or less if prepared from ingredients at ambient temperature, such as reconstituted foods and canned tuna. On 6/1/26 at 0756 hours, an observation and interview was conducted with the Assistant Dietary Manager (ADM). The following were observed inside the walk-in refrigerator:- Egg salad, dated 6/1/26, with a temperature of 70.5 F- Tuna salad, dated 6/1/26, with a temperature of 65.5 F- Ham salad, dated 6/1/26, with a temperature of 54.4 FThe ADM stated the eggs used for the egg salad were cooked in the facility kitchen and the salads were made in the facility kitchen. On 6/1/26 at 0920 hours, an observation and temperature checked of the salads was conducted. The salads were observed stored in the walk-in refrigerator and the temperature of the salads was the following:- Egg salad, dated 6/1/26, with a temperature of 62.1 F- Tuna salad, dated 6/1/26, with a temperature of 59.0 F- Ham salad, dated 6/1/26, with a temperature of 52.7 F On 6/1/26 at 1206 hours, another observation and temperature check of the salads was conducted. The salads were observed stored in the walk-in refrigerator and the temperature of the salads was the following:- Egg salad, dated 6/1/26, with a temperature of 52.7 F-Tuna salad, dated 6/1/26, with a temperature of 53.4 F- Ham salad, dated 6/1/26, with a temperature of 48.0 F On 6/1/26 at 1410 hours, an interview was conducted with the Dietary Manager (DM), ADM, and Lead Registered Dietitian (LRD). The ADM stated egg salad, tuna salad, and ham salad were made in the kitchen in the morning around 0700 to 0730 hours. When asked to show the cool down monitoring for the salads, the Dietary Manager stated they did not have a cool down log since he had been working in the facility. The Dietary Manager added there should be a cool down log. The ADM discarded egg salad, tuna salad, and ham salad. The LRD confirmed the facility did not monitor the cool down process for TCS foods. 2. Review of the facility's P&P titled Hand Hygiene revised dated 12/19/22, showed the staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. a. On 6/1/26 at 0830 hours, using a two-compartment manual ware washing sink, the manual ware washing was observed with Dietary Aide 1. DA 1 was observed scrubbing soiled pans using a two-compartment sink. DA 1 washed the pans in the first sink compartment, rinsed the pans using the faucet and sanitized the pans in the second sink compartment. Next, DA 1 was observed removing her gloves and rinsing her hands using the faucet over the first sink compartment. Finally, DA 1 was observed picking up the clean dish pans without performing hand hygiene and storing the clean dish pans in the dry storage room. b. On 6/2/26 at 1031 hours, an observation was conducted with [NAME] 1. [NAME] 1 wore a black hat and gloves while he was thawing raw chicken in a sink. Using his gloved hands, [NAME] 1 touched the raw chicken then touched his hat. Next, [NAME] 1 removed his gloves and donned a new pair of gloves without performing hand hygiene. On 6/2/26 at 1040 hours, an interview with LRD was conducted. The LRD was informed and acknowledged the above findings and stated kitchen staff should wash their hands using the hand washing station. 3. Review of the facility's P&P titled Thawing Food revised date 4/10/23, showed to label food that is to be thawed with the pull date and the date to be cooked. On 6/1/26 at 0748 hours, an observation and interview were conducted with the ADM. 30 pounds of tilapia, and five pounds of diced beef were observed thawing in the walk-in refrigerator. The tilapia and diced beef did not have a label indicating the date they were pulled from the freezer nor a date they were to be cooked. The ADM stated the thawing process was usually 72 hours and confirmed the tilapia and diced beef should be dated with a pull date and use by date. 4. According to the USDA Food Code 2022, 4-301.12 Manual Ware washing, Sink Compartment Requirements. The 3-compartment requirement allows for proper execution of the 3-step manual ware washing procedure. If properly used, the 3 (three) compartments reduce the chance of contaminating the sanitizing water and therefore diluting the strength and efficacy of the chemical sanitizer that may be used. Alternative manual ware washing equipment, allowed under certain circumstances and conditions, must provide for accomplishment of the same 3 steps: 1. Application of cleaners and the removal of soil; 2. Removal of any abrasive and removal or dilution of cleaning chemicals; and 3. Sanitization. According to the USDA Food Code 2022 4-603.16 Rinsing Procedures. Washed utensils and equipment shall be rinsed so that abrasives are removed and cleaning chemicals are removed or diluted through the use of water or a detergent-sanitizer solution by using one of the following procedures: Use of a distinct, separate water rinse after washing and before sanitizing if using: (3) A 3-step washing, rinsing, and sanitizing procedure in a ware washing system. It is important to rinse off detergents, abrasive, and food debris after the wash step to avoid diluting or inactivating the sanitizer. On 6/1/26 at 0854 hours, an observation of the manual ware washing process using a two-compartment sink was observed with DA 1. DA 1 was observed scrubbing soiled pans in compartment one of the manual ware washing sink with hot soapy water. Then, using the sink faucet, DA 1 rinsed the pan allowing the water to run into compartment one of the manual ware washing sink diluting the cleaning solution. Next, DA 1 was observed submerging the dish pan in compartment two of the ware washing sink with a sanitizing solution. On 6/3/26 at 1008 hours, an interview was conducted with the LRD. The LRD stated the facility's policy did not specify how to use a two compartment manual ware washing sink. The LRD further stated compartment one of a manual ware washing sink was used for both washing and rinsing. The LRD stated the water in compartment one of a manual ware washing sink should be emptied after washing the pots and pans then filled with fresh water to rinse the pots and pans. The washed and rinsed pots and pans are then submerged in a sanitizing solution in compartment two of the manual ware washing sink. 5. Review of the facility's P&P titled Dish and Utensil Procedure revised date 9/22/25, showed any dish, tray, or utensil with debris should not be used. Send back to the dish room to be properly washed and sanitized. On 6/1/26 at 0843 hours, an observation and interview were conducted with the Dietary Manager. Two dirty knives were stored in a knife holder. The Dietary Manager verified the two dirty knives and took the knives to be washed. a. On 6/1/26 at 0910 hours, an observation of the storage of clean kitchen utensils was conducted with the Dietary Manager. Multiple kitchen utensils were observed stored in uncovered plastic bins. The four plastic bins had dried food debris and three food service scoops stored inside the plastic bins were soiled. The Dietary Manager verified the findings and stated they should be cleaned. 6. Review of the facility's P&P titled Dietary Employee Personal Hygiene revised 6/23/25, showed hair restraints a. All dietary staff must wear hair restraints (e.g. hairnet, hat and/or beard restraint) to prevent hair from contacting food. On 6/1/26 at 0748 hours, during the initial tour of the kitchen, the Dietary Manager was observed with facial hair not covered with a beard restraint. On 6/1/26 at 0823 hours, an interview was conducted with the Dietary Manager. The Dietary Manager verified he was not wearing a beard restraint then donned a beard restraint. 7. Review of the facility's P&P titled Air Drying - Dishes and Utensils revised 3/2/26, showed dishes must be stored to promote air drying i.e. use dish racks or trays with plastic mesh that allow air to circulate and air dry the dishes. On 6/1/26 at 0748 hours, during the initial kitchen tour, an observation and interview were conducted with the Dietary Manager. In a room used for clean dishware and utensil storage, the following was observed:- more than five plastic storage bins were wet and stacked together on a drying rack.- multiple steam table pans were stacked wet on a metal rack.- two blenders were store wet.The Dietary Manager verified the food service equipment was not air dried. 8. Review of the facility's P&P titled Dish and Utensil Procedure revised date 9/22/25, showed cutting boards need to be washed and sanitized between each use. Replace cutting boards once lined with knife marks and they are un-sanitizable. On 6/1/26 at 0910 hours, an observation and interview was conducted with the ADM. Five green cutting boards were observed to be heavily marred and one cutting board was soiled. The ADM verified the five green cutting boards were heavily marred and one cutting board was soiled. The ADM removed the five marred cutting boards. 9. According to the USDA Food Code 2022 Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) Equipment, food contact surfaces and utensils shall be clean to sight and touch, (C) Nonfood contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, residue and other debris. On 6/1/26 at 0905 hours, an observation and interview were conducted with the Dietary Manager. Two can openers were not clean, and the blades had excessive wear. The Dietary Manager stated the can opener blades should be replaced and the can openers washed. On 6/4/26 at 1450 hours, an interview was conducted with the LRD and the Administrator. The LRD and Administrator were informed and acknowledged the above findings.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure safe food handling of the food brought for the residents from outside sources. * The facility failed to ensure the visitors and family members were educated on safe food handling practices when bringing food from outside sources. This failure had the potential to cause foodborne illness to the medically vulnerable resident population who consumed food [NAME] from outside resources.Findings: Review of CMS S&C-09-39 dated 5/29/09, showed the residents had the right to choose to accept food from visitors, family, friends, or other guests according to their rights to make choices. The CMS guideline further showed the facility has the responsibility under the food safety regulation to help the visitors to understand safe food handling practices such as not holding or transporting foods containing perishable ingredients at temperatures above 41 degrees Fahrenheit. Review of the facility's P&P titled Outside Food Brought in by Family or Visitor revised 8/18/25, showed It is the right of the residents of this facility to have food brought in by family or other visitors; however, the food must be handled in a way to ensure the safety of the resident. On 6/1/26 at 1236 hours, an observation and interview was conducted with RN 2 in Dining room [ROOM NUMBER]. A designated resident's food refrigerator was observed in Dining room [ROOM NUMBER]. RN 2 stated the residents and family were allowed to bring outside food, which was stored inside the resident's refrigerator. When asked about education provided to residents and families regarding safe food handling practices, RN 2 stated the facility instructed the residents and family that food brought from home could be stored in the refrigerator for 72 hours before being discarded. RN 2 did not describe education on food temperature control, transport, or other safe handling practices. On 6/3/26 at 1042 hours, an interview was conducted with the DON. The DON stated the residents and families were allowed to bring in outside food and uneaten food would be discarded after two hours if not consumed. When asked about education on safe food handling practices, the DON stated the residents and families were educated that manufactured food brought from home would be discarded after 72 hours from open date and unopened manufactured food was kept until its expiration date. The DON verified the residents, and families did not receive education on safe food handling practices as temperature control, transport, and prevention of foodborne illness.

Based on interview and facility document review, the facility failed to ensure the Facility Assessment addressed or included the following:1. Active involvement of required individuals in developing the Facility Assessment;2. A plan to maximize recruitment and retention of direct care staff; and3. A contingency plan for staffing needs. These failures had the potential not to meet the residents' care needs if the assessed population's needs and resources were not comprehensively identified and addressed.Findings: According to the CMS QSO-24-13-NH dated 6/18/24, with an implementation date of 8/8/24, CMS had issued a revised guidance for long-term care facility assessment requirement. The Facility Assessment should address and included the active involvement of the direct care staff in developing the Facility Assessment. Also included the staffing resources necessary to care for the residents, including the weekends; a plan to maximize recruitment and retention of direct care staff member, and a contingency plan for staffing needs for the events not to activate the facility's emergency plan. Review of the Facility's Assessment review dated 10/21/25, did not show the direct care staff member, direct care representatives, residents, residents' representatives, and residents' family members were actively involved in developing the Facility Assessment; a plan to maximize recruitment and retention of the direct care staff; and a contingency plan for staffing needs. On 6/3/26 at 1622 hours, an interview and concurrent facility document review of the Facility Assessment was conducted with the Administrator. The Administrator verified the Facility Assessment review dated 10/21/25, and verified there were no direct care staff, direct care representatives, residents' representatives, and family members actively involved in developing the Facility Assessment. The Administrator further verified there was no documentation of a plan to maximize recruitment and retention of direct care staff and a contingency plan for staffing needs in the Facility Assessment. The Administrator stated she was not aware of the current guidance. The Administrator verified and acknowledged the Facility Assessment was not updated based on the latest guidance from the CMS.

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to implement the facility's infection prevention and control program in accordance with the facility's P&P. * The facility failed to maintain an accurate infection control surveillance program for January 2026 through May 2026. * The facility conducted surveillance based solely on whether the residents' were prescribed antimicrobial medications. * The facility failed to include the residents who exhibited signs and/or symptoms of infection but were not prescribed antimicrobials on the surveillance report. * The facility failed to determine whether the residents who exhibited signs and/or symptoms of infections, and were not prescribed antimicrobial medications, met the facility's criteria for infection (McGeer's criteria) and thus, failed to include these residents in the facility's infection control surveillance program. * The facility failed to ensure the Surveillance Data was accurate to determine whether the residents' infection met McGeer's (a standardized surveillance definitions used to detect infections in long-term care facilities, ensuring consistent reporting and monitoring) criteria for true infection for Residents 21, 37, 55, 104, 243, 244, 245, 246, and 247. These failures posed the risk of not identifying the residents' infections and controlling the potential transmission of communicable diseases to other residents, staff, and visitors throughout the facility.Findings: Review of the facility's P&P titled Infection Prevention and Control Program revised 12/19/22, showed the IP was responsible for oversight of the program and serves as a consultant to the staff on infectious diseases, resident room placement, implementing isolation precautions, staff and resident exposures, surveillance, and epidemiological investigations of exposures of infectious diseases. A system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for residents' staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon a facility assessment and accepted national standards. Review of the facility's P&P titled Infection Surveillance revised 12/19/22, showed all resident infections will be tracked. The CDC's National Healthcare Safety Network (NHSN) Long Term Care Criteria, updated McGeer criteria or other nationally recognized surveillance criteria will be used to define infections. The facility will collect data to properly identify possible communicable diseases or infections before they spread by identifying:Data to be collected, including how often and the type of data to be documented, including:The infection site, pathogen (if available), signs and symptoms, and resident location, including summary and analysis of the number of residents (and staff, if applicable) who developed infections:Observations of staff including the identification of ineffective practices, if any; andThe identification of unusual or unexpected outcomes, infection trends and patterns.How the data will be used and shared and with appropriate individuals when applicable, to ensure that staff minimize spread of the infection or disease. Review of the facility's monthly Infection Surveillance Report from January 2026 through May 2026 showed the following infection surveillance data for HAIs (Healthcare Acquired Infections) and CAIs (Community Acquired Infections):- For January 2026: a total of 45 infections, including 22 HAIs; however, review of the log showed 20 CAIs, 13 HAIs, 12 infections not identified.- For February 2026: a total of 55 infections, including 27 CAIs and 27 HAIs; however, review of the log showed 24 CAIs, 19 HAIs, 12 infections not identified.- For March 2026: a total of 68 infections, including 22 CAIs and 45 HAIs; however, review of the log showed 17 HAIs, 40 HAIs, and 11 infections not identified.- For April 2026: a total of 67 infections, including 34 CAIs and 32 HAIs; however, review of the log showed 27 CAIs, 28 HAIs, and 12 infections not identified.- For May 2026: a total of 78 infections, including 36 CAIs and 41 HAIs; However, review of the log showed 25 CAIs, 28 HAIs, and 25 infections not identified. Further review of the facility's Infection Surveillance Report from January 2026 through May 2026 showed documentation all the residents categorized as having HAI, CAI, or not identified were prescribed antimicrobial medications. There was no documentation showing whether the residents who exhibited signs and/or symptoms of infection and were not prescribed an antimicrobial medication had met McGeer's criteria. On 6/3/26 at 1340 hours, an interview and concurrent facility document review was conducted with the IP. The IP stated he was responsible for conducting surveillance and tracking infections in the facility. The IP stated when the residents had signs and/or symptoms of an infection, the licensed nurses were responsible for initiating the Infection Screening Evaluation. Once the Infection Screening Evaluation was complete, the licensed nurse would notify the physician for orders. The IP stated if the antimicrobial therapy was prescribed (and also for the residents admitted to the facility with antimicrobial therapy), the IP would be responsible for initiating the Antibiotic Time Out to determine if the resident had met the McGeer's criteria for a true infection. The IP stated the tracking of this information was documented in the monthly Infection Surveillance Report. The IP was asked when a resident at the facility exhibited signs and/or symptoms of infection and was not prescribed antimicrobial medications, whether the facility initiated the McGeer's criteria form for these residents and included these residents in the facility's infection surveillance program (from January 2026 through May 2026). The IP stated McGeer's criteria was only used for the residents who were prescribed antimicrobial therapy to determine whether the infection was a true infection and those residents were included in the monthly Infection Surveillance Report. The IP reviewed the facility's monthly Infection Surveillance Reports from January through May 2026 and verified all the residents in the report were prescribed antimicrobial medications. The IP also verified the reported numbers of HAIs and CAIs did not match the numbers in the logs from January 2026 to May 2026. Review of the Antibiotic Time Out for Residents 21, 37, 55, 104, 243, 244, 245, 246, and 247 was conducted with the IP. The residents' Antibiotic Time Out showed the following documentation: a. For Resident 37, the report dated 1/5/26, showed the following:- the antibiotic treatment prescribed for Resident 37 was meropenem (antimicrobial) 1 gm every 12 hours for 10 days for urinary tract infection.- under the presenting clinical symptoms showed pulse oximetry less than or equal to 94 % on room air and asymptomatic. - further review of the form showed the IP documented criteria met; Resident 37 was diagnosed with ESBL (extended-spectrum beta-lactamase, a group of enzymes produced by certain bacteria that make them resistant to many standard antibiotics) in the urine. Per the physician, to complete the antibiotic regimen. - Review of the Infection Surveillance Report for January 2026 showed Resident 37's infection was categorized as an MDRO (multidrug-resistant organism) Infection (not urinary tract infection) and the infection was documented as an HAI. - Review of the Surveillance Data Collection Form for UTIs for residents without an indwelling catheter showed both criteria 1 and 2 must be present. For criteria 1- at least one of the following:- acute dysuria or acute pain,- fever or leukocytosis (high white blood cell count signaling the immune system is responding to an infection) and at least one of the following localizing urinary tract infections: acute costovertebral (connects the ribs and the spine) angle pain or tenderness, suprapubic pain, gross hematuria (blood in the urine), new or marked increase in incontinence, urgency, or frequency,- in the absence off fever or leukocytosis, then two or more of the following localized criteria: suprapubic pain, gross hematuria, or new or marked increased incontinence, urgency, or frequency.However, the Antibiotic Time Out showed Resident 37 was afebrile and asymptomatic. b. For Resident 104, the report dated 1/6/26, showed the following:- the antibiotic treatment prescribed for Resident 104 was ceftriaxone (antimicrobial) 1 gm every 24 hours for five days, for urinary tract infection.- under the presenting clinical symptoms showed the documentation Resident 104 was asymptomatic. - further review of the form showed the IP documented criteria met; Resident 104 was diagnosed with ESBL in the urine. The physician was aware of the lab results, per the physician, to complete the antibiotic regimen. - Review of the Infection Surveillance Report for January 2026 showed Resident 104's infection was documented as HAI. - Review of the Surveillance Data Collection Form for UTIs for residents with an indwelling catheter showed both criteria 1 and 2 must be present. For criteria 1- at least one of the following:a. fever, rigors, or new-onset hypotension, with no alternate site of infection,b. either acute change in mental status or acute functional decline, with no alternate diagnosis and leukocytosis,c. new-onset suprapubic pain or costovertebral angle pain or tenderness,d. purulent discharge from around the catheter or acute pain, swelling, or tenderness Review of Resident 104's Infection Screening Evaluation dated 1/3/26, showed Resident 104 had no malaise or loss of appetite, afebrile, no new onset on hypotension, and no complaints of pain. Further review of Resident 104's Antibiotic Time Out showed Resident 78 was afebrile and asymptomatic. c. For Resident 243, the report dated 2/5/26, showed the following:- the antibiotic treatment prescribed for Resident 243 was levofloxacin (antimicrobial) 750 mg one tablet daily for seven days for sepsis (a serious condition in which the body responds improperly to an infection).- the clinical symptoms included erythema and asymptomatic.- further review of the form showed the documentation no diagnostic tests were ordered and the IP documented: criteria met; Resident 243 was diagnosed with sepsis; the physician was aware of the skin erythema and to complete the antibiotic regimen. - Review of the Infection Surveillance Report for February 2026 showed Resident 243's infection was categorized as blood/systemic infection, and the infection was documented as CAI. - Review of the Surveillance Data Collection Form for other infections, showed the Loebs's Minimum Criteria for Initiating Antibiotic Therapy required both of the following criteria's to be met: a temperature greater than 100 degrees F or 2.4 degrees F above baseline, and at least rigors or delirium; however, none of the symptoms were documented for Resident 243. d. For Resident 244, the report dated 2/27/26, showed the following:- the antibiotic treatment prescribed for Resident 244 was ceftriaxone (antimicrobial) 1 gm daily in the evening, for urinary tract infection.- under clinical symptoms showed the documentation Resident 244 was asymptomatic. - further review of the form showed the IP documented: criteria met, the physician was aware and per the physician, to complete the antibiotic regimen. - Review of the Infection Surveillance Report for February 2026 showed Resident 244's infection was CAI. - Review of the Surveillance Data Collection Form for UTIs for residents without an indwelling catheter showed both criteria 1 and 2 must be present. For criteria 2: a. at least 100,000 cfu/ml of no more than two species of microorganism in a voided urine sample, or b. at least 100 cfu/ml of any number of organisms in a specimen collected by in and out catheter. However, review of Resident 244's medical record failed to show any documentation of the urine culture results. e, For Resident 245, the report dated 3/7/26, showed the following:- the antibiotic treatment prescribed for Resident 245 was Zosyn (antimicrobial) 3.375 gm every six hours for pneumonia (an infection that inflames the air sacs in one or both lungs, causing them to fill with fluid or pus).- under presenting clinical symptoms showed Resident 245 had cough and shortness of breath. - further review of the form showed Resident 245 was afebrile, had no change in activity level and was tolerating meals. The IP documented: criteria met, Resident 245 was diagnosed with pneumonia, the physician was aware of Resident 245's shortness of breath and cough. Per the physician to complete the antibiotic regimen. - Review of the Infection Surveillance Report for March 2026 showed Resident 245's infection was documented as HAI. - Review of Surveillance Data Collection Form for Respiratory Infections, under the criteria for pneumonia, showed all three criteria must be present. For criteria 1- interpretation of chest radiograph as demonstrating pneumonia or the presence of new infiltrates. For criteria 3- at least one of the constitutional criteria: fever, leukocytosis, acute mental status change or acute functional decline. However, review of Resident 245's chest radiograph results dated 3/5/26, showed prominent interstitial markings in both lungs concerning for mild congestion, blunted right costophrenic angle, concerning for pleural thickening. No focal infiltrates are seen and there is no pleural effusion on the left side. f. For Resident 21, the report dated 4/10/26 showed the following:- the antibiotic treatment prescribed for Resident 21 was piperacillin-tazobactam (antimicrobial) 3.375 gm three times a day for sepsis.- under clinical symptoms showed the documentation Resident 21 was afebrile and had confusion.- further review of the form showed no diagnostic tests were ordered and the IP documented: criteria met, Resident 21 was diagnosed with sepsis. The physician was aware of Resident 21's confusion, per the physician to complete the antibiotic regimen. - Review of the Infection Surveillance Report for April 2026 showed Resident 21's infection was categorized as blood/systemic infection, and the infection was documented as HAI. - Review of the Surveillance Data Collection Form for other infections, showed the Loebs's Minimum Criteria for initiating antibiotic therapy required both of the following criteria's to be met: a temperature greater than 100 degrees F or 2.4 degrees F above baseline, and at least rigors or delirium; however, the documentation showed Resident 1 was afebrile. g. For Resident 247, the report dated 4/11/26, showed the following:- the antibiotic treatment prescribed for Resident 247 was levofloxacin 500 mg for pneumonia/leukocytosis.- under presenting clinical symptoms showed Resident 247 had low-grade fever and pulse oximetry reading of less than or equal to 94% on room air. - further review of the form showed Resident 247 was afebrile, had no change in activity level and tolerating meals. The IP documented: criteria met, per the physician to complete the antibiotic regimen. - Review of the Infection Surveillance Report for April 2026 showed Resident 247's infection was categorized as a respiratory infection, and the infection was documented as HAI. - Review of Surveillance Data Collection Form for Respiratory Infections, under the criteria for pneumonia, showed all three criteria must be present. For criteria 1- interpretation of chest radiograph as demonstrating pneumonia or the presence of new infiltrates. However, review of Resident 247's medical records showed the following chest radiograph results:- dated 4/8/26: normal chest x-ray, both lung fields are clear with no consolidation, collapse, nodule, or interstitial changes; and- dated 4/9/26: right lower lung lobe with linear opacities likely inflammatory; prominence of both pulmonary hila and attenuation of bronchovascular markings in bilateral lung represents congestion. h. For Resident 246, the report dated 4/17/26, showed the following:- the antibiotic treatment prescribed for Resident 246 was vancomycin (antimicrobial) 10 ml every six hours for C. difficile (bacterial infection of the intestines that causes diarrhea and inflammation of the colon).- the presenting clinical symptoms showed the documentation: abnormal bowel movements/bowel habits.- further review of the form showed no diagnostic tests were ordered and the IP documented: criteria met, the physician was aware of the abnormal bowel habits, per the physician to complete the antibiotic regimen. - Review of the Infection Surveillance Report for April 2026 showed Resident 246's infection was categorized as HAI. - Review of the Surveillance Data Collection Form for gastrointestinal infections, for C. difficile, showed both criteria 1 and 2 must be met: 1. a. Diarrhea of three or more liquid or watery stools within a 24-hour period or b. the presence of toxic megacolon (abnormal dilation of the large bowel) and 2 a. a stool sample yields a positive laboratory result for C. Difficile toxin A or B, or a toxin- producing C. difficile organism is identified from a stool sample culture or b. Pseudomembranous colitis is identified during endoscopic examination or surgery or in histopathologic examination of a biopsy specimen. However, review of Resident 246's medical record failed to show documented evidence a toxicology of Resident 246's stool was completed. i. For Resident 55, the report dated 4/22/26, showed the following:- the antibiotic treatment prescribed for Resident 55 was ceftriaxone 1 gm daily for urinary tract infection.- under presenting clinical symptoms showed Resident 55 had urinary frequency/urgency. - further review of the form showed the IP documented criteria met, the physician was aware of increased frequency/urgency, per the physician, to complete the antibiotic regimen. - Review of the Infection Surveillance Report for April 2026 showed Resident 55's infection was HAI. - Review of the Surveillance Data Collection Form for UTIs for residents without an indwelling catheter showed both criteria 1 and 2 must be present. For criteria 2: a. at least 100,000 cfu/ml of no more than two species of microorganism in a voided urine sample, or b. at least 100 cfu/ml of any number of organisms in a specimen collected by in and out catheter.However, review of Resident 55's medical record failed to show any documentation the urine cultures were obtained. On 6/3/26 at 1340 hours, an interview and concurrent facility document review was conducted with the IP. The IP reviewed the medical records for Residents 21, 37, 55, 104, 243, 244, 245, 246, and 247 and verified the classification of the residents' infections as true infections were incorrect. The IP stated the determination of a true infection should be accurate to effectively conduct surveillance and track the prevalence of infections in the facility. On 6/4/16 at 1122 hours, an interview was conducted with the DON. The DON stated the IP was responsible for the surveillance of infections in the facility. The DON stated for the residents with signs and/or symptoms of infection, the McGeer's tool should be conducted to determine if the infection was a true infection. The DON stated the determination of true infections and whether it was HAI or CAI should be accurate. The DON further stated the residents with signs and/or symptoms of infection but were not prescribed any antimicrobial medications should be included in the monthly infection surveillance report. On 6/4/26 at 1150 hours, a follow up interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to accurately monitor and address the use of the antibiotics for one final sampled resident (Resident 1) and nine nonsampled residents (Residents 21, 37, 55, 104, 243, 244, 245, 246 and 247) reviewed for antibiotic stewardship. * The facility failed to ensure the Infection Screening Evaluation and Antibiotic Time Out were conducted when Resident 1 was prescribed an antibiotic therapy. * Residents 21, 37, 55, 104, 243, 244, 245, 246, and 247 who did not meet the McGeer's criteria (a set of specific definitions to identify true infections in long term nursing facilities) were prescribed antimicrobial therapy. These failures resulted in continued use of unnecessary antibiotic therapy, increasing the risk of adverse drug reactions, Clostridioides difficile infection, and the development of antibiotic resistant organisms.Findings: According to the Centers for Disease Control and Prevention (CDC), antibiotics are among the most frequently prescribed medications in nursing homes, with up to 70% of residents in a nursing home receiving one or more courses of systemic antibiotics over a year. Studies have shown that 40-75% of antibiotics prescribed in nursing homes may be unnecessary or inappropriate. Harms from antibiotic overuse are significant for the frail and older adults receiving care in nursing homes. These harms include risk of serious diarrheal infections from Clostridium difficile (a type of bacteria that can cause diarrhea and inflammation of the colon), increased adverse drug events and drug interactions, and colonization and/or infection with antibiotic-resistant organisms. Review of the facility's P&P titled Infection Prevention and Control Program revised 12/19/22, showed an antibiotic stewardship program will be implemented as part of the overall infection prevention and control program. Antibiotic use protocols and a system to monitor antibiotic use will be implemented as part of the antibiotic stewardship program. The IP, with oversight from the DON, serves as the leader of the antibiotic stewardship program. Review of the facility's P&P titled Antibiotic Stewardship Program revised 12/19/22, showed the Infection Preventionist coordinates all antibiotic stewardship activities, maintains documentation, and serves as a resource for all clinical staff. The program includes antibiotic use protocols and a system to monitor antibiotic use. Nursing staff shall assess residents who are suspected to have an infection and complete an SBAR prior to notifying the physician. Laboratory testing shall be in accordance with current standards of practice. The facility uses CDC's NHSN Surveillance Definitions, updated McGeer's criteria, or other surveillance tool to define infections. Monitoring antibiotic use: i. Monitor response to antibiotics, and laboratory results when available, to determine if the antibiotic is still indicated or adjustments should be made (e.g. antibiotic time out). ii. Antibiotic orders obtained upon admission, whether new admission or readmission, to the facility shall be reviewed for appropriateness. Review of the facility's monthly Infection Surveillance Report from January 2026 through May 2026 showed the following infection surveillance data for HAIs (Healthcare Acquired Infections) and CAIs (Community Acquired Infections):- for January 2026: a total of 45 infections, including 22 HAIs;- for February 2026: a total of 55 infections, including 27 CAIs and 27 HAIs;- for March 2026: a total of 68 infections, including 22 CAIs and 45 HAIs;- for April 2026: a total of 67 infections, including 34 CAIs and 32 HAIs; and - for May 2026: a total of 78 infections, including 36 CAIs and 41 HAIs. On 6/3/26 at 1340 hours, an interview and concurrent facility document review was conducted with the IP. The IP stated he was responsible for conducting surveillance and tracking infections in the facility. The IP stated when the residents had signs and symptoms of an infection, the licensed nurses were responsible for initiating the infection screening evaluation. Once the infection screening evaluation was complete, the licensed nurse would notify the physician for orders. The IP stated if the antimicrobial therapy was prescribed (and also for the residents admitted to the facility with antimicrobial therapy), the IP would be responsible for initiating the Antibiotic Time Out to determine if the resident had met the McGeer's criteria for a true infection. The IP further stated if the infection did not meet the criteria for a true infection, the physician would be notified that the antimicrobial therapy may not be appropriate, to prevent the unnecessary use of the antimicrobial therapy and thus leading to antimicrobial resistance. The IP stated in the monthly QA meetings he reported the trends in the different types of infections in the facility, the HAI infection rates, and the number of HAIs, CAIs, and the infections that were prescribed antimicrobial therapy and did not meet McGeer's criteria. a. Medical record review for Resident 1 was conducted on 6/1/26. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 1's H&P examination dated 5/25/26, showed Resident 1 had fluctuating capacity. Review of Resident 1's Order Summary Report showed a physician's order dated 5/28/26, to administer azithromycin (antibiotic) 500 mg intravenously daily for five days. However, further review of Resident 1's medical record failed to show documented evidence the Infection Screening Evaluation or the Antibiotic Time Out was completed to determine if Resident 1's infection met the criteria for a true infection. On 6/3/26 at 1340 hours, an interview and concurrent facility document review was conducted with the IP. The IP reviewed Resident 1's medical record and verified the above findings. The IP stated the Antibiotic Time Out should be completed within 72 hours of the antimicrobial therapy being prescribed for the resident to determine if the antimicrobial therapy was appropriate. b. Review of the facility's Antibiotic Time Out for Residents 21, 37, 55, 104, 243, 244, 245, 246 and 247 was conducted with the IP. After reviewing Resident 21, 37, 55, 104, 243, 244, 245, 246 and 247's Antibiotic Time Out forms, the IP verified the residents' infections did not meet the McGeer's criteria for a true infection, yet each residents were prescribed antimicrobial therapy, and the forms did not indicate as DNMC. On 6/4/26 at 1150 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to offer and provide education for the pneumococcal immunizations for three of five final sampled residents (Residents 5, 11, and 69) reviewed for immunizations. * The facility failed to ensure Residents 11 and 69's consent for the pneumococcal vaccination specified the type of pneumococcal vaccine to be administered. * Resident 5's consented for the pneumococcal 21 (type of pneumococcal vaccine) vaccine; however Resident 5 was administered the Prevnar 20 (type of pneumococcal vaccine) vaccination. These failures had the potential for the residents and/or their representatives not being fully informed of the pneumococcal vaccines and to not be aware of the exact type of pneumococcal vaccine being offered by the facility.Findings: Review of the facility's P&P titled Pneumococcal Vaccine (Series) revised 12/19/22, showed each resident will be offered a pneumococcal immunization unless it is medically contraindicated or the resident had already been immunized. Further review of the P&P showed prior to offering the pneumococcal immunization, each resident or the resident representative will receive education regarding benefits and potential side effects of the immunization. A consent form shall be signed prior to the administration of the vaccine and filed in the individual's medical record. The type of pneumococcal vaccine (PCV15, PCV20, or PPSV23/PPSV) offered will depend upon the recipient's age and susceptibility to pneumonia, in accordance with CDC guidelines and recommendations. 1. Medical record review for Resident 5 was initiated on 6/1/26. Resident 5 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 5's MDS assessment dated [DATE], showed Resident 5 was cognitively intact. Review of Resident 5's Pneumococcal Vaccine Consent Form dated 5/4/26, showed Resident 5's signature and consented to receive the pneumococcal 21 vaccine. However, review of Resident 5's MAR for May 2026 showed Resident 5 was administered the Pneumococcal 20-Valent Conjugate Vaccine (type of pneumococcal vaccine) on 5/10/26. 2. Medical record review for Resident 11 was initiated on 6/1/26. Resident 11 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 11's MDS assessment dated [DATE], showed Resident 11 had severely impaired cognitive skills for daily decision making. Review of Resident 11's Pneumococcal Vaccine Consent Form dated 5/5/26, showed Resident 11's resident representative's electronic signature and consented to receive the pneumococcal vaccine. Further review of the consent form showed I have read or had explained to me the vaccine information statement for the pneumococcal vaccine. I have been educated on and understand risk, benefits and potential side effects of the pneumococcal vaccine. Under the section to indicate kind of pneumococcal vaccine to be given did not show any entry (blank). Review of Resident 11's MAR for May 2026 showed Resident 11 was administered the Pneumococcal 20-Valent Conjugate Vaccine (type of pneumococcal vaccine) on 5/10/26. 3. Medical record review for Resident 69 was initiated on 6/1/26. Resident 69 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 69's H&P examination dated 5/22/26, showed Resident 69 had no capacity to understand and make decisions. Review of Resident 69's Pneumococcal Vaccine Consent Form dated 5/8/26, showed Resident 69's Representative electronic signature and consented to receive the pneumococcal vaccine. Further review of the consent form showed I have read or had explained to me the vaccine information statement for the pneumococcal vaccine. I have been educated on and understand risk, benefits and potential side effects of the pneumococcal vaccine. Under the section to indicate kind of pneumococcal vaccine to be given did not show any entry (blank). Review of Resident 69's MAR for May 2026 showed Resident 69 was administered the Pneumococcal 20-Valent Conjugate Vaccine (type of pneumococcal vaccine) on 5/10/26. On 6/3/26 at 1340 hours, an interview and concurrent medical record review for Residents 5, 11, and 69 was conducted with the IP. The IP verified the informed consents for Residents 11 and 69 did not indicate the type of pneumococcal vaccine the resident received. The IP stated the informed consents for the vaccinations should have indicated the type of vaccine the resident received to ensure the resident and resident representatives were fully informed. Additionally, the IP reviewed Resident 5's informed consent and verified Resident 5 did not receive the vaccination her resident representative had consented to. On 6/4/26 at 1150 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to determine if the residents were safe to self-administer the medications left at the bedside for two of 35 final sampled residents (Residents 49 and 113). * The facility failed to ensure it was safe for Resident 49 to self administer the vitamin C (supplement) medication observed at bedside. Additionally, there was no physician's order or care plan problem developed to address the resident's self administration of this medication. * The facility failed to ensure it was safe for Resident 113 to self-administer refresh eye drop (used to lubricate and instantly soothe dry, burning and irritated eyes) medication observed at the bedside. In addition, there was no physician's order, assessment or care plan for the self-administration of the medications. These failures had the potential for Resident 49 and 113 to administer the medications inaccurately and could affect the residents' well-being.Findings: Review of the facility's P&P titled Self-Administration of Medications revised date 12/19/22, showed the following: - Resident's preference so self-administer medications will be documented on the appropriate form and placed in the medical record; - Bedside medication storage is permitted only when it does not present a risk to confused residents who wander into the other resident's rooms or to confused roommates of the resident who self-administers medication. The following conditions are met for bedside storage to occur: The manner of storage prevents access by other residents. Lockable drawers or cabinets are required only if locked storage is ineffective, and the medications provided to the residents for bedside storage are kept in containers dispensed by the provider pharmacy; - All nurses and aides are required to report to the charge nurse on duty any medication found at the bedside not authorized for bedside storage. Unauthorized medications are given to the charge nurse for return to the family or responsible party. Families or responsible parties are reminded of policy and procedures regarding resident self-administration when necessary; and - The care plan must reflect resident self-administration and storage arrangements for such medications. 1. On 6/1/26 at 0918 and 1040 hours, Resident 49 was observed sitting in bed. A bottle of vitamin C was observed on the shelf in the corner of Resident 49's room. Resident 49 did not respond when asked if he would self-administer the vitamin C medication. Medical record review for Resident 49 was initiated on 6/1/26. Resident 49 was admitted to the facility on [DATE]. Review of Resident 49's Self-Administration of Medication dated 4/2/24, showed Resident 49 was not capable of self-administering medications safely. Review of Resident 49's Order Summary Report showed a physician's order dated 12/25/20, to administer ascorbic acid (Vitamin C) 500 mg one tablet two times a day. Review of Resident 49's medical record failed to show a physician's order to self-administer the vitamin C medication. Review of Resident 49's plan of care failed to show that a care plan problem was developed to address the resident's self administration of medications, nor the storage of the medication at bedside. On 6/1/26 at 1052 hours, an observation for Resident 49 and concurrent interview was conducted with LVN 2. LVN 2 verified a bottle of the vitamin C medication was observed on the shelf in the corner of Resident 49's room. Resident 49 stated his family brought the bottle of the vitamin C medication to the facility. On 6/3/26 at 0833 hours, an interview and concurrent medical record review for Resident 49 was conducted with RN 4. RN 4 verified Resident 49 was assessed to be incapable of self-administering medications safely. RN 4 further verified there were no physician's order to self-administer the medication for Resident 49, and there were no care plan problem developed to address the self-administration of medications for the resident. On 6/3/26 at 1522 hours, an interview for Resident 49 was conducted with the DON. The DON was informed and acknowledged the above findings. 2. On 6/1/26 at 0804 hours, during the initial tour of the facility, an observation was conducted for Resident 113. Resident 113 was observed lying in bed with five vials of refresh eyedrop on the overbed table. Medical record review for Resident 113 was initiated on 6/1/26. Resident 113 was admitted to the facility on [DATE]. Review of Resident 113's MDS quarterly assessment dated [DATE], showed Resident 113 had a BIMS summary score of 12 (meaning moderately cognitive impairment). Review of Resident 113's Order Summary Report did not show a physician's order for Resident 113 to self-administer the medications. Review of Resident 113's plan of care did not show a care plan problem to address Resident 113's self-administration of the medications. Further review of Resident 113's medical record failed to show a physician's order to self-administer medications, nor was an assessment completed for Resident 113 to safely self-administer a medication. On 6/1/26 at 0903 hours, an observation, interview with Resident 113, and concurrent interview and medical record review for Resident 113 was conducted with ADON 1. Resident 113 stated she was putting the eyedrop on her eye and she could not remember how often in a day she would put the eyedrops her eyes. The ADON verified there were five vials of refresh eyedrop on Resident 113's overbed table. ADON 1 verified Resident 113 had no physician's order, assessment, or care plan for the self-administration of any medications. ADON 1 further stated that it was not safe to leave a medication at bedside due to other resident's potential access and administer the medication to themselves. On 6/4/26 at 1408 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure the physician was informed of a change of condition for one or three final sampled residents (Resident 1) reviewed for nutrition. * The facility failed to notify Resident 1's physician and the resident's responsible party of the 24 lbs. (16.56%) weight loss from 12/2/25 to 4/1/26. This failure had the potential for Resident 1 to not received the necessary care and treatment to manage the resident's weight loss.Findings: Review of the facility's P&P titled Notification of Changes revised 12/19/22, showed the facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representatives when there is a change requiring such notification. Circumstances requiring notification include significant changes in the resident's physical, mental or psychosocial condition such as deterioration in health, mental, or psychosocial status. Medical record review for Resident 1 was conducted on 6/1/26. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE] with the diagnosis of unspecified severe protein-calorie malnutrition. Review of Resident 1's H&P examination dated 5/25/26, showed Resident 1 had fluctuating capacity. Review of Resident 1's Weights and Vitals Summary from 11/1/25 through 6/30/26, showed the following weights and comparisons for Resident 1:- dated 11/19/25, weight = 149 lb.;- dated 12/2/25, weight = 145 lbs.; and- dated 4/1/26, weight = 121 lbs., -28 lbs., a 18.8% severe weight loss since 11/19/25. Review of Resident 1's E-interact Change in Condition Evaluation dated 4/1/26, showed the physician was notified of Resident 1's poor PO (oral) intake. The licensed nurse documented Resident 1 was noted with PO intake less than 50% with the last three meals. Under most recent weight the licensed nurse documented the weight of 145 lbs. obtained on 12/2/25. Further review of the Change in Condition Evaluation showed the physician was informed with recommendations to continue monitoring Resident 1 for 72 hours, encourage PO and fluid intake, offer substitutions, assist Resident 1 with meals, and offer Boost and high-calorie shakes. However, further review of the Change in Condition Evaluation failed to show the documentation if the physician was informed of Resident 1's current weight of 121 lbs., a weight loss of 24 lbs. from 12/2/25 to 4/1/26. On 6/4/26 at 0919 hours, an interview and concurrent medical record review for Resident 1 was conducted with ADON 2. ADON 2 stated for any weight variances of 3% loss in one week, 5 % loss in one month, or 10% weight loss in three months. ADON 2 further stated the physician would be notified, a change in condition evaluation would be completed to monitor the resident's weight loss and PO intake. When asked about Resident 1's documented weight loss on 4/1/26, ADON 2 reviewed Resident 1's medical record and stated there was no documentation the physician was informed of Resident 1's weight loss of 24 lbs. (16.55%) severe weight loss since 12/2/25. On 6/4/26 at 1122 hours, an interview was conducted with the DON. The DON stated after input of the weight, the unit manager/desk nurse was responsible for reviewing the resident's weights for any significant or severe weight changes. If a weight variance of 5% in one month, or 10% in six months was noted or identified, the unit manager/desk nurse was expected to initiate the Change in Condition evaluation, inform the physician/responsible party, and notify the RD for reassessment. On 6/4/26 at 1556 hours, a follow-up interview was conducted with the DON. The DON verified following the documentation of Resident 1's weight loss on 4/1/26; however, there was no documentation if the physician or the resident's responsible party were informed of Resident 1's 24 lbs. weight loss from 12/2/25 to 4/1/26. The DON was informed and acknowledged the above findings. Cross Reference to F692, #1.

Based on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to ensure one of three sampled residents (Resident 1) attained and maintained the highest practicable physical well-being. * The facility failed to ensure Resident 1's colostomy bag was emptied according to the standards of practice when CNA 1 poured hot water in the colostomy bag. While the hot water was being poured, the colostomy bag touched the resident's skin, resulting in Resident 1 sustaining a burn on the left thigh and requiring pain medication administration and wound treatment. This failure had caused the burn to the resident's skin and the resident to experience pain and need wound treatment. Findings: Review of facility's P&P titled Ostomy Care - Colostomy, Urostomy, and Ileostomy revised 12/19/22, showed it is the policy of the facility to ensure that residents who require colostomy, urostomy, or ileostomy services receive care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goal and preference. Review of the facility's lesson plan titled Emptying an Ostomy bag (undated) showed 1. When applicable, direct care staff will empty the ostomy bag if bowel or air is noted. Supplies must be gathered prior to performing the task such as: wipes, toilet tissue, disposable bag, 2. Once supplies are obtained, direct care staff will wash hands and apply gloves. Then, place the disposable bag over the clamp at the bottom of the ostomy bag. This will ensure all of the contents in the ostomy bag are captured inside the disposable bag. Direct care staff will then, unclamp the clip and begin pushing the bowel or air down towards the opening with your gloved finger slowly, preventing any potential damage to the bag. Once all air or bowel is removed, wipe the ends of the opening and apply clamp. Ensure the clamp is closed. 4. Dispose of the disposable bag. Remove gloves and wash hands. 5. Direct care staff members will notify direct supervisor if resident asks for changing of the pouch or cleaning the inside of the pouch or any other care that direct care staff is not obligated to perform. 6. It is never appropriate for direct care staff to perform such tasks that are not within their scope. These may include, but are not limited to: a. Changing of the pouch. b. Cleaning of the stoma. c. Putting fluids into the pouch. Medical record review for Resident 1 was initiated on 5/20/25. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's H&P examination dated 3/5/25, showed the resident had capacity to understand and make decisions. Review of Resident 1's MDS quarterly assessment dated [DATE], showed a BIMS summary score of 14, indicating the resident was cognitively intact. Review of Resident 1's Order Summary Report as of 5/20/25, showed the following physician's orders: - dated 9/26/24, for colostomy care, wash with soapy water, rinse, and pat dry as needed. - dated 9/27/24, for colostomy care, wash with soapy water, rinse, and pat dry every day shift. - dated 9/26/24, may change the colostomy bag as needed. - dated 9/26/24, may change the colostomy bag every day shift - dated 5/19/25, for the left upper thigh blister, cleanse with NS, pat dry, apply Xeroform and cover with dry dressing every day shift. Review or Resident 1's eINTERACT Change in Condition Evaluation dated 5/16/25, showed at 1455 hours, Resident 1 had a change in condition with symptoms of redness to the left outer hip and left lower abdomen. Review of Resident 1's Wound Progress Note dated 5/19/25, showed the burn was present on the left thigh with blister and wound status open. The wound measurements were as follows: area was 12.5 cm², perimeter was 17.6 cm, length was 6.6 cm, width was 2.1 cm, max depth was 0.1 cm, mean depth was 0.0 cm, and volume was 0.0 cm3. The Body % Burned Total showed 18%. On 5/20/25 at 1333 hours, an interview was conducted with Resident 1. Resident 1 stated on the afternoon of 5/16/25, CNA 1 emptied Resident 1's colostomy bag. CNA 1 was not able to empty the bag completely because there were feces left in the bag. Resident 1 further stated CNA 1 left the room and returned with a cup of water. CNA 1 poured the cup of water into the colostomy bag. Resident 1 stated suddenly she felt a burning sensation on her left thigh and abdomen. Resident 1 further stated it was burning so bad that she was yelling to CNA 1, it's burning, it's burning. However, CNA 1 did not promptly react to Resident 1's response. Resident 1 stated she swatted CNA 1's arm to remove the bag away from her. Resident 1 further stated CNA 1 was apologetic to her and admitted it was his fault to use hot water in cleaning the colostomy bag. Resident 1 stated CNA 1 verbalized he figured the colostomy bag could only be cleaned with hot water. Resident 1 stated the hot water must have burned the skin in her thigh for at least a minute because CNA 1 did not stop. Resident 1 stated her skin was bright red on her abdomen and thigh. Resident 1 stated LVN 1 told her she would be monitored. Resident 1 stated on Sunday afternoon (5/18/25), the redness on her thigh developed to a blister. Resident 1 further stated the nurses did not start the treatment for the blister until Monday (5/19/15). Resident 1 stated the burn still felt painful and sensitive when touched. On 5/20/25 at 1453 hours, an interview was conducted with LVN 1. LVN 1 stated CNA 1 asked him to check Resident 1 on 5/16/25, towards the end of his shift because CNA 1 reported in the process of emptying the colostomy bag, there was a hard feces residue. LVN 1 stated CNA 1 stated he put hot water in the bag which had contact with the resident's skin and caused it to be reddened on the abdomen and left hip area. LVN 1 stated the resident complained of pain and was medicated with acetaminophen 325 mg two tablets orally for the pain scale of 3 (using the pain scale of 0 to 10 with 0 = no pain and 10 = worst pain). On 5/20/25 at 1600 hours, an interview was conducted with the DSD. The DSD stated the CNAs were allowed to empty the ostomy bag in the facility. The DSD stated the CNAs should not put any fluid in the colostomy bag. On 5/21/25 at 1106 hours, a telephone interview was conducted with CNA 1. CNA 1 stated he emptied Resident 1's colostomy bag; however, there were some feces left in the bag. CNA 1 stated he got the water from the water dispenser right by the nursing station and filled the cup halfway. CNA 1 stated he was not paying attention to the temperature of the water because he was in a rush to empty the colostomy bag. CNA 1 stated he put a trash bag against the resident's thigh, however, did not put a towel on top of the resident's thigh. CNA 1 stated the trash bag was placed next to the resident's skin and colostomy bag. CNA 1 stated he poured all the water in the colostomy bag, then Resident 1 started saying, Hot! Hot! Hot! CNA 1 further stated there was redness on the resident's thigh which he reported to LVN 1. On 5/22/25 at 1053 hours, an interview was conducted with the DON. The DON verified CNA 1 emptied the colostomy bag and there were feces remained inside the bag. CNA 1 got hot water, poured it inside the colostomy, rinsed the colostomy bag, in the process, the bag touched the skin and caused the resident to have redness to the left lower abdomen and left hip, and a blister to the left thigh. The blister was observed and treated on 5/19/25. The DON stated the CNAs were not allowed to pour hot water inside the colostomy bag. CNA 1 should have called the charge nurse or treatment nurse. The DON was informed and acknowledged the above findings. Cross reference to F726.

Based on observation, interview, and clinical record review, the facility failed to provide adequate supervision and assistive devices to prevent accidents for three of 29 sampled residents (Residents 6, 26, and 25). *The facility failed to assess and provide assistive devices for Resident 6. The facility failed to assist Resident 6 with ambulating. This resulted in falls and injuries for Resident 6. Resident 6 sustained a laceration on the back of her head, requiring transfer to the acute hospital, and had staples for her laceration when she fell on [DATE]. The resident sustained [REDACTED]. *The facility failed to implement recommendations from the IDT when Resident 26 fell on [DATE]. This poses the potential for further falls and injuries for Resident 26. *Resident 25 had 10 skin tears on the hands and arms over six months. The IDT recommended the use of gerisleeves (a fabric sleeve to protect the upper extremities from abrasions, bruises and skin tears) on two occasions, which were not implemented. Finding: Review of the facility's P&P titled Falling Star Program Development and Implementation (undated) showed program development included to identify the depth of the problems for residents; analyze the frequency and medical condition relating to the falls; identify residents who fall frequently; develop a profile of each high risk resident that identifies the contributing factors to falls, such as environmental factors, resident's purpose for attempting tasks; develop a falling star logo so staff can identify residents in the program; and inservice staff on risk factors/resident profiles. When a fall occurs, nursing and rehab staff complete an incident report and an investigation of the incident; nursing and rehab staff complete/review Fall Risk Assessment; the Fall Assessment will be filed in the resident's clinical record upon completion of the review. Review of the facility's P&P Investigation Guideline (undated) showed accidents or incidents, whether witnessed or unwitnessed, will be thoroughly investigated; investigation shall be conducted by asking specific questions of persons involved, such as identified or possible witness(es), staff assigned to the resident, or family, etc; determine chronological sequence of events. The environment and other factors must be thoroughly explored. Written recommendations by the interdisciplinary team following review of the investigation will be documented in the resident's clinical record on the interdisciplinary team progress notes; the resident's care plan will be revised as necessary by the interdisciplinary team. 1. Review of Resident 6's clinical record was initiated on 7/15/13. The resident was admitted to the facility on [DATE], readmitted to the facility on [DATE], transferred to the emergency room of the acute hospital when she fell on [DATE], returned to the facility on [DATE], transferred to the acute hospital when she fell on [DATE], and readmitted to the facility on [DATE]. The MDS dated [DATE], showed Resident 6's cognition was moderately impaired. She was sometimes understood, and sometimes understands with simple, direct communication only. She needed supervision and required set up help only for bed mobility, transferring, and ambulating. The Fall Risk assessment dated [DATE], showed a score of 14 (total score above 10 represents a high risk for falls). The Physical Therapy Discharge Summaries dated 5/22, and 9/17/12, showed Resident 6 required stand by assistance (one staff stands next to the resident) for transferring, and ambulating. Review of the Nurses Notes showed an entry dated 10/28/12 at 0800 hours, Resident 6 was noted wandering around with a right upper cheek bruise, skin discoloration was noted. She frequently wanders around the unit, enters other residents' rooms during the night shift; she was redirected to her room and placed back in her bed. Review of the Nurses Notes showed an entry dated 11/4/12, showing Resident 6 was asleep and appeared comfortable at 0200 hours. At 0400 hours, Resident 6 was awake, got out of her room, and was walking to room A; a CNA was walking to get the resident to assist her; the resident lost her balance, fell , and found her sitting on her bottom; blood was noted on her head; a 5 cm laceration was noted to the occipital (back of the head) area; and a right elbow skin tear was noted. At 0450 hours, the resident was transferred to the acute hospital. At 0830 hours, the resident returned from the acute hospital with five staples to the back of her head. Review of the Resident Incident assessment dated [DATE], showed Resident 6 was last seen at 0330 hours. She was sleeping in her bed. Review of a care plan showed a care plan problem dated 11/4/12, to address an actual fall with head laceration. The goal was the resident will have no falls in three months. The approaches included to provide frequent visual monitoring, neurochecks (a set of tests to assess if the resident is having bleeding into the brain or skull), reality orientation; vital signs; and report any change. Review of the IDT Accident/Incident Review dated 11/6/12, showed the IDT recommended to assess for pain, monitor for bleeding; monitor vital signs; continue with current treatment; maintain safety precautions; call the physician if laceration not resolved or for change of condition; follow up with ER evaluation; assess for signs and symptoms of fracture; optometry consult. The form did not show the IDT recommended to provide stand by assistance to the resident for ambulating and transferring; pad and/or Tab alarm (a device to alert staff if the resident gets up unassisted) when the resident is in her bed or in her wheelchair; or refer to pharmacy consultant to review the resident's medication regimen. Review of the physician's orders [REDACTED]. Review of the Physical Therapy PT Evaluation & Plan of Treatment dated 11/8/12, showed Resident 6 had increased risk for falls and further decline in function. The form showed the resident needed stand by assistance for bed mobility (sitting from lying position), needed contact guard assistance (hold on to the resident by staff) from transferring (standing from sitting position); needed contact guard assistance for level surfaces (ambulating). Review of the Physical Therapy Daily Documentation showed an entry dated 11/9/12, showing Resident 6 needed stand by assistance for bed mobility; needed stand by assistance and/or contact guard assistance for transferring; needed stand by assistance with 25% of contact guard assistance for locomotion (ambulating). There was no documented evidence to show Resident 6 was evaluated for the use of devices to alert staff when she gets up from a lying position, and/or when she stands up from a lying or sitting position. There was no documented evidence to show the resident was provided stand by assistance and/or contact guard assistance by nursing staff. There was no documented evidence to show how the resident was provided adequate assistance and/or supervision for bed mobility, for transferring, and for ambulating. Review of the Nurses Notes showed an entry dated 11/12/12 at 0600 hours, showing a CNA saw Resident 6 walking in the hallway with a steady gait; the resident fell on her right side when she entered room B; the CNA was unable to assist the resident while falling, as the CNA was still far from the resident; a deep laceration was noted on the right cheek; moderate bleeding noted. The resident was transferred to the acute hospital at 0720 hours. Review of the Nurses Notes showed a late entry dated 11/12/12 at 0700 hours, for 11/12/12 at 0600 hours, showing Resident 6 was noted with a laceration on her right cheek measuring 1 inch by 0.25 inch, linear in shape with some depth. The physician was notified. An order was received to send the resident to the acute hospital for further treatment and suturing. Review of the History and Physical from the acute hospital dated 11/12/12, showed Resident 6 was brought into the emergency room of the acute hospital due to a mechanical fall. The resident was found to have a laceration of approximately 3 mm to the face and the wound was closed at the emergency room . The resident was found to have uremia with acute renal injury. The resident was admitted to the acute hospital for further evaluation and continued treatment. The form showed the resident was diagnosed with [REDACTED]. Review of the Nurse's Admission Record dated 11/15/12, showed Resident 6 was readmitted to the facility. The resident had a laceration on the side of her right cheek, measuring 1.8 cm, with six sutures. During an interview and clinical record review with RN 5 on 7/16/13 at 1035 hours, the RN stated Resident 6 was referred to PT for evaluation when she fell on [DATE], and when she fell on [DATE]. She was asked if the IDT recommended to check for orthostatic hypotension (the blood pressure has a significant drop when the person changes from a lying or sitting position to standing) when the resident was receiving Seroquel (an antipsychotic medication). She stated, no. She was asked if the IDT recommended to review the resident's drug regimen by the pharmacy consultant when the resident fell on ,[DATE], and 11/12/12. She stated, no. She was asked if the resident was referred to an optometrist as the IDT recommended on 11/6/12. She stated the resident was seen by an optometrist on 3/6/13. During an interview and clinical record review with RN 5 on 7/17/13 at 0945 hours, the RN stated Resident 6 was ambulating in the hallway, and fell on ,[DATE], and 11/12/12. She stated the CNAs were unable to reach the resident because they were far from the resident. The RN was asked for, but was unable to find documentation to show a pad and/or Tab alarm was provided to the resident to alert staff when the resident was getting out of her bed and/or her wheelchair prior to readmission from the acute hospital on [DATE]. She was asked for, but was unable to find documentation to show the resident was provided stand by assistance while ambulating and transferring prior to readmission from the acute hospital on [DATE]. She was asked if the above incidents were avoidable. She stated, yes. On 7/17/13 at 1130 hours, LVN 4 stated Resident 6 was ambulating by her self with an unsteady gait prior to readmission on 11/15/13. On 7/17/13 at 1145 hours, CNA 5 stated Resident 6 was walking independently prior to readmission from the acute hospital on [DATE]. She stated the resident was supervised while ambulating prior to the second readmission from the acute hospital. She was asked what supervision means. She stated the resident walked in the unit, and was watched by staff. She was asked if the resident was provided stand by assistance and/or hand held assistance when transferring and ambulating on the previous admission. She stated, no. She was asked if a Tab alarm was provided to the resident to alert staff when the resident was getting up from her bed and/or her wheelchair on the previous admission. She stated, no. She was asked if any special instructions were provided to her regarding the resident's safety while ambulating and/or transferring on the previous admission. She stated, no. She stated the resident was in her wheelchair, was unable to walk independently after readmission from the acute hospital. On 7/17/13 at 1135 hours, PT 1 stated the resident was discharged from PT on 9/17/12, and reevaluated by PT on 11/8/12. She stated the resident required stand by assistance with transferring and ambulating when the resident was discharged from PT on 9/17/12. She stated the resident's gait was unsteady when evaluated by PT on 11/8/12. PT 1 stated Resident 6 required stand by assistance for bed mobility and transferring, required stand by assistance with 25% contact guard assistance for ambulating on 11/9/12. She stated the PT communicated with nursing staff regarding safety with transferring for Resident 6. She stated stand by assistance means the resident requires staff standing closely to the resident, to be able to catch the resident, but not necessary hold on to the resident. She stated contact guard assistance means the resident requires staff to hold on to the resident while ambulating. 2. Review of Resident 26's clinical record was initiated on 7/16/13. The resident was admitted to the facility on [DATE]. Review of the Fall Risk assessment dated [DATE], showed a score of 14. Review of the Nurses Notes entry dated 7/4/13 at 0900 hours, shows Resident 26 was sitting in the dining room after breakfast. His eyes were closed. He was seen to suddenly fall on his right side. The resident said he fell asleep. He was noted with a small linear cut on the right side of his forehead, and slight swelling on his right knee. Review of the IDT Accident/Incident Review dated 7/5/13, showed the IDT's recommendation included to monitor the resident's sleeping pattern at night. There was no documented evidence to show the IDT recommended to review the resident's medication regimen. Review of the care plan showed a care plan problem dated 7/19/12, with approaches to monitor for adverse reactions of psychoactive medications every shift and report to the physician if needed. Review of the Short Term Problem showed a care plan problem dated 7/4/13, to address status [REDACTED]. On 7/16/13 at 1500 hours, LVN 4 was asked if Resident 26 was monitored for hours of sleep, and/or his sleep pattern. She stated, no. During an interview and clinical record review with RN 5 on 7/17/13 at 0845 hours, the RN stated the IDT recommended to monitor sleep the pattern when Resident 26 fell on [DATE]. She was asked how she communicated recommendations with the nursing staff. She stated she communicates with the nursing staff whenever the IDT makes recommendations. 3. Clinical record review for Resident 25 was initiated on 7/16/13. Review of the Non-Pressure Sore Skin Problem Report dated 12/24/12, showed Resident 25 had a skin tear measuring 3.5 cm x 1.4 cm on the right forearm. The wound was treated and documented as resolved on 1/4/13. Further review showed no IDT Accident/Incident Review was available to investigate the incident. Documentation on the Non-Pressure Sore Skin Problem Report dated 1/1/13, showed Resident 25 had a new skin tear to the left arm measuring 5 cm x 2.5 cm. The Resident Incident assessment dated [DATE], showed the resident was seen at 0415 hours, sleeping in bed. The IDT Accident/Incident Review dated 1/3/13, showed the resident was found with bleeding, but was unable to explain what had happened due to a memory deficit. The IDT recommended assessment of the wound and report any change of condition to the physician. The wound was documented as resolved on 1/14/13. Documentation on the Non-Pressure Sore Skin Problem Report dated 1/8/13, showed a new skin tear to the right hand measuring 2 cm x 0.5 cm. The IDT Accident/Incident Review dated 1/11/13, showed the resident was found at 1000 hours in his room with the skin tear and bleeding. The resident was unable to explain what happened due to a memory defect. The IDT recommended assessment of the wound and report any change of condition to the physician. This wound was resolved on 1/28/13. Documentation on the Non-Pressure Sore Skin Problem Report dated 1/19/13, showed the resident sustained [REDACTED]. The IDT Accident/Incident Review dated 1/21/13, showed the resident's spouse discovered the skin tear. The IDT recommended assessment of the wound and report any change of condition to the physician, and provide lotion to the resident's dry skin. Documentation on the Non-Pressure Sore Skin Problem Report dated 2/16/13, showed Resident 25 sustained a new skin tear to the left upper arm measuring 1.8 cm x 0.3 cm. The IDT Accident/Incident Review dated 2/18/13, showed the resident was in his room and attempted to get out of bed. The IDT recommended assessment of the wound and report any change of condition to the physician, continue the pad alarm and make sure the resident is clean and dry. Documentation on the Non-Pressure Sore Skin Problem Report dated 3/31/13, showed Resident 25 had an abrasion on the right upper arm measuring 4.5 cm. x 1.5 cm which was resolved on 4/15/13. There was no documented IDT Accident/Incident Review available. Documentation on the Non-Pressure Sore Skin Problem Report dated 4/1/13, showed Resident 25 sustained a skin tear to the right hand measuring 2 cm x 2 cm. The IDT Accident/Incident Review dated 4/2/13, showed the resident was yelling and the injury was witnessed. The wound care to the injury included the use of steri-strips (sterile adhesive strips used to secure, close and support small cuts, wounds and surgical incisions). According to the IDT Accident/Incident Review dated 4/29/13, Resident 25 sustained an unwitnessed skin tear to the left hand measuring 1 cm x 1 cm, which was discovered while providing care. The recommendations were to cut the resident's fingernails, assess the wound and provide gerisleeves. Review of the physician's orders [REDACTED]. Review of the care plan showed no documentation of the need for gerisleeves. An observation of Resident 25 on 7/16/13 at 1600 hours, and on 7/17/13 at 0900 hours, showed the resident was not wearing gerisleeves. An interview with LVN 4 was initiated on 7/17/13 at 0930 hours. The LVN was asked to show documentation the geri-sleeves have been provided to the resident as recommended by the IDT. LVN 4 stated the gerisleeves should be documented in the care plan or in the physician's orders [REDACTED].

Based on interview and clinical record review, the facility failed to ensure two of 17 sampled residents (Resident 22 and Resident 2) were free from accident hazards or received enough supervision to prevent accidents. *Resident 22 had two falls in July 2013 while in the bathroom. The IDT recommended the resident receive assistance from two staff members while toileting. On 8/19/13, Resident 22 had another fall while in the bathroom. According to the facility's investigation report, two staff members were assisting the resident in the bathroom, but one staff member left the room to retrieve patient care items. The resident had to be transferred to the hospital due to an injury and received sutures above her eye. *Resident 2 did not have the required protection while smoking. These failures have the potential for residents to sustain preventable injuries. Findings: 1. Clinical record review for Resident 22 was initiated on 9/10/13. Review of the MDS dated [DATE], showed Resident 22 has poor cognition. Review of the IDT Accident/Incident Review dated 7/23/13, showed on 7/22/13, Resident 22 was receiving assistance to the bathroom. After the resident was assisted to wash her hands, the resident stood up from the bathroom chair and fell to the floor. Resident 22 received a skin tear to the left lower foot and left lower leg. The report further showed the resident has impulsive behavior and is confused due to dementia. The IDT recommended to treat the skin tear and provide frequent visual checks. Review of the IDT Accident/Incident Review dated 8/2/13, showed Resident 22 had another fall on 7/31/13, while in the bathroom. The resident was seated on the toilet and stood up unassisted. The resident took a step and fell . Resident 22 was transferred to the hospital due to profuse bleeding and altered level of consciousness. Resident 22 returned to the facility with orders for ice packs to the right eye, cheek and upper lip. The IDT recommended Resident 22 have a bedside commode and assistance of two people with toileting, frequent visual checks and receive a pharmacy and physical therapy screening. Review of the care plan to address the problem of Falls dated 8/5/13, showed an approach/plan for the risk of falls and injuries to continue the Falling Star program, provide a non-release belt when up in the chair and provide extensive assistance of two people for toileting. Review of the IDT Accident/Incident Review dated 8/20/13, showed on 8/19/13, Resident 22 was being assisted to the bathroom by a CNA after a shower. The resident stood up and fell to the floor. The report showed the resident sustained [REDACTED]. Review of the acute care hospital Discharge Instructions dated 8/19/13, showed Resident 22 had a head injury and a two inch eye laceration. Resident 22 had five sutures to the eye area. An interview with CNA 11 was initiated on 9/11/13 at 0915 hours. The CNA stated the resident will rock in the chair and occasionally lurches forward. CNA 11 stated Resident 22 is better since they started a medication. Further review of the clinical record showed a physician's orders [REDACTED]. An interview with the Administrator was initiated on 9/11/13 at 1000 hours. The Administrator stated the facility did an investigation into what happened to Resident 22. He stated the resident had two staff members assisting with the toileting of the resident on 8/19/13. A CNA and RNA were assisting the resident, but the RNA stepped out of the bathroom to get the resident some new socks. This is when the resident fell . 2. Review of the facility's P&P titled Smoking dated 2001 revised 9/2010, showed smoking safety aprons will be available for those residents who require them. During an observation on 9/9/13 at 1520 hours, Resident 2 was observed smoking on the patio, unsupervised and without using a smoking safety apron. Review of Resident 2's clinical record was initiated on 9/9/13 at 1525 hours. Resident 2 is alert and oriented, but requires extensive assistance of one person for his ADLs. Review of the IDT Smoking assessment dated [DATE], shows a recommendation from the IDT to have nursing apply and remove an apron when smoking. Review of the Short Term Care Plan dated 7/23/13, and revised date 8/12/13, shows Resident 2 is unable to pick up the apron safely when dropped on the ground. Nursing to put the apron on the resident when the resident is smoking and the charge nurse will also remove the apron. Interview and clinical record review was conducted with LVN 10 on 9/10/13 at 1315 hours. When asked about the care plan and IDT smoking assessment for Resident 2, LVN 10 stated the resident goes outside and smokes by himself without supervision. When asked who helps the resident put on the apron, LVN 10 stated she is not sure. During an interview with Resident 2 on 9/11/13 at 0730 hours, when asked what he likes to do if he does not want to attend activities, Resident 2 stated he goes outside and smokes. When asked if he gets help from the staff and if he uses an apron, Resident 2 stated he just does it himself and does not use an apron.

Based on observation, interview, and clinical record review, the facility failed to ensure three of 29 sampled residents (Residents 4, 6, and 26) drug regimens are free from unnecessary drugs. This has the potential for exposing the residents at high risk to serious side effects of the medications. *The facility failed to ensure non-pharmacologic interventions were attempted for Residents 4 and 6 prior to using antipsychotic and antianxiety medications. *The facility failed to monitor Residents 6 and 26 for the side effects of the medications. Resident 6 sustained numerous falls after losing her balance while attempting to ambulate. The facility failed to monitor Resident 6 for the side effects being a possible cause of instability when ambulating. Findings: 1. Resident 4's clinical record review was initiated on 7/16/13. Resident 4 was readmitted to the facility on [DATE]. The MDS dated [DATE], showed the resident's BIMS (Brief Interview of Mental Status) was 6 (0-7 severe impairment). The MDS dated [DATE], showed a BIMS of 3. Review of the acute care hospital transfer discharge summary and the physician's orders [REDACTED]. The hospital discharge [DIAGNOSES REDACTED]. The admitting physician's orders [REDACTED]. Further review of the physician's orders [REDACTED]. Further review of the clinical record failed to show documented evidence the facility provided non-pharmacologic interventions prior to using an antipsychotic medication. On 7/16/13 at 0815 hours, Resident 4 was observed in a wheelchair, in the dining room eating. On 7/16/13 at 1535 hours, LVN 4 was asked if Resident 4 was seen by a psychiatrist. LVN 4 stated the resident was not seen by a psychiatrist, but the primary care physician sees the resident. On 7/17/13 at 0845 hours, CNA 2 was asked if Resident 4 has behaviors of angry outbursts. He stated the resident has none and communicates at times in a foreign language. On 7/17/13 at 0925 hours, the DON was informed of the finding. She stated she will review the clinical record. She stated the nurse verified the admitting orders with the physician; however, she acknowledged there was no non-pharmacologic interventions attempted prior to using an antipsychotic medication. 2. Review of the facility's P&P titled Psychopharmacological Medication Used revised 12/12, showed the interdisciplinary team will identify nonpharmacological approaches to managing behaviors, symptoms, and medical conditions in an effort to avoid the use of psychopharmacological medications; these approaches will be included in the plan of care for the resident. Further review showed nursing staff shall monitor and report any of the following side effects to the physician: sedation, orthostatic [MEDICAL CONDITION], lightheadedness and increased psychotic symptoms. Review of Resident 6's clinical record was initiated on 7/15/13. The resident was admitted to the facility on [DATE], readmitted to the facility on [DATE], transferred to the emergency room of the acute hospital on [DATE], returned to the facility on [DATE], transferred to the acute hospital on [DATE], and readmitted to the facility on [DATE]. She has a history of hypertension, and is receiving [MEDICATION NAME] (a medication used for high blood pressure), and [MEDICATION NAME] (a medication used for high blood pressure) daily. a. Review of the physician's orders [REDACTED]. Another physician's orders [REDACTED]. According to Lexi-Comp Online, [MEDICATION NAME] carries a U.S. Boxed Warning. Elderly patients with dementia-related [MEDICAL CONDITION] treated with antipsychotics are at increased risk of death compared to placebo; most deaths appear to be either heart failure, sudden death or infection in nature; [MEDICATION NAME] is not approved for the treatment of [REDACTED]. Further review showed to use with caution in residents at risk for this effect, in residents who would not tolerate transient hypotensive episodes, in residents who have [MEDICAL CONDITION] or concurrent medication use which may predispose to [MEDICAL CONDITION], and in residents with [MEDICAL CONDITION]. Review of the MAR for the months of June and July 2013 showed Resident 6 received [MEDICATION NAME] until 7/11/13. There was no documented evidence to show orthostatic (same as postural) [MEDICAL CONDITION] was monitored. During an interview and clinical record review with RN 3 on 7/16/13 at 1000 hours, he was asked for, but was unable to find documentation to show orthostatic [MEDICAL CONDITION] was monitored when Resident 6 was receiving the [MEDICATION NAME]. b. Review of the physician's recapitulated orders for the months of July, 2013, showed a physician's orders [REDACTED]. Review of the MAR for the month of July 2013 showed Resident 6 received [MEDICATION NAME] on 7/5 and 7/13/13. Review of the reverse side of the MAR for the month of July 2013 showed Resident 6 received [MEDICATION NAME] 0.5 mg for increased anxiety manifested by being physically aggressive toward staff on 7/5/13 at 1700 hours; and on 7/13/13 at 1700 hours. There was no documented evidence to show nonpharmacologic interventions were attempted for the resident prior to administering [MEDICATION NAME]. During an interview and clinical record review with RN 3 on 7/16/13 at 1000 hours, he was asked for, but was unable to find documentation to show nonpharmacological interventions were attempted for Resident 6 prior to administering [MEDICATION NAME]. 3. Review of Resident 26's clinical record was initiated on 7/16/13. The resident was admitted to the facility on [DATE]. Review of the physician's orders [REDACTED]. Review of the physician's orders [REDACTED]. Review of the physician's orders [REDACTED]. Review of the MAR for the months of April, May, June, and July 2013, failed to show the resident was monitored for orthostatic [MEDICAL CONDITION]. During an interview and clinical record review with LVN 4 on 7/16/13 at 1455 hours, the LVN stated Resident 26 received [MEDICATION NAME] for angry outbursts, and being combative with care. She was asked for, but was unable to find documentation to show the resident was monitored for orthostatic [MEDICAL CONDITION].

Based on observation, interview and clinical record review, the facility failed to provide treatment and services to prevent the development of pressure ulcers for two of 28 sampled residents (Residents 7 and 23). Resident 7 was readmitted to the facility with four blisters and developed multiple pressure ulcers while in the facility. The facility failed to ensure pressure was kept off (offloaded) Resident 7's bony prominence, failed to conduct ongoing skin assessments by the RN, and failed to ensure the resident received adequate calories, protein, and fluid intake to promote wound healing. Resident 23 developed recurrent Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister) pressure ulcer to the coccyx (the area at the end of the spine, or the tail bone) and buttocks. The facility failed to ensure pressure was kept off (offloaded) Resident 23's bony prominence, failed to conduct ongoing skin assessments by the RN, and failed to address high blood sugar level. This resulted in Residents 7 and 23 developing more pressure ulcers, which were not healing. Findings: According to California Code of Regulations Title 16 2518.5, "The LVN performs services requiring technical and manual skills which include the following: basic assessment, which the LVN Scope of Practice defines as data collection. The LVN may not perform an assessment that requires analysis or synthesis (evaluation) of data. Data collected by the LVN can be used by the RN to assist in the assessment process. LVNs are not independent practitioners, but may implement components of patient care assigned to them by the RN responsible for the patient. 1. During initial tour rounds of the facility on 8/14/12 at 0815 hours, with RN 3, Resident 7 was observed in bed, asleep, in the fetal position (the resident is lying on their side with their arms and legs bent at the joints and curled up) and turned towards his left side. The resident's heels were wrapped with bandages and resting directly on the mattress. He had a GT (a tube inserted through the abdomen into the stomach used for long-term enteral nutrition.). A 1000 ml bottle of Nepro (formula for people with kidney problem) was observed running via a pump at 50 ml per hour. The documentation on the bottle of formula showed the bottle was hung on 8/12/12 at 1100 hours. There was 500 ml of formula left in the bottle. RN 3 was asked what was the date on the bottle and she confirmed it was 8/12/12. On 8/14/12 at 1025 hours, Resident 7 was observed in bed, in the fetal position, turned towards his left side. His heels were not offloaded (pressure relieved from the heels). The tube feeding was observed running at 50 ml per hour with 400 ml of formula left in the bottle. Clinical record review for Resident 7 was initiated on 8/14/12. The resident was admitted to the facility on [DATE], transferred to the acute care hospital and readmitted on [DATE]. The Nurses' Admission Record dated 7/25/12, showed the resident had a wound to the left side of his back measuring 4 cm x 2 cm, and two wounds to the right side of his back measuring 2 cm x 2 cm and 7 cm x 3 cm. It also showed there was redness to the left outer thigh. The MDS dated [DATE], showed the resident requires extensive assistance for bed mobility and is totally dependent on staff for transfers, toileting, hygiene and bathing. The recapped physician's orders [REDACTED]. It also showed the resident is picked-up by ambulance at 1215 hours for [MEDICAL TREATMENT] every Monday, Wednesday and Friday ([MEDICAL TREATMENT], a procedure to remove waste products from the blood when the kidneys no longer function adequately.) Review of a care plan problem dated 7/25/12, to address the wounds to the right side of the resident's back showed the approaches to apply triple antibiotic ointment daily and assist with turning and repositioning. There was no care plan developed to address the wound to the left side of the resident's back. The care plan problem dated 7/26/12, and revised on 7/29/12, and 8/7/12, to address further skin breakdown, showed the approaches included to reposition every two hours, nutritional support with GT feeding and offload both heels with pillows. Review of the Nurses Notes dated 7/29/12 at 0900 hours, showed blood filled blister were noted. The Weekly Wound assessment dated [DATE], showed the resident developed UTD (unable to determine depth: full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.) pressure ulcers to the following: - the left heel, measuring 3 cm x 3.6 cm. - the left first metatarsal head (close to the big toe), measuring 1.2 cm x 1.5 cm. - the left fifth metatarsal tuberosity (between the pinky toe and the heel), measuring 3 cm x 2.2 cm. - the left fifth metatarsal head (close to the pinky toe), measuring 2.5 x 3 cm. - the right first metatarsal head (close to the big toe), measuring 2 cm x 1.2 cm. The Interdisciplinary Wound Care Committee form dated 7/31/12, showed the resident developed multiple blood blisters to the feet. It showed the committee (RD and Nursing) recommended an APP (Alternating Pressure Pad) mattress, monitor wounds daily and informed the physician for abnormal changes. The Dietary Progress Notes dated 8/6/12, showed recommendations to increase the tube feeding to Nepro 50 ml per hour for 20 hours to provide 1800 calories to aid in wound healing. Review of the Nurses Note dated 8/7/12 at 1500 hours, showed the physician was informed the resident developed new blisters to multiple areas caused by the resident's legs, which are contracted, rubbing against each other. The Weekly Wound assessment dated [DATE], showed the resident developed a DTI (Deep Tissue Injury - purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear) to the left medial (inner) heel measuring 1.2 cm x 1.5 cm and three pressure ulcers to the following: - Stage II pressure ulcer to the right mid inner foot measuring 1 cm x 1 cm - Stage II pressure ulcer to the left upper lateral thigh measuring 2.5 cm x 2 cm - Stage II pressure ulcer to the left inner ankle measuring 2 cm x 1.5 cm The Nurses Notes dated 8/10/12 at 1530 hours, showed the nurse received a call from the physician to go ahead and increase the resident's tube feeding of Nepro to 50 ml per hour for 20 hours. The Wound Care Committee Meeting dated 8/13/12, showed the committee recommended to change treatment as needed and consider a vascular consult (a consultation by a physician who specializes in problems with the blood vessel system). There was no documentation on what treatment was recommended. The Dietary Progress Note dated 8/14/12, showed the RD called the RD at the [MEDICAL TREATMENT] center and advised them to turn the resident. It also showed the RD recommended to give the resident zinc and vitamin C for wound healing; however, the RD at the [MEDICAL TREATMENT] disagreed. The RD recommended to increase the Nepro to 60 ml per hour to provide 1944 calories. On 8/14/12 at 1120 hours, Resident 7 was observed in bed, on his left side (the resident had a Stage II pressure ulcer to his left thigh) and his heels were not offloaded (UTD pressure ulcers to the heel and feet). The tube feeding was observed running at 50 ml per hour with around 1000 ml of formula in the bag. When LVN 10 was asked if the bottle of formula was a new one, she stated she hung it around 1100 hours, and documented on the Enteral Feeding Monitoring Log. Review of the Enteral Feeding Monitoring Log and Intake and Output Record showed the resident did not receive the prescribed amount of tube feeding. (Cross reference F 328) On 8/14/12 at 1400 hours, LVN 9 stated she was unable to provide treatment at this time because she was waiting for the delivery of Santyl (used to remove necrotic tissue of the wound). She further stated she left a message for the physician to inform him about the change of treatment. She stated the physician usually gets upset when the nurses call him for treatment orders. She stated the physician told her to just let him know. On 8/14/12 at 1525 hours, LVN 9 stated the physician called back and was informed of the change of treatment. During a wound treatment observation of Resident 7, with LVN 9, CNA 15 and the RNP, the RNP was asked if she had seen the wounds before. She replied, no, it was her first time to see the wounds. Five open wounds were observed to Resident 7's left side and five open wounds to the right side of his back. LVN 9 stated she measured the whole area with wounds and not individually. She was asked how can she track the progress of each wound or if there are new wounds developed. She stated "I see what you mean." A Stage III pressure ulcer (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.) was observed to the left hip. LVN 9 stated the pressure ulcer had slough in it. When the RNP was asked if it is a pressure ulcer, she stated it is on a pressure area. LVN 9 removed the dressing to the resident's feet. Six pressure ulcers were observed to the left foot and three pressure ulcers to the right foot. Review of the Weekly Wound Assessments dated 8/14/12, showed the following: - UTD to the left heel measuring 3 cm x 3.5 cm, with 75 to 100% adherent necrotic tissue. - UTD to the left first metatarsal measuring 1.2 cm x 1.5 cm, with 75 to 100% adherent necrotic tissue. - UTD to the left fifth metatarsal tuberosity measuring 3.5 cm x 5 cm, with 75 to 100% adherent necrotic tissue. - UTD to the left fifth metatarsal head (close to the big toe) measuring 3 cm x 4 cm with 75 to 100% adherent necrotic tissue. - DTI to the left medial heel measuring 3 cm x 4 cm, with 75 to 100% adherent necrotic tissue. - Stage III pressure ulcer to the right inner foot measuring 1.5 cm x 2.5 cm, with 25 to 50% yellow, loosely adherent slough. - Stage III pressure ulcer to the left upper lateral thigh measuring 4 cm x 3 cm, with 25% yellow, loosely adherent slough. - UTD to the left inner ankle measuring 2.5 cm x 2.5 cm, with 50 to 75% yellow, loosely adherent slough. - DTI to right fifth metatarsal measuring 2 cm x 2 cm, with 75 to 100% adherent necrotic tissue. - Stage II to right lateral mid foot measuring 2 cm x 1.5 cm. - DTI to the right heel measuring 4 cm x 4 cm, with 75 to 100% adherent necrotic tissue. - Stage II pressure ulcer to the right side of back measuring 19 cm x 20 cm. - Stage II pressure ulcer to the left side of back measuring 18 cm x 19 cm. During an interview with the ADSD on 8/15/12 at 0842 hours, she was asked to describe Resident 7's wounds when he was readmitted to the facility. She stated Resident 7 had a blister to his mid upper left side of his back. She further stated the resident developed four blisters to the left foot and one to the right foot; then, he developed four more to his left upper back, the blister to the left upper thigh popped, and two to the right and left foot, one was open. She stated she called the charge nurse and both looked at the blisters. She stated the charge nurse called the physician and the physician did not give specific treatment orders, but stated to treat it. She further stated the nurses usually get the order from the RNP if they can not get ahold of the physician, like the order for the low air loss mattress (a form of therapeutic support surfaces to prevent and treat pressure ulcers) was from the RNP. She was asked if they asked the RN to assess it. She replied, no. An interview was conducted with LVN 11 on 8/15/12 at 1105 hours. She was asked if she saw the blisters to Resident 7's back and feet. She replied, yes. She stated she called the physician and left a message to call back because Resident 7 developed blisters to multiple areas of his feet. She stated, since Resident 7 was contracted (the joints are stiff, bent and immobile), his inner legs and feet are rubbing against each other, causing pressure. She stated, when the physician called back, he was upset, and, when he was informed about the resident's skin problem, he did not give specific treatment orders. The physician's exact words were "treat it." She stated she just put a pillow between the resident's legs. She was asked if the RN supervisor assessed the wounds. She replied, she was not sure. She was asked who was the RN supervisor. She replied, RN 4. She was asked if she got the order from the RNP. She replied, no. Review of the telephone physician's orders [REDACTED]. The care plan problems dated 8/7/12, to address the DTI to the left medial heel and blisters to the right inner foot, left lateral thigh, left inner ankle and left upper back, showed the approaches included to apply [MEDICATION NAME] daily and to assist with turning and repositioning. There was no intervention included to address the pressure caused by the resident's legs rubbing against each other. During an interview with RN 4 on 8/15/12 at 1155 hours, she was asked if she had assessed Resident 7's wound. She replied, no. An interview was conducted with the RD on 8/15/12 at 1530 hours. The RD stated she is at the facility four and a half days a week. She stated she conducts nutritional assessments on newly admitted residents and readmitted residents. She was asked about her Enteral Feeding assessment dated [DATE]; she crossed out the information Resident 7 had wounds upon readmission. She stated, when she reviewed the admission record, it showed the resident had wounds, however, when she verified with the nurse, the nurse told her the resident did not have any wounds. She was asked if she had known the resident had wounds, would she recommend the same tube feeding. She replied, no. She was asked what would it be. She calculated and stated she would recommend the resident get 1800 calories to promote wound healing. She was asked how much formula she would recommend. She replied, Nepro 50 ml per hour for 20 hours. She was asked why the resident who developed blisters on 7/29/12, wasn't assessed until 8/6/12, eight days later. She had no answer. She was asked what would she recommend if the resident had pressure ulcers. She stated the facility had nutritional protocol and got the Nutrition and Dietary Decubitus Protocol from the nurses' station. Review of the protocol showed, for a Stage II pressure, add one extra egg, add 4 ounces of citrus juice, 8 ounces of milk, administer multivitamins with minerals and vitamin C 500 mg daily. She was asked why the protocol was not implemented whereas, the resident had orders for oral gratification. She stated the resident was not eating. She stated she called the RD at the [MEDICAL TREATMENT] center and the RD disagreed on administering multivitamins and vitamin C because the resident was on [MEDICAL TREATMENT]. She was asked, when the resident developed more blisters and pressure ulcer on 8/7/12, why she didn't assess and called the [MEDICAL TREATMENT] center until 8/14/12, seven days later. She had no answer. On 8/16/12 at 1010 hours, during an interview with the RNP and LVN 9, the RNP was asked if she gave orders for Resident 7. She replied she can not remember giving orders for Resident 7. She was asked if she was aware the nurses had problems getting orders from Resident 7's physician. She stated the Medical Director is aware of the problem and he addressed it. LVN 9 stated, when Resident 7's physician called back on Tuesday (8/14/12), he was yelling all the time. LVN 9 further stated, he called back only because the Medical Director called him. During an interview with RN 5 on 8/16/12 at 1410 hours, she stated she received a report from the nurses Resident 7 developed more blisters. She was asked she was aware that the nurse has a problem getting orders from Resident 7's physician. She stated she was aware that the nurse did not get a good response from the physician and the physician simply stated you are nurses and you should treat it. She was asked what she did. She stated she mentioned it during the IDT meeting on 8/13/12. She was asked if the nurse received a treatment order. She replied she does not know if there was an order written [REDACTED]. She replied she has not seen the wounds. She further stated she was supposed to check on it, but the resident went to [MEDICAL TREATMENT]. During an interview with RN 3 on 8/16/12 at 1440 hours, she was asked if she had assessed Resident 7's wounds. She stated the resident was transferred to this station a couple of days ago, and she has not seen the wounds. She was asked if she was aware the nurses had problems with Resident 7's physician. She stated Resident 7's physician is hard to get ahold of and would not call back. She was asked if she was aware Resident 7's physician does not want to be called for treatment orders. She replied, yes, and further stated, for any orders. She stated they have communicated it to the DON. 2. On 8/15/12 at 1525 hours, 1720 hours and 1800 hours, Resident 23 was observed in bed, on his back. Clinical record review for Resident 23 was initiated on 8/15/12. The resident was admitted to the facility on [DATE]. The MDS dated [DATE], showed the resident is totally dependent on staff for bed mobility, transfer, eating, toileting, hygiene and bathing. The Braden Scale - For Predicting Pressure Sore Risk dated 7/30/12, showed resident's score was 12, which represents a high risk for developing pressure ulcers. The care plan problem dated 7/30/12, to address the risk for recurrent skin breakdown showed the approaches include to provide incontinence care, nutritional support, and administer multivitamins with minerals and vitamin C. The recapped physician's orders [REDACTED]. BS 131 to 160 mg/dl = 2 units 161 to 200 mg/dl = 3 units 201 to 250 mg/dl = 4 units 251 to 300 mg/dl = 6 units 301 to 350 mg/dl = 8 units 351 to 400 mg/dl = 10 units For a BS greater than 400 mg/dl or less than 60 mg/dl, call the physician. The Nurses Weekly Progress Notes dated 3/25/12, showed the resident had a Stage II pressure ulcer to the coccyx. The Nutritional assessment dated [DATE], showed the resident's Stage II pressure ulcer to the coccyx was healed. The Nurses Notes dated 5/21/12, showed redness was noted to the resident's left buttock. The Nurses Notes dated 5/25/12, showed the resident developed a Stage II pressure ulcer to the left buttock measuring 0.3 cm x 0.3 cm. Review of the Weekly Wound Assessment of the pressure ulcer to the left buttock showed: *On 5/21/12, the Stage I (intact skin with non-blanchable redness of a localized area usually over a bony prominence) pressure ulcer measured 5 cm x 1 cm. *On 5/25/12, the Stage II pressure ulcer measured 0.3 cm x 0.3 cm. *On 6/12/12, the Stage II pressure ulcer measured 0.8 cm x 0.8 cm. *On 6/19/12, the Stage II pressure ulcer measured 0.5 cm x 0.5 cm. *On 7/17/12, the Stage II pressure ulcer measured 0.8 cm x 0.8 cm. *On 8/7/12, the Stage II pressure ulcer measured 0.5 cm x 0.5 cm. *On 8/14/12, the Stage II pressure ulcer measure 0.8 cm x 0.8 cm. The Nurses Notes dated 5/29/12, showed redness was noted to the resident's right buttock. Review of the Weekly Wound Assessment of the pressure ulcer to the right buttock showed: *On 5/29/12, the Stage I pressure ulcer measured 3 cm x 3 cm. *On 6/5/12, the Stage I pressure ulcer measured 2.5 cm x 3 cm. *On 6/12/12, the Stage I pressure ulcer measured 2.5 cm x 3 cm. *On 6/19/12, the Stage I pressure ulcer measured 2.3 cm x 2.5 cm. *On 6/26/12, the Stage I pressure ulcer measured 2 cm x 2 cm. *On 7/3/12, the Stage I pressure ulcer measured 1 cm x 1 cm. *On 7/17/12, the Stage I pressure ulcer measured 0.8 cm x 0.8 cm. *On 7/31/12, the Stage I pressure ulcer measured 1 cm x 1 cm. *On 8/7/12, the Stage I pressure ulcer measured 0.5 cm x 0.8 cm. *On 8/14/12, the Stage I pressure ulcer measured 0.8 cm x 0.8 cm. The laboratory result of Hemoglobin A1c (evaluates the average blood sugar level over 3 months) dated 7/5/12, showed the resident's level was 8.2. (Normal level is 4.4 to 5.6) The physician's orders [REDACTED]. Review of the Medication Record from 7/6/12 to 7/31/12, showed the resident had 13 episodes of having a BS greater than 300 mg/dl when checked before dinner, and had 11 episodes of having a BS greater than 300 mg/dl when checked before bedtime. Review of the Medication Record from 8/1/12 to 8/15/12, showed the had 3 episodes of having BS greater than 300 mg/dl when checked before dinner and had 4 episodes of having BS greater than 300 mg/dl when checked before bedtime. On 8/16/12 at 0715 hours, with LVNs 6, 9, and 12, the pressure ulcers were observed to the resident's right and left buttocks. The Weekly Wound assessment dated [DATE], showed: *the Stage I pressure ulcer to the right buttock deteriorated to a Stage II pressure ulcer measuring 3 cm x 0.5 cm *the Stage II pressure ulcer to the left buttock increased in size to 1 cm x 1 cm. On 8/16/12 at 1040 hours, the RNP was asked if the nurses had informed her there were multiple episodes of the resident's blood sugar being high. She stated she increased the dose of [MEDICATION NAME] already. She was informed that, even after the dosage of [MEDICATION NAME] was increased on 7/5/12, the resident had multiple episodes of blood sugars over 300 mg/dl. She stated the nurses did not inform her. She reviewed the clinical record and stated she will consult the physician to determine if they should adjust the resident's medication. On 8/16/12 at 1440 hours, an interview was conducted with RN 3. She was asked if she was aware Resident 23's pressure ulcers were not healing and the resident had multiple episodes of high blood sugar. She replied, no. She was asked if she had assessed Resident 23's pressure ulcers. She replied, no. According to the website http://www.nursingtimes.net/nursing-practice-clinical-research/diabetes-and-its-effect-on-wound-healing-and-patient-care/ 0.article, maintaining normal blood sugar levels is important, as [MEDICAL CONDITION] (high blood sugar) has been correlated with impaired wound healing. In order to optimize wound-healing potential, patients should be encouraged to achieve target levels for Hemoglobin A1c. The target is 7.2% in type 1 diabetes and for people with type 2 diabetes, the target is similar at 7%.

Based on interview, observation and clinical record review, the facility failed to ensure two of 28 sampled residents (Residents 3 and 8) and one nonsampled resident (Resident A) maintained acceptable parameters of nutritional status, such as body weight and protein levels, and received follow up and adjustments to their therapeutic diets to correct their nutritional problems. *Resident 3 was admitted to the facility weighing 180 pounds. When Resident 3 was admitted to the hospital five months later, his weight was 147 pounds (a weight loss of 18.3%), the physician's progress note shows severe [MEDICAL CONDITION] and a GT (a small tube placed through the stomach wall used to provide liquid nutrition, hydration and medications) was inserted. *Resident 8 had a weight loss of eight pounds in a month (5.2%). *Resident A had a weight loss of ten pounds in a month (5.9%). The facility failed to conduct ongoing assessments of the residents' weights, intake and preferences, and implement interventions to prevent further weight loss. As a result, the residents had avoidable, severe weight loss. Findings: 1. Clinical record review for Resident 3 was initiated 8/14/12. Review of the Nutritional Assessment Screening dated 2/7/12, shows Resident 3's weight was 180 pounds, and notes the weight in the hospital was 184 pounds. Resident 3 has a regular diet with no added salt and no concentrated sweets. The RD noted Resident 3 was consuming 63% of meals, has a suboptimal protein status secondary to a low [MEDICATION NAME] (a protein found in the plasma portion of the blood) of 3.2 (normal is 3.5 - 5) and has increased nutritional needs related to wound healing. Resident 3's estimated nutrient requirements are 2,460 to 2706 calories, 98 to 115 gm of protein and 2460 to 2706 ml of water per day. The goal is to improve the oral intake. The RD recommended to continue Glucerna (a liquid supplement for diabetics) with meals, add an extra egg at breakfast, four ounces of juice [MEDICATION NAME] with vitamin C at lunch and a multivitamin with minerals. Review of the dietary notes from 3/1/12 through 5/22/12, shows ongoing errors in calculations of Resident 3's weight losses. The Dietary Progress Note dated 3/1/12, shows a weight of 172 pounds, a decrease of 6 pounds (actual weight loss of 8 pounds or 4.4%) in three weeks. The goal is to improve intake and prevent further weight loss. The RD recommended diet health shakes twice a day between meals, and weekly weights for four weeks. The Dietary Progress Note dated 3/9/12, showed a weight of 170 pounds (this is a significant weight loss of 5.5% in one month). Resident 3's diet was a regular diet, no added salt, no concentrated sweets, Glucerna one can with meals and a diet health shake twice a day between meals. The RD noted Resident 3's average daily meal intake was 73% and his average fluid intake was 1085 ml (this fluid intake is 56% of Resident 3's assessed fluid need). The RD spoke with Resident 3 about the weight loss and updated his preferences. Resident 3 stated he did not like the Glucerna, but would drink the health shakes, and he liked mashed potatoes. The RD recommended discontinuing the Glucerna and the twice per day health shakes, changing the diet health shakes to three times per day between meals, and changing the diet to a fortified diet, no added salt and diabetic desserts. There are no additional Dietary Progress Notes until 5/7/12. Review of the weight record shows the following weights: 3/14/12 = 167 pounds, 3/22/12 = 169 pounds, 3/28/12 = 170 pounds, 4/4/12 = 170 pounds, 5/3/12 =165 pounds (this is a 15 pounds weight loss, or a loss of 8.3% in three months). The Dietary Progress Note dated 5/7/12, shows Resident 3's weight was 165 pounds, a decrease of five pounds in one month (2.9% in one month). (Note - the actual weight loss is 15 pounds, or 8.3% in three months). The RD noted Resident 3 was consuming an average of 84% of meals and 1696 ml of fluid from meals for the last 30 days. The RD spoke to Resident 3 about the weight loss and documented Resident 3 is happy with the weight loss, and Resident 3's weight goal is 160 pounds. (Note: This is the first mention of a weight loss goal for Resident 3. Prior to 5/7/12, there was no weight loss plan from the RD and no weight loss order from Resident 3's physician). Resident 3 requested ice cream with lunch and dinner. The RD recommended ice cream per Resident 3's request, and weekly weights for four weeks. Notes from a nutrition support committee meeting dated 5/10/12, showed a weight of 165 pounds, a decrease of five pounds in one month (2.9%), good oral intake and a goal weight of 160 pounds. (Note - no mention is made of Resident 3's initial weight of 180 pounds, the 15 pounds total weight loss, or the lack of a weight loss plan). The Dietary Progress Note dated 5/22/12, showed a weight of 158 pounds, a decrease of six pounds in one week, or 3.6%. (Note - this is a decrease of seven pounds in two weeks, or 4.2%; the total weight lost since the admission was 15 pounds, or 8.3% in three months). The RD noted Resident 3 was consuming an average of 69% of meals and 1327 ml of fluid from meals for the previous seven days. The nursing staff suggested Resident 3 might benefit from the RNA feeding program. The RD noted Resident 3 was now below his goal weight of 160 pounds. Resident 3 agreed to try Glucerna again to help improve his intake. The RD recommended discontinuing the health shakes and starting Glucerna, one can twice a day between meals. Notes from a nutrition support committee dated 5/25/12, showed a weight of 158 pounds, a decrease of six pounds in one week, average meal consumption at 64% and a recommendation to discontinue the health shakes between meals, and the RNA feeding program for breakfast and lunch. The RD made no recommendation for a follow up [MEDICATION NAME] or [MEDICATION NAME] level during the period from 2/3/12 through 5/25/12. Review of the weight record shows the following weights: 5/28/12 = 160 pounds, 6/4/12 = 162 pounds. Resident 3 was hospitalized from [DATE] through 6/15/12. While hospitalized , a nutrition assessment noted Resident 3's [MEDICATION NAME] level was 2.3. A decreased [MEDICATION NAME] level is indicative of [MEDICAL CONDITION]. Resident 3 was readmitted to the facility on [DATE]. Review of the physician's orders [REDACTED]. The [MEDICATION NAME] level on 6/15/12 was 2.3. A nutritional assessment screening dated 6/20/12, showed Resident 3's weight was 151 pounds, a decrease of 11 pounds in one week. (Note - Resident 3 weighed 180 pounds when admitted to the facility 2/3/12). The RD noted Resident 3 was consuming 75% of meals and calculated the nutritional needs as 2070 - 2415 calories per day, 69 - 83 gm of protein and 1380 - 1725 ml of fluid per day. The RD recommended one can of [MEDICATION NAME] (a protein supplement) twice per day between meals, a multivitamin and an extra egg at breakfast. Review of the physician's orders [REDACTED]. A Dietary Progress Note dated 6/28/12, shows a [MEDICATION NAME] level of 13 (normal level is 15 - 36), the average meal intake for the previous seven days was 42%, the average fluid intake was 1107 ml, and the current diet remains appropriate. The note also shows "Patient with CKD" ([MEDICAL CONDITION]). Review of the facility and hospital records do not show a [DIAGNOSES REDACTED]. A Dietary Progress Note dated 7/3/12, shows Resident 3's weight at 147 pounds, down five pounds in a week (3.3% significant weight loss). (Note - this is a 33 pounds weight loss, or 18.3% in five months). The RD noted Resident 3 was consuming an average of 54% of meals and the average fluid intake was 1210 ml. The RD documented she will talk to the nurse practitioner about an alternate source of nutrition. Resident 3 was admitted to the hospital on [DATE], for a decreased level of consciousness. The emergency room record shows an [MEDICATION NAME] level of 2.2 and a consultation with a [MEDICATION NAME] (a physician specializing in disorders of the stomach) was ordered due to poor oral intake. A GT was inserted on 7/7/12. The operative report shows the indications for the operation as [MEDICAL CONDITION] and failure of oral feeding. A physician's progress note dated 7/7/12, shows severe [MEDICAL CONDITION]. A physician's progress note dated 7/8/12, shows an [MEDICATION NAME] level of 2, severe [MEDICAL CONDITION]. A physician's progress note dated 7/9/12, shows an [MEDICATION NAME] level of 1.9, and [MEDICAL CONDITION]. During an interview with the RD on 8/16/12 at 1440 hours, the RD was asked about Resident 3's weight loss of 33 pounds in five months. The RD stated Resident 3 was happy with the weight loss and Resident 3's goal weight had been 160 pounds. When asked to see the discussion between the RD and Resident 3 about a planned weight loss at the time of admission, the weight loss plan and the order from Resident 3's physician for a planned weight loss, no documentation was found in the clinical record. Review of the laboratory results shows a low [MEDICATION NAME] level in February when Resident 3 was admitted to the facility. The RD was asked why no follow up [MEDICATION NAME] level was done until 6/10/12, when Resident 3 was admitted to the hospital. The RD was unable to answer. 2. Clinical record review was initiated for Resident 8 on 8/14/12. The resident was readmitted to the facility on [DATE]. The MDS dated [DATE], showed the resident requires assistance with bed mobility and is totally dependent on staff for eating, toileting and bathing. The care plan problem dated 5/4/12, to address the risk for nutritional deficit, showed the approaches included to monitor the weight weekly for four weeks, monitor meal intake and assist with feeding. The Vital Signs and Weight Record showed the resident was readmitted with a weight of 159 pounds. It also showed on 6/15/12, the resident had a weight loss of five pounds in a month. The care plan problem revised date 6/5/12, to address weight loss, showed the approach was to monitor the weight weekly for four weeks. The recapped physician's orders [REDACTED]. Review of the Vital Signs and Weight Record showed the following weights: * 6/15/12 - 154 pounds * 6/12/12 - 153 pounds * 6/19/12 - 152 pounds * 6/25/12 - 154 pounds * 7/4/12 - 153 pounds * 7/10/12 - 153 pounds * 8/6/12 - 145 pounds Review of the meal and nourishment intake from 7/1/12 to 8/14/12, showed the average intake for breakfast was 96%, for lunch was 92% and dinner was 93%; however, the average intake for the 1000 hours nourishment was 10%, and the 1400 hours nourishment was 18%. For the 1000 hours nourishment, there was no intake for 38 days, and for the 1400 hours nourishment, there was no intake for 35 days. On 8/14/12 at 1035 hours, CNA 10 was asked if Resident 8 is dependent of staff for eating. He replied, yes, because he can not see well. CNA 10 was asked how Resident 8's appetite is. He replied, the resident eats a good lunch, depending on his mood. An interview was conducted with the RD on 8/15/12 at 1530 hours. She was asked what she recommends for a resident who has significant weight loss. She stated she will recommend weekly weights, provide supplements like Ensure (nutritional supplement for added nutrients and calories), provide a fortified diet, and update the resident's preferences. She was asked about Resident 8's weight loss; what interventions were implemented. She stated she recommended weekly weights, add an extra egg and orange juice, multivitamins, and Glucerna. She was asked why were the weekly weights discontinued. She replied, because the weight was stable. She was asked if she reviewed the meal and nourishment percentages. She replied, no. She was asked how she reevaluates the interventions implemented for a resident with weight loss. She stated the nurses inform her if there are changes or further weight loss. On 8/16/12 at 1345 hours, a staff member delivered a tray of nourishments to the nurses' station. Resident 8's nourishment was not observed on the tray. CNA 4 came and picked-up the tray. She was asked if Resident 8 had a nourishment. She checked the tray and stated, if it is not here, he does not have one. LVN 6 came and asked if Resident 8 has a nourishment. She reviewed the chart and stated he has Glucerna. She left, came back and stated she will give the Glucerna. On 8/16/12 at 1440 hours, RN 3 was asked if she reviewed the meal and nourishment percentages for Resident 8. She replied, no. 3. On 8/16/12 at 0830 hours, CNA 4 was observed in a resident's room feeding a resident. The other resident (Resident A) in the room was in bed, and his breakfast tray was on the bedside table. CNA 4 was asked if Resident A is totally dependent for eating. She stated Resident A refuses his meals. She was asked if Resident A refuses breakfast. She replied, breakfast and lunch. Clinical record review for Resident A was initiated on 8/16/12. The resident was readmitted on [DATE]. The MDS dated [DATE], showed the resident requires assistance with bed mobility, dressing, eating, toileting and hygiene. The Vital Signs and Weight Record showed the following weights: * 7/23/12 - 235 pounds * 7/31/12 - 231 pounds * 8/6/12 - 231 pounds * 8/15/12 - 221 pounds Review of the meal percentages from 8/6/12 to 8/15/12, showed the following average intake: * Breakfast - 53 % * Lunch - 67% * Dinner - 23% An interview was conducted with the RD on 8/16/12 at 1100 hours. She was asked what interventions had been implemented for Resident A to prevent weight loss. The RD stated the resident was on weekly weights and recommended an appetite stimulant. She was asked if the appetite stimulant was ordered. The RD reviewed the clinical record and was unable to find an order for [REDACTED]. She replied, no. She stated the nurses usually alert her if there is a change. She was asked if the nurse informed her about Resident A's decreased meal intake. She replied, no. An interview was conducted with RN 3 and LVN 6 on 8/16/12 at 1115 hours. RN 3 was asked if she was aware of the RD's recommendation for an appetite stimulant for Resident A. She replied, yes; however, when she asked the RNP, the RNP wanted to hold off and see if Resident A lost weight. RN 3 stated Resident A was not eating because he did not like the puree diet. LVN 6 stated Resident A can not tolerate a mechanical soft diet. RN 3 was asked if she reviewed the meal intake of Resident A. LVN 6 stated she had communicated to the RD that Resident A had a decreased meal intake. LVN 6 provided a list to be seen by the RD. Resident A was included on the list with a date of 8/7/12. LVN 6 was informed the RD was unaware. LVN 6 stated all she (the RD) has to do was go through the list.

Based on interview, observation and clinical record review, the facility failed to ensure one of 28 sampled residents (Resident 10) is free from chemical restraints. Resident 10 informed the facility he did not wish to continue [MEDICAL TREATMENT] treatments (a treatment for [REDACTED]. The facility was giving Resident 10 medications to sedate him and continued to send him to [MEDICAL TREATMENT]. Resident 10 was disoriented from the medication and was having increasing behavior issues that could endanger the resident's safety at the [MEDICAL TREATMENT] center. The sedating medications were than increased or changed to stronger medications disorienting the resident further. The facility did not thoroughly address the resident's objection to the [MEDICAL TREATMENT] treatments, or provide a hospice referral for the resident as requested by the Nephrologist (a physician who specialized in kidney diseases) on 7/11/12. As a result, Resident 10 was having increasing problems with his behavior and depression. Findings: Clinical record review for Resident 10 was initiated on 8/14/12. Review of the Initial History and Physical dated 4/2/12, showed Resident 10 has the capacity to understand and make decisions. Review of the MDS (an assessment tool) dated 7/7/12, showed Resident 10 is cognitively intact. Review of the Physicians Orders dated May, 2012, showed Resident 10 was started on [MEDICAL TREATMENT] ([MEDICAL TREATMENT]) on 4/20/12. A Progress Evaluation Note dated 5/11/12, showed Resident 10 was receiving [MEDICAL TREATMENT] and was very depressed. Physician 1 started the resident on [MEDICATION NAME] (an antidepressant) 20 mg to be given prior to [MEDICAL TREATMENT], and [MEDICATION NAME] (antipsychotic medication) 0.25 mg to be given daily. The physician showed the resident was depressed and wanted to die, was refusing his medication and needed counseling. The physician did not document the reason for the depression, why the resident wants to die or why he is refusing medications. The physician did not document if there are any problems with the [MEDICAL TREATMENT] treatments. An Initial Psychological Diagnostic Assessment Form dated 5/17/12, documented by Psychologist 1, showed Resident 10 was depressed but denies [MEDICAL CONDITION]. According to the note, the resident stated "if I die, it would be ok." The assessment does not address the reason for the resident's depression, or discuss [MEDICAL TREATMENT]. A progress note dated 7/4/12, from the [MEDICAL TREATMENT] center, showed Resident 10 was extremely disruptive during [MEDICAL TREATMENT] treatment on 7/3/12. The resident became more agitated and tried to stand up while hooked up to the machine. The resident began to yell he wanted to die. Resident 10 was taken off [MEDICAL TREATMENT] early. The RN from the [MEDICAL TREATMENT] center called the facility. The facility told the [MEDICAL TREATMENT] center Resident 10 had a recent psychiatric evaluation done at the hospital and would fax the report to the center. The evaluation was not received. Review of the Nurses Notes dated 7/3/12, showed a call was received from the [MEDICAL TREATMENT] center; Resident 10 was agitated during [MEDICAL TREATMENT]. A new order was given for Klonopin (a benzodiazepine, used for panic disorder) 1 mg prior to [MEDICAL TREATMENT] treatments. According to Lexi-Comp online, a pharmacy website used by healthcare professionals, Klonopin's side effects include behavior problems, disorientation and memory loss. A usual starting dose is 0.25 mg twice daily; the target dose is 1 mg per day. Review of the Progress Evaluation Note dated 7/4/12, documented by Physician 1, showed Resident 10 was agitated and disruptive during [MEDICAL TREATMENT], withdrawn and had decreased appetite. The physician ordered [MEDICATION NAME] (antianxiety medication) 1 mg before [MEDICAL TREATMENT]. The physician also prescribed [MEDICATION NAME] (an antidepressant) 15 mg. The physician did not document if the resident wanted to continue [MEDICAL TREATMENT] or if any other options were discussed with Resident 10, such as hospice care. A note dated 7/6/12, by RNP 1 showed she spoke to Resident 10 about [MEDICAL TREATMENT] and the resident agreed to continue [MEDICAL TREATMENT] treatments. A Progress Note from the Nephrologist (a physician who specializes in disorders of the kidneys) at the [MEDICAL TREATMENT] center dated 7/10/12, showed a discussion with Resident 10 during his [MEDICAL TREATMENT] treatment regarding discontinuing [MEDICAL TREATMENT] treatments. The Nephrologist documented the resident wanted to stop [MEDICAL TREATMENT] and he will request a hospice evaluation be done at the facility. A note marked "urgent" from the [MEDICAL TREATMENT] center to the facility dated 7/11/12, showed the resident wants to stop [MEDICAL TREATMENT] and go on hospice. Review of the physician progress notes [REDACTED]. The RNP documented the resident wants hospice and does not want to continue [MEDICAL TREATMENT]. The RNP ordered a transfer to an acute care hospital for a psychiatric evaluation. Review of the Nurses Notes dated 7/11/12 at 1600 hours, showed the resident was refusing [MEDICAL TREATMENT] because he wants to terminate his life. An order to transfer Resident 10 for a psychiatric evaluation at an acute care hospital was made. Further review of the note showed Resident 10 refused to go to the hospital. At 1645 hours, the resident was given [MEDICATION NAME] 1.5 mg to calm him down "and will not resist the transfer."A later entry at 1800 hours showed the resident again refused to be transferred. The resident was documented as saying he has rights and is not crazy. A Nurses Notes entry dated 7/12/12, showed the resident is still refusing to go to [MEDICAL TREATMENT]. The licensed nurse documented Resident 10 stated "I just don't want it," he has rights, and he is not crazy. On 7/13/12, the Nurses Notes showed the resident was reminded he was going to [MEDICAL TREATMENT] (tomorrow); the resident stated, no. A Nurses Notes dated 7/16/12, showed to discontinue the transfer to the acute care hospital for the psychiatric evaluation because Resident 10 was refusing to go. Review of the Progress Notes Report dated 7/17/12, from the [MEDICAL TREATMENT] center, showed Resident 10 wanted to come off treatment and continued to express not wanting to come to [MEDICAL TREATMENT] anymore. A physician's orders [REDACTED]. According to the Progress Notes Report dated 7/27/12, from the [MEDICAL TREATMENT] center, on 7/24/12, Resident 10 was extremely agitated during [MEDICAL TREATMENT]. The resident tried to stand up. [MEDICAL TREATMENT] was ended early due to the resident's behaviors. On 8/14/12 (scheduled [MEDICAL TREATMENT] day) at 0815 hours, Resident 10 was observed to be alert and oriented and appropriately answering questions about the facility. Review of the MAR indicated [REDACTED]. At 1115 hours on 8/14/12, Resident 10 was observed to be disoriented. The resident was rocking back and forth on the edge of the bed with a blanket covering his head. Resident 10 did not answer when asked his name. The resident was later observed at 1135 hours, to be sleeping in bed, on his side, with his top leg hanging off the bed. The resident was snoring loudly. At 1230 hours, the resident's lunch tray was brought into the room. The CNA called loudly to the resident, but the resident remained asleep. The CNA took the tray out of the room with her. A Progress Notes Report dated 8/14/12, from the [MEDICAL TREATMENT] center, showed the resident was agitated during [MEDICAL TREATMENT]. The resident kept yelling he wanted to die and tried to stand up during treatment. Resident 10's [MEDICAL TREATMENT] was ended early. Review of a physician's orders [REDACTED]. An interview with Resident 10 was initiated on 8/15/12 at 1400 hours. Resident 10 was asked if he remembered what happened at [MEDICAL TREATMENT] yesterday. The resident stated he did not remember anything that occurred while on the machine. He was asked if he remembers if he ate lunch prior to treatment, he stated he doesn't remember. He was asked if anyone at the facility discussed hospice care with him. He stated, no. Resident 10 stated he is not afraid to die. On 8/16/12 (scheduled [MEDICAL TREATMENT] day) at 0800 hours, Resident 10 was alert and oriented and discussed his former occupation. The resident was observed receiving his medications at 0930 hours. At 1030 hours, Resident 10 was observed sleeping, with a blanket over his head, snoring loudly. An interview with the DON was initiated on 8/16/12 at 1530 hours. The DON stated she knew the Nephrologist had ordered the Klonopin medication and was concerned it may be too much. When asked if she had communicated her concern with the [MEDICAL TREATMENT] center about the medication, she stated she has not. (cross reference to F155)

Based on interview and clinical record review, the facility failed to honor one of 28 sampled residents right to refuse treatment (Resident 10). Resident 10 wanted to discontinue [MEDICAL TREATMENT] treatments (a treatment for [REDACTED]. The facility did not honor his request. As a result, Resident 10 became disruptive during his [MEDICAL TREATMENT] treatments, which led to the staff chemically restraining him in preparation for his [MEDICAL TREATMENT] treatments. Findings: Clinical record review for Resident 10 was initiated on 8/14/12. Review of the Initial History and Physical dated 4/2/12, showed Resident 10 has the capacity to understand and make decisions. Review of the MDS (an assessment tool) dated 7/7/12, showed Resident 10 is cognitively intact. Review of the Physicians Orders dated May, 2012, showed Resident 10 was started on [MEDICAL TREATMENT] ([MEDICAL TREATMENT]) on 4/20/12. Review of the Nurses Notes dated 7/3/12, showed Resident 10 became disruptive during his [MEDICAL TREATMENT] treatment. A new order was given for Klonopin (a benzodiazepine used for panic disorder) 1 mg. Review of the Progress Evaluation Note dated 7/4/12 showed Resident 10 was agitated and disruptive during [MEDICAL TREATMENT]. The physician ordered [MEDICATION NAME] (an antianxiety medication) 1 mg before [MEDICAL TREATMENT]. the physician also ordered [MEDICATION NAME] (an antidepressant) 15 mg. On 7/10/12, a Progress Note from the Nephrologist (a physician who specializes in diseases of the kidneys) at the [MEDICAL TREATMENT] center showed a discussion with Resident 10 during his [MEDICAL TREATMENT] regarding discontinuing [MEDICAL TREATMENT] treatments. The Nephrologist showed the resident wanted to stop [MEDICAL TREATMENT] and he (the nephrologist) will request a hospice evaluation be done at the facility. A note marked "urgent" from the [MEDICAL TREATMENT] center to the facility dated 7/11/12, showed the resident wants to stop [MEDICAL TREATMENT] and go on to hospice. Review of on the physician progress notes [REDACTED]. The RNP showed the resident wanted hospice and does not want to continue [MEDICAL TREATMENT]. The RNP ordered a transfer to an acute care hospital for a psychiatric evaluation. Review of the Nurses Notes dated 7/11/12 at 1600 hours, showed the resident was refusing [MEDICAL TREATMENT] because he wants to terminate his life. An order to transfer Resident 10 for a psychiatric evaluation at an acute care hospital was made. Further review of the note showed Resident 10 refused to go to the hospital. At 1645 hours, the resident was given [MEDICATION NAME] 1.5 mg to calm him down so the resident would not refuse the transfer. A later entry at 1800 hours showed the resident again refused to be transferred. The resident stated he had rights and was not crazy. An entry into the Nurses Notes dated 7/12/12, showed the resident is still refusing to go to [MEDICAL TREATMENT]. The resident stated "I just don't want it," he has rights and he is not crazy. An entry in the Nurses Notes dated 7/13/12, showed the resident was reminded he was going to [MEDICAL TREATMENT] (tomorrow), the resident stated, no. Review of the Progress Notes Report dated 7/17/12, from the [MEDICAL TREATMENT] center, showed Resident 10 wanted to come off treatment and continued to express not wanting to come to [MEDICAL TREATMENT] anymore. The Medical Social Worker (MSW) at the center called the facility and was told the resident had a psychiatric evaluation and they were waiting for the RNP to talk to the resident. Review of the Nurses Notes dated 7/17/12 at 1730 hours showed the resident returned to the facility from [MEDICAL TREATMENT] with a new order from the Nephrologist to increase the dose of Klonopin to 2 mg before [MEDICAL TREATMENT] treatments. According to the Progress Notes Report dated 7/27/12, from the [MEDICAL TREATMENT] center, on 7/24/12, Resident 10 was extremely agitated during [MEDICAL TREATMENT]. The note further showed the facility told the [MEDICAL TREATMENT] center the Ombudsman spoke to Resident 10 about hospice care. The RNP also had a conversation with the resident and it was decided Resident 10 would continue [MEDICAL TREATMENT]. An interview with Resident 10 was initiated on 8/15/12 at 1400 hours. Resident 10 was asked if anyone at the facility discussed hospice care with him. He stated, no. Resident 10 stated he was not afraid to die. An interview with the Ombudsman was initiated on 8/15/12 at 1415 hours. The Ombudsman was asked if he spoke to Resident 10 about [MEDICAL TREATMENT] or hospice care. The Ombudsman stated he was told by the facility there was an issue with Resident 10, but he has been on jury duty for three weeks and had not yet spoke to the resident. A telephone interview with the [MEDICAL TREATMENT] center MSW was initiated on 8/15/12 at 0945 hours. The MSW stated Resident 10 had told her and the Nephrologist repeatedly that he does not want to have [MEDICAL TREATMENT]. He has been prescribed medications to keep him calm during treatment but they are not effective, in fact, the behaviors are getting worse. The MSW stated the resident comes to [MEDICAL TREATMENT] disoriented and sedated. After about an hour, he wakes up and is confused. He tries to stand up while on the machine. If the needles come out while he is trying to stand, he could bleed to death in a few minutes. So the resident is taken off the machine early. The MSW stated she had tried to communicate with the facility about Resident 10 on many occasions. She had called the SSD twice; once she left a message and the other time she was put on hold, but the SSD did not pick up her call. Since then, she had talked to different nurses at the facility. Each time she is given a different answer to her questions. The MSW stated a hospice referral was sent to the facility by the Nephrologist on 7/11/12. She does not know if the resident has been seen by hospice yet. She had been told Resident 10 was sent to the hospital for a psychiatric evaluation and had requested a copy of the report, but has not received it. She has been told the Ombudsman spoke to the resident, but she can not confirm this. The MSW stated she has been frustrated by the lack of communication from the facility. An interview with RNP 2 was initiated on 8/16/12 at 1500 hours. RNP 2 stated the Ombudsman spoke to Resident 10 about hospice. She was asked if she was present during the discussion. She stated, no, but she assumed it was done. She further stated RNP 1 discussed [MEDICAL TREATMENT] with Resident 10 on 7/6/12, and he agreed to go. RNP 2 was asked about her Progress Note dated 7/11/12, regarding her documentation that the resident wanted to terminate his life and stop [MEDICAL TREATMENT]. The RNP confirmed she had documented this.

Based on interview, and clinical record review, the facility failed to provide the necessary care to maintain the highest practicable physical well being for Resident 1. Resident 1 had episodes of loose stools, decreased oral intake, and was receiving [MEDICATION NAME] (a medication used for diarrhea) and [MEDICATION NAME] (a medication used for diarrhea) from 1/23/12 to 1/26/12. The facility failed to assess Resident 1's loose stools for the potential of having an infection with [DIAGNOSES REDACTED] (a bacteria which causes diarrhea or infection in the intestine). The facility failed to reevaluate and notify the physician of Resident 1's condition. Resident 1 was transferred to the acute hospital on [DATE], and was diagnosed with [REDACTED]. Finding: Review of Resident 1's closed clinical record was initiated on 2/9/12. She was admitted to the facility on [DATE], and was transferred to the acute hospital on [DATE]. Review of the Physician's admission orders [REDACTED]. Review of the physician's orders [REDACTED]. Review of the MAR for the month of January, 2012, showed Resident 1 was receiving [MEDICATION NAME] daily. She received [MEDICATION NAME] from 1/12 to 1/16/12. Review of the facility's P&P titled [MEDICAL CONDITION] revised 2/11, showed residents considered at high risk for diarrhea associated with [DIAGNOSES REDACTED] includes the resident with advancing age, receiving a PPI, and receiving antibiotic therapy in the last six months. When the resident with these risks has symptoms of diarrhea, a high degree of suspicion for [DIAGNOSES REDACTED] should be demonstrated. Other symptoms may include loss of appetite, abdominal pain and cramping. Further review showed steps to prevent and early intervention include include increasing awareness of the staff regarding risk factors of the residents and the epidemiology of the organism; considering [DIAGNOSES REDACTED] in differential diagnosis, especially in the residents with high risk factors. Review of the Group I/O by Day Chart from 1/12 to 1/21/12, showed Resident 1's average intake was 86.7% to 100% per day. Review of the Bowel and Bladder Chart Detail Report showed Resident 1 had episodes of loose stools on 1/9, 1/12, 1/15, and 1/21/12. There was no documented evidence to show Resident 1's loose stools were assessed for mucus, foul odor, or blood on the above dates. There was no documentation to show the physician was notified of the resident's condition. Review of the Infection Control Surveillance for the month of January, 2012, showed on 1/19, and 1/22/12, there were two residents identified as having loose stools and [DIAGNOSES REDACTED] throughout the facility. Review of the Bowel and Bladder Chart Detail Report showed Resident 1 had one episode of loose stool out of three episodes of bowel movements on 1/23/12. Review of the Group I/O by Day Chart showed Resident 1's average intake was 66.7% on 1/22/12, and 76.7% on 1/23/12. Review of the Nurses Notes dated 1/23/12 at 1200 hours, showed Resident 1 had episode of loose stool. Another entry dated 1/23/12 at 1300 hours, showed the physician was notified. There was no documented evidence to show Resident 1's loose stool was assessed for mucus, foul odor, or blood. Review of the physician's orders [REDACTED]. Review of the Lexi-Comp (a drug reference) for the use of [MEDICATION NAME] (same as [MEDICATION NAME]) showed to discontinue [MEDICATION NAME] if symptoms of acute diarrhea persist more than 48 hours, or worsen. Further review showed the medication may prolong and/or worsen diarrhea resulting from some infection, and from pseudomembranous [MEDICAL CONDITION] (an infection of the colon, a result of antibiotic-associated diarrhea); the medication is not to be used for these conditions. Review of the MAR for the months of January, 2012, showed [MEDICATION NAME] was given Resident 1 for loose stool on 1/23/12 at 1300 hours. Review of the Short Term Problems showed a care plan problem dated 1/23/12, to address loose stools. The target date was 1/24/12. The goal was the loose stools will be resolved within one to two days. The approaches included to monitor and assess for fever and abdominal pain; assess color and smell of stool; assess if it is loose or watery stool; medication as ordered; call the physician if more than one episode of loose stool is noted, or if large amounts of loose stool persist. Review of the Bowel and Bladder Chart Detail Report showed Resident 1 had two episodes of loose stools out of four episodes of bowel movements on 1/24/12. Review of the Group I/O by Day Chart showed Resident 1's average intake was 73.3% on 1/24/12. Review of the MAR for the month of January, 2012, showed Resident 1 received two tablets of [MEDICATION NAME] for complaint of loose stool on 1/24/12 at 1800 hours. Review of the Nurses Notes dated 1/24/12 at 2000 hours, showed Resident 1 had one episode of loose stool, and was medicated with [MEDICATION NAME], with good effect. There was no documented evidence Resident 1's loose stool was assessed for mucus or foul odor. There was no documented evidence to show the physician was notified the resident was having more loose stools. Review of the Bowel and Bladder Chart Detail Report showed Resident 1 had two episodes of loose stools out of two episodes of bowel movements on 1/25/12. Review of the Group I/O by Day Chart showed Resident 1's average oral intake was 28.3% on 1/25/12. She consumed 25% of breakfast, 0% of lunch, 60% of dinner, and 0% of nourishments. Review of the MAR for the month of January, 2012, showed Resident 1 received [MEDICATION NAME] on 1/25/12 at 0900 hours, and at 1900 hours, for complaint of loose stools. Review of the Nurses Notes dated 1/25/12 at 1000 hours, showed no loose stools were reported. Another entry dated 1/25/12 at 1500 hours, showed Resident 1 complained of having more episodes of loose stools and eating poorly. A half sandwich and 7 Up were given to the resident and a message was left for the physician. There was no documented evidence to show the resident was considered and evaluated for the risk of an infection with [DIAGNOSES REDACTED]. Review of the Nurses Notes dated 1/26/12 at 0730 hours, showed Resident 1 complained of having a loose stool; one loose stool was noted. No foul odor was noted. [MEDICATION NAME] was given to the resident. The resident refused breakfast because of having loose stools. There was no documented evidence to show the physician was notified of Resident 1's condition. Review of the Nurses Notes dated 1/26/12 at 1130 hours, showed Resident 1's family member called regarding the resident's condition. The family member requested Resident 1 be transfer to the acute hospital for further evaluation. Resident 1 refused lunch, and requested Jello. The physician was called. Review of the Nurses Notes dated 1/26/12 at 1330 hours, showing Resident 1's family member was informed they were waiting for the physician to call back. The resident's family member insisted they transfer the resident to the acute hospital. Another entry dated 1/26/12 at 1500 hours, showed the physician called back and was aware of Resident 1's condition. The physician ordered blood tests, urine test, and stool test for [DIAGNOSES REDACTED] in the morning for further evaluation. Resident 1's family member was made aware and still insisted they transfer the resident to the acute hospital. The physician agreed and ordered to transfer the resident to the acute hospital. On 2/9/12 at 0940 hours, LVN 1 stated Resident 1 had episodes of diarrhea. On 2/9/12 at 1025 hours, CNA 1 stated Resident 1 had two episodes of diarrhea during her shift. The CNA was asked how the resident's stools looked. She stated the resident's stools had mucus, but did not have a strong odor. She was asked how the resident's oral intake was. She stated the resident ate solid food, and ate a little bit. The CNA was asked if the resident complained of abdominal pain. The CNA stated the resident complained of abdominal pain on the last day when she was taking care of the resident. She stated she reported the resident's condition to the charge nurse. On 2/9/12 at 1140 hours, an interview and review of Resident 1's closed clinical record was conducted with the ADON and LVN 1. LVN 1 stated [MEDICATION NAME] and [MEDICATION NAME] were given to Resident 1 when the resident complained of loose stools. LVN 1 was asked if the resident's loose stools were assessed for mucus, blood, or foul odor. The LVN stated the resident's stools had no mucus, and were soft. LVN 1 and the ADON were asked for, but were unable to find documented evidence to show Resident 1's loose stools were assessed for mucus, blood, or odor. The ADON stated the documentation showed the resident had episodes of loose stools, but there was no documented evidence to show the loose stools were assessed for muscus, blood or odor. They were also asked for, but were unable to find documentation to show the physician was notified the resident was having more loose stools, and decreasing oral intake from 1/23/12 at 1300 hours to 1/26/12 at 1130 hours. They were asked for, but were unable to find documentation to show a care plan problem was revised to address the resident's loose stools. Review of Resident 1's closed clinical record from the acute hospital was initiated on 2/10/12. Review of the Emergency Department Patient Care Record dated 1/26/12, showed Resident 1's temperature was 100.2 degrees Farenheit. The Emergency Physician Record dated 1/26/12 at 1723 hours, showed Resident 1 complained of having intermittently right lower abdominal pain, and intermittent loose stools for one month. She also complained of a low appetite. Resident 1 was diagnosed with [REDACTED]. Review of the results of a CBC (Complete Blood Count, to check for white blood cell count(WBC)) collected on 1/26/12 at 1745 hours, showed the WBC was 49.4 (normal range is 4.8 - 10.8) (an elevated WBC level indicates an infection). Review of a stool specimen result collected on 1/26/12 at 1750 hours, for [DIAGNOSES REDACTED] toxin A and B showed positive for [DIAGNOSES REDACTED]. Review of the Progress Record showed an entry dated 1/28/12, showing Resident 1 had severe [DIAGNOSES REDACTED] (an infection of the intestine caused by [DIAGNOSES REDACTED]), was taking [MEDICATION NAME] (an antibiotic used to treat a [DIAGNOSES REDACTED] infection) and [MEDICATION NAME] (an antibiotic used to treat a [DIAGNOSES REDACTED] infection). Review of the Progress Record dated 1/30/12, showed Resident 1 had severe pseudomembrane [MEDICAL CONDITION] of the entire colon. The surgeon recommended a total colectomy (a surgery to remove the colon) and [MEDICAL CONDITION] (a surgery to bring the end of the small intestine out onto the surface of the skin) for ischemic bowel (a medical condition in which inflammation and injury of the large intestine results from inadequate blood supply). Review of the Progress Record dated 1/30/12, dated 1/30/12, showed Patient 1 was diagnosed with [REDACTED]. On 2/14/12 at 1455 hours, a telephone interview was conducted with Physician 1. The Physician 1 was asked if he was notified Resident 1 was having persistent loose stools since 1/23/12. He stated he did not remember. However, he stated he was notified of Resident 1 having loose stool, and he ordered [MEDICATION NAME] for the resident. Then he received a second call from the facility a couple of days later regarding a request to transfer the resident to the acute hospital. He stated when the resident had diarrhea, he gave [MEDICATION NAME] to the resident; if the resident was still having diarrhea or loose stools and was not getting better after one or two days, the resident needed to be worked up further. He was asked if he expected the staff to call him if the resident was not getting better. He stated, yes. He was asked if the resident can [MEDICAL CONDITION], and ischemic bowel from an infection of [DIAGNOSES REDACTED]. He stated, yes.

Based on clinical record review and interview, the facility failed to provide sufficient fluid intake to meet the hydration needs for one of 30 sampled residents (Resident 8). Resident 8 was identified to be at risk for dehydration (dehydration occurs when fluid intake is less than body requirements). The facility failed to develop a plan of care specific to Resident 8's fluid needs and implement the plan of care to monitor Resident 8 for fluid intake and signs/symptoms of dehydration, resulting in dehydration and hospitalization . Findings: Clinical record review for Resident 8 was initiated on 5/2/11 at 1550 hours. Resident 8 was readmitted to the facility on [DATE]. Review of the MDS (an assessment tool) dated 11/23/10, shows risk factors for dehydration including vision/hearing impairment, dysphagia (difficulty swallowing) and [MEDICAL CONDITION] (paralysis of one side of the body) secondary to a stroke, muscle weakness, total dependence in ADLs and extensive assistance for eating. The MDS Care Area Assessment identified problem areas for care planning included dehydration/fluid maintenance. Review of Resident 8's care plan shows a care plan problem dated 11/15/10, to address the risk of nutritional deficit related to depression and risk for dehydration. Interventions include monitor the percentage of meal intake, monitor signs/symptoms of dehydration (decreased output, skin turgor, dry, itchy skin), and report to the physician if noted. The Nutritional Assessment Screening - OBRA by the RD dated 11/16/10, shows Resident 8's fluids needs is 1150-1350 ml/day (approximately 1.5 quarts). The RD recommended the addition of NTL (nectar thick liquids, used for people with swallowing problems) with all meals. A Dysphagia Evaluation by the SLP (speech language pathologist) dated 11/16/10, shows a decline in swallowing function and a downgrade of Resident 8's diet to pureed foods with NTLs. The stated goal of the dysphagia therapy was to eat/drink safely in sufficient amounts to sustain nutritional needs. Dysphagia therapy continued five times a week until 12/20/10. The final clinical note dated 12/21/10, shows Resident 8 does not manifest safe swallowing of thin liquids in sufficient amounts to advance the diet; the caregiver has been instructed in safe swallowing strategies; Resident 8 is functioning at her highest capacity at this time. No further dysphagia therapy was planned. An RD note dated 11/30/10, shows Resident 8's weight at 94 pounds, a weight loss of three pounds in one week. Resident 8's intake for a one week period was noted as 73% for breakfast, 60% for lunch and 67% for dinner. The RD noted this intake was meeting Resident 8's needs. The RD documented Resident 8 was put on 24 hours of IV fluids. There was no further documentation the RD addressed the resident's fluid needs. An RD note dated 12/9/10, shows a weight gain of one pound in a week. The RD also noted Resident 8's meal intake is variable but stable. Laboratory values show an increased BUN (blood urea nitrogen) at 27 (normal range 6-23). The RD recommended pushing fluids and to continue with the plan of care. An update to the plan of care dated 12/11/10, showed a three pound weight loss in one week. Updated interventions included an RD consult, continue oral intake monitoring and weekly weights, Glucerna 60 ml NTL with medication pass and Glucerna 120 ml (NTL) three times a day with meals. There was no intervention to include the RD's recommended assessed needs of 1150-1350 ml of fluids per day, and did not include the RD's recommendation to push fluids. Additional revisions to the care plan problem addressing nutritional needs were made on 12/20/10 and 12/21/10, but these revisions did not address Resident 8's fluid needs. An RD note dated 2/7/11, shows Resident 8's weights as 98 pounds in 11/10, 96 pounds in 1/11 and 97 pounds in 2/11. The RD also noted Resident 8's intake was between 30-90% of meals. There was no RD assessment of Resident 8's hydration status for fluid intake compared to identified fluid needs. No further RD notes are found in Resident 8's clinical record prior to her hospitalization on [DATE]. Review of the Nursing Assistant Daily Flow Sheet for February, 2011, shows breakfast, lunch and dinner intake between 60-90% of food on the tray, but no separation of food intake from fluid intake, total dependence in eating, and no nourishments at 1000 hours and 1400 hours. The flow sheet also shows documentation fluids were offered, but does not show the amount of fluids taken by Resident 8. Review of the Nurses Notes dated 2/6/11 through 2/25/11, fail to show any assessment for dehydration or Resident 8's intake of food or fluids. Review of the Nursing Assistant Daily Flow Sheet for March, 2011, shows breakfast, lunch and dinner intake between 30-90% of food on the tray, but no separation of food intake from fluid intake, total dependence in eating, and no nourishments at 1000 hours and 1400 hours. The flow sheet also shows documentation fluids were offered, but does not show the amount of fluids taken by Resident 8. Review of the Nurses Notes dated 3/2/11 through 3/25/11, fails to show any intervention/assessment for dehydration, as identified on the plan of care (decreased output, poor skin turgor, or dry, itchy skin) an assessment of Resident 8's intake of fluids or if Resident 8 was meeting the daily fluid requirements assessed by the RD. Review of the Nursing Assistant Daily Flow Sheet for 4/1 through 4/4/11, shows breakfast, lunch intake between 20-40% of food on the tray but no separation of food intake from fluid intake. The flow sheet shows fluids were offered, but does not show the amount of fluid taken by Resident 8. Review of the Nurses Note dated 4/4/11 at 1345 hours, shows Resident 8 had bluish finger tips, bilateral upper and lower extremities appeared bluish, the blood pressure was 90/60 (normal blood pressure for Resident 8 was 122/62 to 130/78) and the heart rate was 118 (normal for Resident 8 was 70 to 74). The oxygen saturation was 74% on 3 liters of oxygen (previous oxygen saturation for Resident 8 on room air was 93%). The NP was notified and came to see Resident 8. The oxygen was increased to 15 liters via a non-rebreather mask (a mask to deliver 100% of oxygen). The NP note dated 4/4/11, showed Resident 8's change of condition and the NP's assessment of [MEDICAL CONDITION] (decreased blood pressure), [MEDICAL CONDITION](rapid heart rate) and possible dehydration. The plan was to check laboratory values and give IV (intravenous) fluids. Review of the Nurses Note dated 4/4/11 at 1549 hours, shows Resident 8's blood pressure was 98/60, the heart rate was 104, unable to obtain an oxygen saturation (due to cool extremities) and oxygen continues at 15 liters via a non-rebreather mask. Review of a Nurses Note dated 4/4/11 at 1600 hours, shows a nine pound weight loss was reported to the physician. The physician ordered weekly weights and an RD consult. There is no documentation of a report to the physician of Resident 8's change in status at 1345 hours, ongoing low blood pressure, [MEDICAL CONDITION] inability to obtain oxygen saturation at 1549 hours, or the need for oxygen via non-rebreather mask at 15 liters per minute. Laboratory blood work was ordered on [DATE] at 1540 hours and drawn at 1615 hours. The results were reported on 4/4/11 at 2202 hours. The results showed the BUN was 120 (a critically high value, normal is 6-23), the creatinine was 2.9 (Normal 0.6-1.5), the sodium was 159 (normal 135-148), and the chloride was 124 (normal 96-112). These values were reported to the NP. According to the Drug Information Handbook 15th addition, 2007, in the Appendix, increased sodium is seen in excess water loss. An increased chloride is seen in dehydration and acute [MEDICAL CONDITION]. An increased BUN is seen in acute [MEDICAL CONDITION] and dehydration. An increased creatinine is seen in any renal impairment. Review of a Nurses Notes dated 4/4/11 at 2230 hours, shows Resident 8's blood pressure was 80/50, the heart rate was 100 and the oxygen saturation was 60%. The NP ordered Resident 8's transfer to the hospital, and 911 was called. Review of the hospital's history and physical dated 4/5/11, shows laboratory values of BUN 117, creatinine 2.9, sodium 157 and [MEDICATION NAME] 2.9. The physician's impressions were [MEDICAL CONDITION] (a blood stream infection), urinary tract infection and dehydration. An inpatient nephrology consultation dated 4/5/11, shows the reason for the consultation as acute [MEDICAL CONDITION] and severe [MEDICAL CONDITION]. The physician's impression shows ..."I suspect her acute [MEDICAL CONDITION] is secondary to volume depletion as well as [MEDICAL CONDITION] from free water depletion. Her [MEDICAL CONDITIONS] may be related to her electrolyte abnormalities. During an interview with the ADON and the RD on 5/3/11 at 1500 hours, Resident 8's clinical record was reviewed. The ADON and the RD were unable to show any plan of care entries documenting Resident 8's fluid needs, any assessment of Resident 8's actual fluid intake compared to the identified daily fluid needs, any assessment of hydration or dehydration, or any plan of care update or communication to staff of the RD's recommendation to push fluids. The RD was unable to explain why there had been no further RD assessment after 2/7/11. The ADON could not explain why a resident with dysphagia, documented poor intake and NTLs was not placed on intake and output monitoring. During an interview with CNA 1 on 5/3/11 at 1545 hour, CNA 1 was asked if she had been told how much fluid Resident 8 was to take during the shift, CNA 1 stated she had not been told a specific amount of fluid to give to Resident 8, but she tried to get Resident 8 to take at least 200 ml of thickened fluid. CNA 1 further stated she has not been told to document the amount of fluid taken by Resident 8, only the amount of each meal taken by the resident. During an interview with CNA 2 on 5/4/11 at 1415 hours, CNA 2's intake record for Resident 8 shows 150 ml of fluids from 0700 hours through 1300 hours today. CNA 2 stated she has not been told how much fluid to give to Resident 8 on her shift, but she offers fluids every two hours. During an interview with NP 1 on 5/5/11 at 0930 hours, the history and physical and the nephrology consultation notes dated 4/5/11, from Resident 8's hospitalization were reviewed. NP 1 stated Resident 8 had a urinary tract infection causing the decreased mental status. When asked what caused the sodium of 157, NP 1 stated Resident 8 was dehydrated.