Every finding on record at Balboa Nursing & Rehabilitation Center

Based on interview and record reviews, the facility staff failed to report an allegation of abuse for one of three sampled resident (Resident 1). This failure had the potential for further abuse to Resident 1. Findings: On 4/14/26 at 6:48 P.M. the Department received a complaint from a hospital staff. The hospital staff stated a resident (Resident 1) who came from (name of facility) skilled nursing facility (SNF) told him that he was physically assaulted by a staff at the SNF where he was residing. On 4/22/26 at 9:55 A.M., an unannounced visit was conducted at the facility to investigate an abuse allegation involving Resident 1. Per the Facility's admission Record, Resident 1 was admitted to the facility on [DATE] with diagnoses which included Depression (a serious, common mental health condition causing persistent sadness, low interest and low energy) and Chronic Obstructive Pulmonary Disease (a chronic lung disease causing difficulty in breathing). A review of Resident 1's Minimum Data Set (MDS - a federally mandated assessment tool) dated 4/2/26 indicated a brief interview for mental status (BIMS) score of 15 which indicated Resident 1's cognition (thought process) was intact. On 4/22/26 at 4:19 P.M., an interview with the DON was conducted. The DON stated on 4/17/26 she received a report that Resident 1 reported to the hospital staff that he was physically assaulted. The DON stated she did not do anything with this information and acknowledged she did not report it to the Department. The DON indicated it was important to report allegations of abuse to keep residents safe and to start the investigation timely. This was not done for Resident 1. A review of the facility's policy titled, Abuse, Neglect , Exploitation and Misappropriation Prevention Program dated April 2021, indicated, 9. investigate and report any allegations within time frames required by federal requirements.

Based on interview, and record review the facility failed to implement an effective infection control prevention and antibiotic (medication for infection) stewardship (responsible use) process for three of three sampled residents (Resident 1, Resident 2, and Resident 3) reviewed from 12 residents identified on the Infection Preventionist (IP) list of health-care associated infection (HAI-infections acquired at the facility) for urinary tract infections (UTI- an infection in the bladder/urinary tract) when:1. Resident 1 received an order for an antibiotic on 1/9/26 for Macrobid (a commonly prescribed antibiotic used specifically to treat bacterial urinary tract infections) without supporting documentation for monitoring UTI symptoms and/or side effect monitoring. Resident 1 received two antibiotics Levofloxacin (used to treat bacterial infections in many different parts of the body) for UTI and Methenamine Hippurate (an antibiotic used to prevent or treat recurring urinary tract infections) for infection prophylaxis (prevention) both ordered on 2/11/26; however, the infection screening dated 2/11/26 documented no symptoms of infection with an evaluation score of 0 (no infection symptoms). Despite the absence of an infection screening evaluation confirming a UTI diagnosis, and the Methenamine Hippurate order did not include a documented diagnosis supporting infection prophylaxis (prevention) or a stop date.2. Resident 2 received an antibiotic (Cefuroxime Axetil- antibiotic used to kill bacteria causing various infections) on 2/4/26 for dysuria (Double check) for seven days; however, the facility did not complete an infection evaluation screening to assess for UTI prior to initiating antibiotic therapy.3. Resident 3 was prescribed an antibiotic (Ciprofloxacin- antibiotic used to treat serious bacterial infections) order on 2/8/26 for a suspected UTI; however clinical documentation indicated the antibiotic was initiated based on confusion, which did not meet the diagnostic criteria for UTI. In addition, no infection screening evaluation was completed prior to initiating antibiotic therapy, and no monitoring of UTI symptoms while on antibiotic treatment, indicating lack of appropriate assessment and antibiotic stewardship oversite.These deficient practices placed all three residents at risk for receiving unnecessary antibiotic treatment, delayed identification of actual infection, development of antibiotic resistance, and potential medication-related adverse effects.Cross-reference F757.Findings:1. A review of Resident 1's admission Record indicated Resident 1 was re-admitted to the facility on [DATE] with diagnoses which included history of quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury) and immunodeficiency (group of conditions that make it hard for the body to fight infections).A record review of Resident 1's minimum data set (MDS - a federally mandated resident assessment tool) dated1/28/26 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 15 points out of 15 possible points which indicated Resident 1 had no (pertaining to memory, judgement and reasoning ability) deficits. On 3/4/26 at 1:35 P.M., an interview and record review was conducted with the Infection Prevention (IP) nurse. The IP nurse stated the facility tracked residents with UTIs using an infection surveillance list and monitored infections through infection tracking and mapping. The IP stated used a clinical document titled Infection Screening Evaluation to assess and/or evaluate residents for signs and symptoms of infection prior to initiating antibiotic therapy as part of the facility's infection prevention and antibiotic stewardship program. The IP nurse stated Resident 1 had a suprapubic catheter and a history of recurrent UTIs and had a care plan addressing risk for infection dated initiated 2/6/26. The IP nurse stated Resident 1's Infection Screening Evaluation was completed on 2/11/26 that indicated no symptoms consistent with UTI.On 3/5/26 at 1:13 PM a follow-up interview and record review was conducted with the IP nurse. The record reviews indicated:- Resident 1's clinical document titled, Infection Screening Evaluation showed scores of 50 (symptom/s of infection) on 1/12/26 with acute dysuria (one symptom for UTI) and was manually triggered (regardless of score) to indicate active infection. Resident 1's urine culture on 1/9/26 indicated, .Gram Positive Cocci [round bacteria that turn purple under a microscope when stained, indicating a thick, protective outer layer] Colony count 50,000-90,000. Resident 1's physicians (MD) order Macrobid 100 mg was started on 1/9/26 through 1/16/26 for the treatment of UTI. No supporting documentation for monitoring UTI symptoms and/or side effect monitoring for antibiotic use.- Resident 1's clinical document titled, Infection Screening Evaluation showed a score of zero on 2/11/26 (no symptom of infection). Resident 1's urine culture result on 1/9/26 indicated .Gram Positive Cocci Colony count 50,000-90,000.; despite this Resident 1 was prescribed Levofloxacin 250 mg on 2/10/26 through 2/17/26 for UTI and Methenamine Hippurate 1 gram for infection prophylaxis without a stop date. No supporting documentation for monitoring UTI symptoms and/or side effect monitoring for antibiotic use.The IP nurse stated Resident 1 should have been monitored for signs and symptoms of UTI during antibiotic therapy, including while receiving Macrobid and Levofloxacin. The IP further stated Resident 1's MD order Methenamine Hippurate should have included a stop date and the diagnosis of infection prophylaxis required clarification, as it did not identify specific symptoms or criteria for monitoring. The IP nurse stated antibiotics should have a defined duration and monitoring plan to prevent inappropriate antibiotic use and reduce the risk of antibiotic resistance and infection.On 3/5/26 at 2:41 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated the facility expected staff to follow appropriate clinical criteria and physician diagnosis when initiating antibiotic therapy. The DON stated it was important to follow McGreer criteria (a standardized set of rules to determine if a resident has a true UTI) when evaluating residents for UTI prior to initiating antibiotics. The DON further stated when a new antibiotic order was received, the IP nurse should complete the Infection Screening Evaluation and notify the physician if the resident did not meet the criteria for antibiotic therapy, and alternative interventions should be considered prior to initiating antibiotics. A review of the facility's policy and procedure titled, Antibiotic Stewardship dated December 2016, indicated .1. The purpose of our antibiotic stewardship program is to monitor the use of antibiotics in our residents .4. If an antibiotic is indicated, prescribers will provide complete antibiotic orders including the following elements. d.Duration of treatment: (1) Start and stop date; or (2) Number of days of therapy.2. A review of Resident 2's admission Record indicated Resident 2 was re-admitted to the facility on [DATE] with diagnoses which included history of Parkinson's (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements).A record review of Resident 2's minimum data set (MDS - a federally mandated resident assessment tool) dated 12/12/25 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 13 points out of 15 possible points which indicated Resident 2 had moderate cognitive (pertaining to memory, judgement and reasoning ability) deficits. On 3/4/26 at 1:46 P.M., an interview and record review was conducted with the Infection Prevention (IP) nurse. The IP nurse stated Resident 2 complained of dysuria (difficulty urinating) on 2/2/26 and had a urinalysis (medical test for urine) completed on 2/3/26 which indicated the presence of .many bacteria. LN 2 stated Resident 2 was prescribed Cefuroxime Axetil 250 mg for seven days beginning 2/4/26 through 2/11/26 for treatment of a suspected UTI. The IP nurse stated Resident 2 was at baseline incontinent (the involuntary or accidental leakage of urine/bladder control or feces/bowel control) and did not have a urinary catheter at the time symptoms were reported.On 3/5/26 at 1:42 P.M., a follow-up interview and record review was conducted with the Infection Prevention (IP) nurse. The IP nurse stated only one progress note dated 2/10/26 at 22:30 (10:30 P.M.) documented monitoring of UTI symptoms, which stated, .Continue on ABT for UTI. no c/o bladder discomfort. The IP nurse stated nursing staff should monitor and document signs and symptoms of UTI throughout the duration of antibiotic therapy to evaluate the effectiveness of treatment and ensure antibiotics were used appropriately. The IP nurse stated that the clinical document titled Infection Screening Evaluation was not completed prior to initiating antibiotic therapy to determine whether Resident 2 met diagnostic criteria for UTI according to the McGeer (a standardized set of rules to determine if a resident has a true UTI) criteria. The IP nurse further stated no consistent monitoring for UTI symptoms was documented during the course of antibiotic treatment.On 3/5/26 at 2:41 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated the facility expected staff to follow appropriate clinical criteria and physician diagnosis when initiating antibiotic therapy. The DON stated it was important to follow McGreer criteria when evaluating residents for UTI prior to initiating antibiotics. The DON further stated when a new antibiotic order was received, the IP nurse should complete the Infection Screening Evaluation and notify the physician if the resident did not meet the criteria for antibiotic therapy, and alternative interventions should be considered prior to initiating antibiotics.A review of the facility's policy and procedure titled, Antibiotic Stewardship dated December 2016, indicated .1. The purpose of our antibiotic stewardship program is to monitor the use of antibiotics in our residents .3. A review of Resident 3's admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses which included history of Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing).A record review of Resident 3's minimum data set (MDS - a federally mandated resident assessment tool) dated 1/29/26 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 13 points out of 15 possible points which indicated Resident 3 had moderate cognitive (pertaining to memory, judgement and reasoning ability) deficits. On 3/4/26 at 2:49 P.M., an interview and record review was conducted with the Infection Prevention (IP) nurse. The IP nurse stated Resident 3's physicians (MD) order Ciprofloxacin 500mg started on 2/8/26 through 2/15/26 for a suspected UTI for confusion and a urinalysis showing a colony count (measure of bacteria) greater than 100,000 Escherichia (ecoli- bacteria found in the gut). The IP nurse stated according to McGeer (a standardized set of rules to determine if a resident has a true UTI) criteria, residents without an indwelling catheter must exhibit two or more clinical symptoms in addition to a positive culture to support the diagnosis of UTI, and confusion alone did not meet the diagnostic criteria for initiating antibiotic therapy. The IP nurse stated McGeer criteria should be used to evaluate whether a resident has a true infection prior to initiating antibiotic therapy. The IP nurse stated that the clinical document titled Infection Screening Evaluation was not completed and should have been completed to ensure antibiotics were prescribed appropriately and to reduce the risk of antibiotic resistance and additional infections.On 3/5/26 at 2:41 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated the facility expected staff to follow appropriate clinical criteria and physician diagnosis when initiating antibiotic therapy. The DON stated it was important to follow McGreer criteria when evaluating residents for UTI prior to initiating antibiotics. The DON further stated when a new antibiotic order was received, the IP nurse should complete the Infection Screening Evaluation and notify the physician if the resident did not meet the criteria for antibiotic therapy, and alternative interventions should be considered prior to initiating antibiotics.A review of the facility's policy and procedure titled, Antibiotic Stewardship dated December 2016, indicated .1. The purpose of our antibiotic stewardship program is to monitor the use of antibiotics in our residents .

Based on interview, and record review the facility failed to ensure the use of unnecessary drugs by administering antibiotics without adequate indication, monitoring or appropriate duration, for two of three sampled residents (Resident 1, Resident 2, and Resident 3) reviewed from 12 residents identified on the Infection Preventionist (IP) list of health-care associated infection (HAI-infections acquired at the facility) for urinary tract infections (UTI- an infection in the bladder/urinary tract) when:1. Resident 1 received an order for an antibiotic on 1/9/26 for Macrobid (a commonly prescribed antibiotic used specifically to treat bacterial urinary tract infections) without supporting documentation for monitoring UTI symptoms and/or side effect monitoring. Resident 1 received two antibiotics Levofloxacin (used to treat bacterial infections in many different parts of the body) for UTI and Methenamine Hippurate(an antibiotic used to prevent or treat recurring urinary tract infections) for infection prophylaxis (prevention) both ordered on 2/11/26; however, the infection screening dated 2/11/26 documented no symptoms of infection with an evaluation score of 0 (no infection symptoms). Despite the absence of an infection screening evaluation confirming a UTI diagnosis, and the Methenamine Hippurate order did not include a documented diagnosis supporting infection prophylaxis (prevention) or a stop date.2. Resident 3 was prescribed an antibiotic (Ciprofloxacin- antibiotic used to treat serious bacterial infections) order on 2/8/26 for a suspected UTI; however clinical documentation indicated the antibiotic was initiated based on confusion, which did not meet the diagnostic criteria for UTI. In addition, no infection screening evaluation was completed prior to initiating antibiotic therapy, and no monitoring of UTI symptoms and side effects during the course of antibiotic therapy, indicating the medication was initiated and continued without adequate clinical indication or appropriate monitoring, consistent with unnecessary drug use.Findings:1. A review of Resident 1's admission Record indicated Resident 1 was re-admitted to the facility on [DATE] with diagnoses which included history of quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury) and immunodeficiency (group of conditions that make it hard for the body to fight infections).A record review of Resident 1's minimum data set (MDS - a federally mandated resident assessment tool) dated1/28/26 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 15 points out of 15 possible points which indicated Resident 1 had no (pertaining to memory, judgement and reasoning ability) deficits. On 3/4/26 at 1:35 P.M., an interview and record review was conducted with the Infection Prevention (IP) nurse. The IP nurse stated the facility tracked residents with UTIs using an infection surveillance list and monitored infections through infection tracking and mapping. The IP stated the facility used a clinical document titled Infection Screening Evaluation to assess and/or evaluate residents for signs and symptoms of infection prior to initiating antibiotic therapy as part of the facility's infection prevention and antibiotic stewardship program. The IP nurse stated Resident 1 had a suprapubic catheter and a history of recurrent UTI's and had a care plan which had addressed risk for infection dated initiated 2/6/26. The IP nurse stated Resident 1's Infection Screening Evaluation was completed on 2/11/26 that indicated no symptoms consistent with UTI.On 3/5/26 at 1:13 PM a follow-up interview and record review was conducted with the IP nurse. The record reviews indicated:Resident 1's clinical document titled, Infection Screening Evaluation showed scores of 50 (symptom/s of infection) on 1/12/26 with acute dysuria (one symptom for UTI) and was manually triggered (regardless of score) to indicate active infection. Resident 1's urine culture on 1/9/26 indicated, .Gram Positive Cocci [round bacteria that turn purple under a microscope when stained, indicating a thick, protective outer layer] Colony count 50,000-90,000. Resident 1's physicians (MD) order Macrobid 100 mg was started on 1/9/26 through 1/16/26 for the treatment of UTI. No supporting documentation for monitoring UTI symptoms and/or side effect monitoring for antibiotic use.Resident 1's clinical document titled, Infection Screening Evaluation showed a score of zero on 2/11/26 (no symptom of infection). Resident 1's urine culture result on 1/9/26 indicated .Gram Positive Cocci Colony count 50,000-90,000.; despite this Resident 1 was prescribed Levofloxacin 250 mg on 2/10/26 through 2/17/26 for UTI and Methenamine Hippurate 1 gram for infection prophylaxis without a stop date. No supporting documentation for monitoring UTI symptoms and/or side effect monitoring for antibiotic use.The IP nurse stated Resident 1 should have been monitored for signs and symptoms of UTI during antibiotic therapy, which included the time when receiving Macrobid and Levofloxacin. The IP further stated Resident 1's MD order Methenamine Hippurate should have included a stop date and the diagnosis of infection prophylaxis required clarification, as it did not identify specific symptoms or criteria for monitoring. The IP nurse stated antibiotics should have a defined duration and monitoring plan to prevent inappropriate antibiotic use and reduce the risk of antibiotic resistance and infection.On 3/5/26 at 2:41 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated the facility expected staff to follow appropriate clinical criteria and physician diagnosis when initiating antibiotic therapy. The DON stated it was important to follow McGreer (a standardized set of rules to determine if a resident has a true UTI) criteria when evaluating residents for UTI prior to initiating antibiotics. The DON further stated when a new antibiotic order was received, the IP nurse should complete the Infection Screening Evaluation and notify the physician if the resident did not meet the criteria for antibiotic therapy, and alternative interventions should be considered prior to initiating antibiotics.A review of the facility's policy and procedure titled, Urinary Tract infection/Bacteriuria - Clinical Protocol dated April 2018, indicated .Nurses should observe, document, and report signs and symptoms (for example, fever or hematuria) in detail and avoid premature diagnostic conclusions.When a resident has a persistent or recurrent urinary tract infection after treatment with antibiotics, the physician will review the situation carefully with the nursing staff and consider other or additional issues (such as urinary obstruction or indwelling catheter change or removal) before prescribing additional courses of antibiotics.Physicians should justify continuing or resuming antibiotic treatment beyond an initial course.2. A review of Resident 3's admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses which included history of Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing).A record review of Resident 3's minimum data set (MDS - a federally mandated resident assessment tool) dated 1/29/26 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 13 points out of 15 possible points which indicated Resident 3 had moderate cognitive (pertaining to memory, judgement and reasoning ability) deficits. On 3/4/26 at 2:49 P.M., an interview and record review was conducted with the Infection Prevention (IP) nurse. The IP nurse stated Resident 3's physicians (MD) order Ciprofloxacin 500mg started on 2/8/26 through 2/15/26 for a suspected UTI for confusion and a urinalysis showing a colony count (measure of bacteria) greater than 100,000 Escherichia (ecoli- bacteria found in the gut). The IP nurse stated according to McGeer (a standardized set of rules to determine if a resident has a true UTI) criteria, residents without an indwelling catheter must exhibit two or more clinical symptoms in addition to a positive culture to support the diagnosis of UTI, and confusion alone did not meet the diagnostic criteria for initiating antibiotic therapy. The IP nurse stated McGeer criteria should be used to evaluate whether a resident has a true infection prior to initiating antibiotic therapy. The IP nurse stated that the clinical document titled Infection Screening Evaluation was not completed and should have been completed to ensure antibiotics were prescribed appropriately and to reduce the risk of antibiotic resistance and additional infections.On 3/5/26 at 2:41 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated the facility expected staff to follow appropriate clinical criteria and physician diagnosis when initiating antibiotic therapy. The DON stated it was important to follow McGreer criteria when evaluating residents for UTI prior to initiating antibiotics. The DON further stated when a new antibiotic order was received, the IP nurse should complete the Infection Screening Evaluation and notify the physician if the resident did not meet the criteria for antibiotic therapy, and alternative interventions should be considered prior to initiating antibiotics.A review of the facility's policy and procedure titled, Urinary Tract infection/Bacteriuria - Clinical Protocol dated April 2018, indicated .Nurses should observe, document, and report signs and symptoms (for example, fever or hematuria) in detail and avoid premature diagnostic conclusions. New onset of nonspecific or general symptoms alone ( change in mental status, decline in appetite, etc.) is not enough to diagnose a UTI.

Based on observation, interview, and record review the facility failed to protect and keep private residents' Protected Health Information (PHI- refers to any individual identifiable health information that is created, received, stored or transmitted by a healthcare provider which includes demographic data, medical history, test results, and payment information and this information is protected under HIPPA-the Health Insurance Portability and Accountability Act of 1996) for 59 of 194 residents when it posted lists of residents' Enhanced Barrier Precautions (EBP) in the 2nd, 3rd, and 4th floor shower rooms.This failure did not protect the residents' medical privacy and had the potential to allow residents' PHI to be seen by anyone going into the shower room. Findings:On 1/9/26 at 10:35 A.M., a concurrent observation of the 3rd floor shower room and interview with Certified Nursing Assistant 5 (CNA) was conducted. A document titled 3rd Floor EBP was posted on the shower mirror when entering the room. This document contained 23 resident names with room numbers and reason for EBP. CNA 5 stated that the list was a list for EBP patients to remind the staff about needed personal protective equipment (PPE-gowns, gloves, mask, face shield) when residents were showered. CNA 5 stated she thought the Infection Preventionist (IP) hung the lists. CNA 5 stated that residents' private information should not be posted in public areas because anyone could come in and read the information. CNA 5 stated that residents' private information should be protected.On 1/9/26 at 10:45 A.M., a concurrent observation of 2nd floor shower room and interview with CNA 6 was conducted. A document titled 2nd Floor EBP was posted on the shower mirror when entering the room. This document contained 16 resident names with room numbers and the reason for EBP. CNA 6 stated that the list was a list for EBP patients to remind them who needed PPE when being showered. CNA 6 stated that residents' private information should not be posted in public areas because anyone could come in and read the information. CNA 6 stated that residents' private information should be protected for their privacy and respect.On 1/9/26 at 10:55 A.M., a concurrent observation of the 4th floor shower room and interview with CNA 7 was conducted. A document titled 4th Floor EBP was posted on the shower mirror when entering the room. This document contained 20 resident names with room numbers and reason for EBP. CNA 7 stated that the list was a list for EBP residents. CNA stated that residents' private information should not be posted in public areas because anyone could come in and read the information. CNA stated that residents' private information should be protected for their privacy.On 1/9/26 at 11:05 A.M., a concurrent observation of 4th floor shower room and interview with Quality Assurance Nurse (QAN) was conducted. QAN stated that the list was for EBP patients to remind the staff about needed PPE when residents were showered. QAN stated that residents' private information should not be posted in public area because anyone could come in and read the information. QAN stated that residents' private information should be protected for their privacy.On 1/9/26 at 11:20 A.M., an interview with Licensed Nurse (LN) 2 about the EBP list in shower room [ROOM NUMBER] was conducted. LN 2 stated that residents' private information should not be posted in public areas because anyone could come in and read the information. LN 2 stated that residents' private information should be protected for their privacy.On 1/9/26 at 11:35 A.M., an interview with LN 3 about the EBP list in shower room [ROOM NUMBER] was conducted. LN 3 stated that residents' private information should not be posted in public areas because anyone could come in and read the information. LN 3 stated that residents' private information should be protected for their privacy.On 1/9/26 at 12:05 P.M., an interview with RN 3 about the EBP list in shower room [ROOM NUMBER] was conducted. RN 3 stated that residents' private information should not be posted in public areas because anyone could come in and read the information. RN 3 stated that residents' private information should be protected for their privacy.On 1/9/26 at 12:20 P.M., an interview with RN 4 was conducted about the EBP list in shower room [ROOM NUMBER]. RN 4 stated that residents' private information should not be posted in public areas because anyone could come in and read the information. RN 4 stated that residents' private information should be protected for their privacy.On 1/9/26 at 12:45 P.M., an interview with RN 5 about the EBP list in shower room [ROOM NUMBER], was conducted. RN 5 stated that residents' private information should not be posted in public areas because anyone could come in and read the information. RN 5 stated that residents' private information should be protected for their privacy.On 1/9/26 at 1:10 P.M., an interview with LN 4 about the EBP list in shower room [ROOM NUMBER] was conducted. LN 4 stated that residents' private information should not be posted in public area because anyone could come in and read the information. LN 4 stated that residents' private information should be protected for their privacy.On 1/9/26 at 1:15 P.M., an interview with the IP about the list in shower room [ROOM NUMBER], was conducted. The IP stated that residents' private information should not be posted in a public area because anyone could come in and read the information. The IP stated that residents' private information should be protected for their privacy.On 1/13/26 at 1:36 P.M., an interview with the Director of Nursing (DON) was conducted. The DON stated the expectation is that PHI should not be posted in a public area like a shower room. The DON stated the importance of keeping PHI private was to keep it in a secured area to protect the residents' private information from being disclosed to the public.RR of facility policy titled Residents Rights, dated 2001, indicated Federal and stated laws guarantee certain basic rights to all residents of this facility. These include the resident's right to: .3. The unauthorized release, access, or disclosure of resident information is prohibited. All release, access, or disclosure of resident information must be in accordance with current laws governing privacy of information issues. All inquiries concerning the release of resident information should be directed to the HIPPA compliance officer.RR of facility policy titled Protected Health Information (PHI), Management and Protection of, dated 2001, indicated .1. It is the responsibility of all personnel who have access to resident and facility information to ensure that such information is managed and protected to prevent unauthorized release or disclosure.4. When using or disclosing PHI.reasonable efforts must be made to limit the PHI used or disclosed to the minimum necessary to accomplish the purpose of the use or disclosure of such information.

Based on observations, interviews and record review the facility failed to maintain a homelike environment for four of nine residents (3,4,5,16) when it did not fix leaking ceilings and windows in resident rooms 417,421, and 425.This failure created hazardous non-homelike environment for the affected residents when it rained.Findings:On 1/2/26 between 2 P.M and 4:10 P.M, a concurrent interview with the Director of Maintenance (DOM) and tour of the facility's kitchen, the 2nd, 3rd, and 4th floor residents' room was conducted. All resident rooms on each floor were observed and alert residents were interviewed. The DOM stated that they (the facility) just got a new roof, and the only leak that staff had told him about was the leak in the 3rd floor dining room, and it was fixed by resealing the sliding glass door with caulk. A tour of the fourth floor was conducted and three rooms (417, 421, 425) had severe leaks from the ceiling when it rained on 12/31/25 per the residents interviewed (Resident 3, 4, 5, 16).Record review of admission Record for Resident 3 indicated she was admitted on [DATE] for diagnoses which included: Fracture of right femur (broken large leg bone), Fall, Atrial Fibrillation (a common heart condition where the heart's upper chambers beat irregularly, rapidly, and out of sync with the lower chambers), and Chronic Kidney Disease (a long-term condition where the kidneys become damaged and lose the ability to filter waste and excess fluid from the blood effectively).Record review of Brief Interview For Mental Status (BIMS-Test used to test thinking), dated 11/1/25, for Resident 3 indicated a score of 11, which indicated moderate cognitive impairment.On 1/2/26, at 2:20 P.M., a concurrent interview with Resident 3 and observation of room [ROOM NUMBER] 's bathroom was conducted. Resident 3 was alert, oriented, and lying in bed. Resident 3 stated that she had been at the facility for four months and this is the first time that they had problems with flooding in the bathroom. Resident 3 stated The floor was very wet last night, and staff had to put down lots of towels to absorb the water. Water damage was observed on bathroom ceiling with wet spots and some towels on floor. Resident 3 stated that the flooding and water damage were not homelike. The DOM stated he was not aware of damage in observed area.Record review of admission Record for Resident 4 indicated she was admitted on [DATE] for diagnoses which included: Neuropathy( damage or dysfunction of one or more nerves ), Rheumatoid Arthritis (a chronic, systemic autoimmune disease where the immune system mistakenly attacks the lining of joints, causing inflammation, pain, swelling, and stiffness), and Fibromyalgia (a chronic disorder causing widespread musculoskeletal pain, fatigue, sleep disturbances, and cognitive(thinking) issues, stemming from altered pain processing in the central nervous system).Record review of BIMS for Resident 4, dated 10/14/25, indicated a score of 12, which indicated moderate cognitive impairment.On 1/2/26 at 2:25 P.M., a concurrent interview with Resident 4 and observation of room [ROOM NUMBER]'s bathroom was conducted. Resident 4 was alert, oriented, and lying in bed. Resident 4 stated that the bathroom was flooded last night and staff had to place lots of towels down to soak up the water. Resident 4 stated that the water on the floor last night was dangerous and not homelike. Resident 4's bathroom showed signs of water damage and paint bubbling to the ceiling.Record review of admission Record for Resident 5 indicated she admitted on [DATE] for diagnoses which included: Acute Kidney Failure (the sudden loss of kidney function, usually over hours to days), Rheumatoid Arthritis, and Depression (a serious mood disorder causing persistent sadness and loss of interest, affecting thoughts, feelings, and daily functioning for at least two weeks).Record review of BIMS for Resident 5, dated 10/14/25, indicated a score of 15, which indicated intact cognition.On 1/2/26 at 2:30 P.M., a concurrent interview with Resident 5 and observation of room [ROOM NUMBER]'s outer wall was conducted. Resident 5 was alert, oriented, and sitting in her wheelchair next to her bed. Resident 5 stated that her roommate in bed C, by the wall was complaining of the wall leaking water a lot last night. Resident 5 stated staff had to put down lots of towels to absorb the water that had leaked down on the floor. No standing water was observed in room at time of observation. Resident 5 stated that the leaking wall was not homelike and could have been dangerous if someone slipped on it.On 1/2/26 at 3:20 P.M., an observation of the 3rd floor dining and interview with the DOM was conducted. The DOM stated that there was a complaint of a leak at the sliding door that led to outdoor patio, as water had leaked through the sliding glass door, the DOM stated that they applied new sealant that day that stopped the leak. Large fans were observed blowing in the room.On 1/2/26 at 4:20 P.M., a concurrent interview with the Director of Maintenance (DOM) and record review of maintenance binder for 4th floor was conducted. The DOM stated that his Maintenance Workers (MW) round daily, but they did not detect the water damage for rooms [ROOM NUMBERS], but room [ROOM NUMBER] was reported on 12/31/25 by a Certified Nursing Assistant (CNA). Review of the 4th floor maintenance binder indicated no maintenance entries about the leaks. The DOM stated that the areas with leaks should have been reported to him and documented in the log.On 1/2/26 at 4:45 P.M. an interview with Registered Nurse (RN) 1 was conducted. RN 1 stated that if he saw the leaking ceiling, he would first try to control the water to prevent slipping with towels. RN 1 stated that that process for reporting leaking ceilings to maintenance and repair is to contact maintenance by phone or Teams app, then write in the maintenance binder. RN 1 stated that leaking ceilings were not homelike and could be a slipping hazard for residents.On 1/2/26 at 4:55 P.M. an interview with RN 2 was conducted. RN 2 stated that if she saw there was a leak, she would first try and move residents from the area affected then control water with towels. RN 2 stated that that process for reporting problems to maintenance was to contact maintenance by phone or Teams app, then write in the maintenance binder. RN 2 stated that leaking ceilings and water damaged walls were not homelike.On 1/2/26 at 5:05 P.M., an interview was conducted with CNA 2. CNA 2 stated that if the ceiling was leaking, she would attempt to soak up the water with towel, make her charge nurse aware then call maintenance then document in maintenance binder. CNA 2 stated leaking ceilings and flooding were not homelike.On 1/2/26 at 5:15 P.M., an interview with CNA 3 was conducted. CNA 3 stated that if she saw a leaking ceiling she would move the residents from the are that was flooded, then try and mop up the water with towels, then call maintenance and document in the maintenance binder. CNA 3 stated that leaking ceilings were not homelike or safe.On 1/2/26 at 5:30 P.M., an interview with RN 1 was conducted. RN 1 stated that if she saw a leaking ceiling she would first move affected residents and then try to control the water by putting down towels, RN 1 stated she would contact maintenance via Teams app or by phone to let them know there was a leak, then write in the maintenance binder. RN 1 stated that leaking ceilings and flooded bathrooms are not homelike.On 1/2/26 at 5:45 P.M., an interview with CNA 4 was conducted. CNA 4 stated that if the ceiling was leaking water she would first move affected residents, then try to soak up the water with towels, then call maintenance, and document in maintenance binder. CNA 4 stated that the expectation was to keep the floor dry and non-slippery. CNA 4 stated leaking ceilings were not homelike.On 1/6/26 at 3:50 P.M., an interview with CNA 1 was conducted. CNA 1 stated that if she saw a leaking ceiling she would move the residents from the are that was flooded, then try and mop up the water with towels, then call maintenance, and then document in maintenance binder. CNA 1 stated that leaking ceilings were not homelike or safe.Record review of admission record for Resident 16 indicated she was admitted on [DATE] with diagnoses which included: Fall, Chronic Obstructive Pulmonary Disease (is a progressive lung disease causing airflow limitation, characterized by persistent breathing difficulties), Congestive Heart Failure a chronic condition where the heart muscle weakens or stiffens, failing to pump blood efficiently enough to meet the body's needs, causing a backup of blood and fluid ).Record review of BIMS dated 10/22/25, for Resident 16 indicated a score of 11, which indicated moderate cognitive impairment.On 1/9/26 at 10:10 A.M., an observation of room [ROOM NUMBER]'s bathroom and interview with Resident 16 was conducted. Resident 16 was alert, oriented, and agreeable to interview. Resident 16 was in bed. Resident 16 stated . there was a lot water on the floor last week, they had to put down big towels, and no one could go in the bathroom, staff put towels from the wall to the toilet to the door, but it didn't come out of the bathroom. Resident 16 stated the leaking ceilings and flood were not homelike.On 1/9/26 at 11:50 A.M., a concurrent interview with Maintenance Worker (MW) 1 and record review of maintenance binder for 4th floor was conducted. MW 1 stated I check the maintenance book every day. Staff should write in the book the problems and type of maintenance or repair done, and I sign off when it's completed. MW 1 stated that could not find any entries in the 4th floor maintenance binder about the leaking ceilings or flooded resident bathrooms in 417, 421, or 425. MW stated .the DOM sends him texts about what he needed to fix. MW 1 stated the repairs should also be documented in the maintenance binder because there would be no way to know if a repair was made. MW 1 stated the expectation is staff should report the needed repair by call or teams and write in the maintenance binder, and the DOM will text him what needed to be repaired. MW stated the importance of clear communication between maintenance workers is to keep the residents safe and maintain a homelike environment.On 1/9/26 at 1:50 P.M., an interview was conducted with the DOM. The DOM stated that leaking ceilings are not homelike and can be dangerous. The DOM stated the expectation is for staff to call him about any flooding or free water or leaks via Teams app and to document it on the maintenance binder. The DOM stated the importance of reporting required maintenance and documenting it in maintenance binder is to make sure repairs are done in a timely manner. The DOM stated the importance of clear communication between maintenance workers is to keep the residents safe and maintain a homelike environment.On 1/9/26 at 2 P.M., an interview with the Administrator (ADM) was conducted. The ADM stated the leaking ceilings and water damage walls are not homelike. The ADM stated that the facility should be aware of any leaks in the ceiling and they should be repaired immediately. The ADM stated that the DOM should be aware of all repairs that should need immediate attention. The ADM stated the importance of timely repair of leaking ceilings is to prevent slip hazards for the safety of residents and staff.Record review of facility policy Homelike Environment dated 2001 indicated Residents are provided with a safe, clean, homelike environment.2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. clean, sanitary, and orderly environment.

Based on observation, interview and record review the facility failed to identify a resident's behavior of hitting and yelling at staff and residents for one of two residents reviewed for behavioral disturbances. (Resident 1) This failure had the potential for Resident 1 to have further altercations with other residents of the facility and a potential safety risk for Resident 1.Findings: On 11/26/25 at 8:23 A.M. and on 12/12/25 at 8:25 A.M., an unannounced onsite visit at the facility was conducted related to a reported resident to resident altercations. A review of the facility's five-day (5-day) summary investigation dated 11/17/25 was conducted. The 5-day summary indicated Resident 1 entered another resident's room and grabbed the other resident's walker on 11/14/25. The 5-day summary indicated the other resident initiated physical contact with Resident 1's left inner arm to protect his space. A review of the facility's five-day (5-day) summary investigation dated 12/1/25 was conducted. The 5-day summary indicated Resident 1 struck another resident on the head with her cane. Resident 1 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease (a brain disorder that slowly destroys memory, thinking skills and eventually the ability to carry out simple tasks) with late onset and cerebral infarction (disrupted blood flow to the brain, a stroke) according to the facility's admission Record. During an observation and interview on 11/26/25 at 8:36 A.M. with Resident 1, Resident 1 was sitting at the edge of her bed with Certified Nurse Assistant (CNA) 1 at bedside. Resident 1 was smiling and stated she had no problems with any of the other residents in the facility. Resident 1 stated she did not get upset with anyone in the facility and had not hit anyone. An interview on 11/26/25 at 8:38 A.M. was conducted with CNA 1. CNA 1 stated Resident 1 had behavioral problems. CNA 1 stated Resident 1 got up from bed frequently, walked down the hall, told staff or other residents what to do and yelled at others which made other residents angry. During an interview on 11/26/25 at 8:44 A.M. with Licensed Nurse (LN) 2, LN 2 stated Resident 1 used her cane to try to hit others and yelled at other residents. LN 2 stated Resident 1 needed close monitoring even prior to the resident-to-resident altercation on 11/14/25. A review of Resident 1's care plans (CP) were conducted. CP dated 11/14/25 indicated, Resident is at risk for alteration/psychosocial distress r/t [related to] alleged victim of abuse .Resident exhibits episodes of wandering in hallways and entering rooms.at risk for behavioral symptoms such as combative, verbally or physically abusive to due diagnosis of Dementia [a condition characterized by loss of memory, language, problem solving and other thinking abilities] There was no care plan regarding Resident 1's behaviors prior to 11/14/25. During a review of the Order Summary Report for Resident 1, the Order Summary Report indicated, Monitor episodes of behavior AEB [as evidenced by] physical aggression every shift for 3 Days.Order Date 11/15/25.End Date 11/18/25. There were no other behavior monitoring prior to Resident 1's altercation on 11/14/25. During a review of Resident 1's Minimum Data Set (MDS- a clinical assessment tool) dated 11/7/25, the MDS indicated zeros (no behaviors) in section E0200A physical behavioral symptom and E0200B verbal behavioral symptoms. An interview on 11/26/25 at 11:19 A.M. with the social service assistant (SSA) was conducted. The SSA stated she completed Resident 1's MDS but did not interview staff and was not aware of Resident 1's behavior. An interview was conducted on 11/26/25 at 11:31 A.M. with the Quality Assurance (QA-) nurse. The QA nurse stated Resident 1's behaviors should have been identified and care planned to determine how to care for the resident. A review of the facility's policy and procedure (P&P) titled, Behavioral Assessment, Intervention, and Monitoring, dated February 2025 was conducted. The P&P indicated, As part of the comprehensive assessment, staff evaluate [based on input from the resident, family and caregivers, review of the medical record, and general observations].the resident's usual patterns of cognition, mood, and behavior.The IDT [Interdisciplinary Team-team members with various areas of expertise who work together toward the goals of their residents] evaluates behavioral symptoms in residents to determine the degree of severity, distress, and potential safety risk to the resident, and develops a plan of care accordingly.

Based on observation, interview and record review, the facility failed to administer pain medication for one of two residents (Resident 1) in a timely manner. This failure placed Resident 1 at risk of unnecessary pain. Findings: Resident 1 was admitted to the facility on [DATE]and 8/21/25 with diagnoses to include right trochanteric bursitis (inflammation of the hip joint), type 2 diabetes, chronic pain syndrome according to the facility's admission Record. According to the physician History and Physical Examination (H&P) dated 8/22/25, indicated Resident 1 has the capacity to understand and make decisions. On 9/9/25 at 2:22 P.M., concurrent observation and interview was conducted with Resident 1. Resident 1 stated on 9/5/25 around 2 A. M., she was in severe pain and asked for pain pill multiple times. Resident 1 stated she was not given pain medication at that time. Resident 1 stated there was a lack of communication between the employees. On 9/9/25 at 3:08 P.M., a concurrent interview and record review was conducted with Licensed Nurse (LN) 1. According to the physician orders, Resident 1 received Hydrocodone-acetaminophen 10-325 milligrams (mg), give two tablets by mouth every 8 hours as needed for moderate pain (pain scale 4 to 6 out of a possible 10 as the worst pain) and Oxycodone 10 mg, give 1 tablet by mouth every 4 hours as needed for sever pain ( pain scale 7 to10 and 10 as the worst pain). According to the electronic Medication Administration Record (eMAR), Hydrocodone-acetaminophen 10-325 mg was last administered on 9/4/25 at 6:01 P.M. and 9/5/25 at 4:40 A.M. According to the electronic Medication Administration Record (eMAR), Oxycodone 10 mg was last administered on 9/4/25 at 8:50 P.M. and 9/5/25 at 8:27 A.M. During this interview and record review, LN 2 acknowledged there was an opportunity to provide pain medication around 9/5/25 12AM to 2 AM window. There was no pain medication at around 2 A.M. On 9/9/25 at 4:26 P.M. an interview with LN 2 was conducted with the Quality Assurance Nurse (QA) present. LN 2 stated around 2 AM, Resident 1 was asking for pain medications, but the medication nurse assigned to Resident 1 was on break and did not endorse her medication cart keys. LN 2 stated there was no pain medication given to Resident 1 at that time. LN 2 stated around 3 A.M., the medication nurse assigned to Resident 1 returned, but LN 2 forgot to inform the medication nurse assigned to Resident 1 that Resident 1 was asking for pain medications. LN 2 stated there was no pain medication given to Resident 1 at that time. LN 2 stated around 4 A.M., Resident 1 awakened and was asking for pain medication. The medication nurse assigned to Resident 1 was not available for interview. On 9/9/25 at 4:45 P.M., a concurrent interview and record review was conducted with QA Nurse.The QA Nurse stated LN 2 did not have the medication cart keys and LN 2 forgot to endorse Resident 1's request for pain medication to the assigned LN to Resident 1. QA Nurse stated the expectation when Resident 1 complained of pain and requested a pain medication, LNs should check the physician orders and offer what was available in the emergency kit. The QA nurse stated Resident 1's pain should be addressed in a timely manner for patient comfort.During this interview and record review, QA Nurse acknowledged there was an opportunity to provide pain medication around 9/5/25 12AM to 2 AM window.

Based on observation, interview and record review, the facility failed to provide resident safety when a resident (Resident 1) eloped form the facility without staff being aware. As a result, Resident 1 had successful elopement and was found on 8/19/25. Findings: On 8/18/25 the Department of Public Health received a report of elopement for Resident 1 at 8/16/25 and facility search done at 10 P.M. per the report. During a review of Resident 1's facility record on 8/17/25 at 1:23 P.M. indicated .Resident left facility without MDs [doctor's] order, not informing staffs or signing out.received a report that Resident left the unit around lunch time. Resident does walk throughout building on a daily basis. Resident has not back yet, unknow location at this time. Staff has searched the building and surrounding neighborhood.Observed that established history of walking throughout the premises and able to go back to his room, ambulate around with no assistance. A building-wide search was promptly initiated.but the he could not be located. On 8/19/25 at 12 P.M., an observation of the facility was conducted. The facility building has three entrances/exit. The entrance/exit included the front lobby, the side entrance/exit by the parking area and at the back. On 8/19/25 at 12:10 P.M. an interview with the Quality Assurance Nurse (QA). The QA stated Resident 1 was last seen on 8/16/25 around lunch time. QA stated Resident 1 was last seen around 12:18 P.M. using the elevator. On 8/19/2025 at 12:53 P.M., an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated Resident 1 was independent. CNA 1 stated Resident 1 roam around and used elevator. On 8/19/25 at 2:03 P.M., an interview with Receptionist 1 was conducted. Receptionist 1 stated facility front entrance/exit opened from 8 A.M. to 8 P.M. Receptionist 1 stated some residents could be in the front lobby by the front entrance/exit. Receptionist 1 stated licensed nurse would inform me when residents would need supervision or could be by themselves. Receptionist 1 stated there were two elopements last week. On 8/19/25 at 4:10 P.M., an interview with the Administrator (ADM) and QA was conducted. The ADM stated there were three elopements in the last six (6) months and the two elopements occurred this month. ADM stated there three were entrances/exits in the building. QA stated the back entrance/exit was locked. ADM stated the facility would increase surveillance. ADM stated Resident 1's elopement happened on the weekend when there were less staff. QA stated nobody saw Resident 1 leaving the building. QA stated her expectation was to make sure elopement would not occur again for resident safety.

Based on observation, interview and record review, the facility failed to ensure the presence of a full-time Director of Nursing (DON) to manage and oversee nursing services. This deficient practice placed all 188 residents at risk for uncoordinated care, delays in addressing clinical concerns, and inconsistent implementation of nursing policies and procedures. On 7/23/25 10:30 A.M., a complaint investigation was initiated with the Administrator (ADM). The ADM stated the facility did not have a Director of Nursing (DON) and would be assisted by the Quality Assurance (QA) nurse for any assistance during the complaint investigation. On 7/23/25 at 1:22 P.M., an interview was conducted with LN 2. LN 2 stated we don't have a full-time DON yet. LN 2 stated the QA nurse was the former DON. On 7/24/25 at 4:02 P.M., an interview was conducted with the Director of Staff Development (DSD). The DSD stated she had only been working as a DSD for one month, so she was not sure if the facility was short or had any staffing waivers. The DSD stated the facility did not have a DON. On 7/30/25 at 10:06 A.M., an interview was conducted with the QA nurse. The QA nurse stated, we are still interviewing and in the process of hiring a full-time DON. The QA nurse stated they have a consultant who is available for the facility but was not present during the first day of the complaint investigation (7/23/25). The QA nurse stated it was important to have a full-time DON because the DON oversees the clinical care of residents' care planning and coordination for the safety and well-being of residents by addressing clinical concerns. A review of the facility's policy and procedure titled DIRECTOR of NURSING SERVICES (DNS) dated August 2022, indicated .1. The director is employed full-time (40-hours per week) and is responsible for, but is not necessarily limited to: a. developing and periodically updating the nursing service objectives and statements of philosophy; b. overseeing standards of nursing practice.

Based on interview, and record review, the facility failed to supervise residents who smoke according to resident's smoking assessment for one of three sampled residents (Resident 2).As a result, Resident 2 was not supervised as required, which could have led to potential safety risks for smoke related injuries and for other residents who smoke.A review of Resident 2's admission Record indicated Resident 2 was re-admitted to the facility on [DATE] with diagnoses which included a history of hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness of the arm, leg and trunk on the same side of the body) affecting the left side of the body. A record review of Resident 2's minimum data set (MDS - a federally mandated resident assessment tool) dated 6/30/25 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 14 points out of 15 possible points which indicated Resident 14 had no cognitive (pertaining to memory, judgement and reasoning ability) deficits. On 7/23/25 at 12:47 P.M., an interview was conducted with Resident 1, in Resident 1's room. Resident 1 had a MDS dated [DATE] BIMS score of 14 which indicated he had no cognitive deficits. Resident 1 stated that the facility did not have scheduled smoking times and that he was free to smoke at any time if it was outside of the facility perimeter (indoor/outdoor areas such as the parking lots) because there was no designated areas to smoke within the facility perimeter. Resident 1 stated when residents smoke outside of the facility no staff members ever supervised. Resident 1 stated he signed a smoking waiver to not smoke anywhere around the premises of the facility and that it was on the residents to find a place to smoke. On 7/23/25 at 1:00 P.M., an interview was conducted with Resident 2, in Resident 2's room. Resident 2 stated, it would be safer if the facility had a designated area to smoke but the facility is a non-smoking facility so that's why they don't have it. Resident 2 stated the facility did not have designated times to smoke and smoked anytime. Resident 2 stated whenever he smoked there was no supervision provided by staff and further stated, it can be dark at night and that's why we should have a designated area to feel safer. On 7/23/25 at 1:30 P.M., an interview was conducted with the Activities Director (AD). The AD stated that the facility currently does not have a smoking program/process for residents who smoke. The AD stated that they try to supervise and check on them (facility residents who smoke) but it's not always the case. The AD stated they don't currently have a smoking attended because they currently are still in-progress of making a smoking program. The AD stated Resident 2 smoked unattended and did not need to be supervised. The AD stated smoke related injuries can occur if residents who need to be supervised are not supervised according to their smoking evaluations/assessments and care plans. The AD stated they [the facility] don't have designated smoking times and areas. The AD stated residents who smoke were free to smoke outside the facility and not on the premises (facility indoor/outdoor areas) at their own risk. A record review was conducted on Resident 2's clinical chart that indicated:- MDS dated [DATE] indicated that Resident 2 was a smoker, had falls in the past and had impairments to his upper and lower body. - Resident 2's care plan dated 6/26/25 indicated, .Resident is a smoker and is at risk for smoking related injury as evidenced by poor safety awareness. and .Supervision provided while resident is smoking . - Resident 2's interdisciplinary team (IDT) note dated 6/26/25 indicated, .requires supervision when smoking .- Resident 2's Smoking Observation/assessment dated [DATE] indicated, .visual impairment. and .Supervision required.On 7/30/25 at 10:19 A.M., an interview was conducted with the Quality Assurance (QA) nurse. The QA nurse stated the facility was still working on their smoking program and that it was still in-progress. The QA nurse stated Resident 2 should be supervised while smoking to prevent smoking related injuries that can happen such as burns. A review of the facility's policy and procedure titled Smoking Policy dated October 2023, did not indicate smoking safety for staff supervision.

Based on interview and record review, the facility failed to ensure physician orders were obtained, signed, and transcribed to maintain continuity of care one of three residents (Resident 1) reviewed with a wound vacuum assisted closure (vac- medical device used to help wounds heal by creating a vacuum over the wound, drawing out excess fluid and infectious materials, and promoting the formation new tissue) device. As a result, Resident 1 was sent to the hospital without a wound vac as ordered post-operatively (OP) and placed Resident 1 at risk for delayed wound healing infection and worsening of their condition due to improper or interrupted treatment. According to the National Library of Medicine at https://pmc.ncbi.nlm.nih.gov/articles/PMC6739293 titled Vacuum assisted closure (VAC)/negative pressure wound therapy dated 6/19/19, indicated .Negative pressure wound therapy stabilizes the wound environment, reduces wound edema/bacterial load, improves tissue perfusion [circulation], and stimulates granulation [healthy tissue that promotes wound healing] tissue.A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included a history of diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing).A clinical chart review indicated:- Wound order dated 7/4/25 indicated, .Cleanse left groin area surgical wound with NS [normal saline] pat dry and apply transparent dressing around the open area then apply black foam to wound bed f//b [sic, followed by] transparent dressing then apply wound vac setting at 125mm\\ [sic]hg continuous, change dressing q M [Monday]-W [Wednesday]-F [Friday] x 21 days then reassess dc [discontinue] when healed and change as needed for soiled or dislodged.- Care plan initiated 7/8/25 indicated, Disease groin dehiscence with exposed graft nonhealing right BKA, c/f infected L to R fem bypass, s/p wound vac.- Care plan initiated 7/8/25 indicated for .Resident is at risk for skin breakdown related to Peripheral Artery Disease. s/p wound vac.Care plan initiated 7/9/25 indicated, .Surgical Incision: Resident has a surgical incision and is at risk for delayed healing. - Physician's (MD) order dated 7/10/25 indicated, .Send pt [patient] to ER [emergency room] for purulent right groin wound.- Change of Condition (COC) note dated 7/10/25 indicated, .Wound noted with purulent drainage Right Groin Area.Upon MD Assessment resident noted with Purulent drainage and Dehiscence on Right Groin Surgical Site. Wound Cleaned and Redressed with foam dressing to go to hospital. Received order from MD to send resident out to UCSD for further evaluation.Send Resident to UCSD for further evaluation. Family member notified [Name of Family Member]- Skin/wound Note dated 7/10/25 indicated, .All wound cleaned prior to leaving. Wound Vac removed prior to leaving and clean dressing applied.- Discharge Summary-Physician note dated 7/10/25 indicated, .Patient seen today at the facility during routine weekly rounding, Examination revealed purulent drainage from the right groin surgical incision site, accompanied by mild surrounding erythema. A retainer suture is present; no evidence of dehiscence at this time.Nursing staff were notified and instructed to arrange non-emergent transport via BLS.On 7/23/25 at 1:22 P.M., an interview and record review was conducted with Licensed Nurse (LN) 2. LN 2 stated Resident 1 had post-op orders for a wound vac due to a surgical procedure for an infected left (L) and right (R) femoral (relating to location on the upper thigh groin area) bypass (used to treat a blocked femoral artery) graft (replacing damaged tissue). LN 2 stated Resident 1's R groin wound was assessed by the facility's MD that displayed symptoms of infection of the wound site with purulent (containing pus) drainage, and it was dehisced (wound rupture). LN 2 stated Resident 1's L groin (with the wound vac) did not display symptoms of complications when he did the wound care. LN 2 stated Resident 1's L groin was not healed and did not have complications associated with the L groin upon transfer as assessed by the MD. LN 2 stated Resident 1 did not have parameters to remove the L groin wound vac prior to reassessment after 21 days (Resident 1 was sent out on day 7 of facility stay on 7/10/25). LN 2 stated the purpose of a wound vac was to promote healing and prevent complications of wound infections and if not used as prescribed could lead to complications (poor healing and infections). LN 2 stated he removed Resident 1's L groin wound vac prior to transfer to the hospital because the facility MD wanted to asses Resident 1's L groin wound so the wound vac was removed. LN 2 stated if there was no complications found on the L groin wound vac area the wound vac should have stayed on. LN 2 stated he did not transcribe and/or documented an MD order to discontinue Resident 1's L groin wound vac and did not follow up with Resident 1's surgeon regarding the L groin wound vac removal. On 7/24/25 at 4P.M., an interview and record review with LN 1 was conducted. LN 1 stated she was the LN who did Resident 1's admission and confirmed orders with the hospital nurses and the facility MD. LN 1 stated Resident 1 had a wound vac on her L groin upon admission. LN 1 stated she was unable to find orders to discontinued orders for the wound vac upon transfer to the hospital on 7/10/25. LN 1 stated if Resident 1's wound vac needed to be removed then an order should be transcribed and documented. LN 1 stated a verbal order needs to be documented for continuum of care and communication with other nursing staff. LN 1 stated it's important to have an MD order documented because we can't just d/c [discontinue] a wound vac. LN 1 stated not following Resident 1's L groin wound vac orders can lead to complication (poor wound healing, infection, and dehiscence). On 7/24/25 at 4:11 P.M., an interview and record review with the Quality Assurance (QA) nurse was conducted. The QA nurse stated there was no order for the L groin wound vac removal in Resident 1's clinical chart. The QA nurse stated that the MD discharge summary did not include complications with the L groin wound vac site nor did it mention orders to remove the L groin wound vac upon transfer on 7/10/25.On 7/30/25 at 10:11 A.M., a final interview and record review was conducted with the QA nurse. The QA nurse stated if an MD did give LN 1 a verbal order then LN 1 should have clarified and transcribed the order for Resident 1's L groin wound vac order and documented for continuum of care upon transfer. The QA stated Resident 1 went to the hospital without an MD order documented and was not according to professional standards of practice because verbal orders needed to be transcribed, clarified and documented for continuum of care upon transfer. The QA nurse stated wound vacs were important to drain excess fluid from draining wounds to promote wound healing and prevent infections. A review of the facility's policy and procedure titled MEDICATION and TREATMENT ORDERS dated July 2016, indicated .Verbal orders must be recorded immediately in the resident's chart by the person receiving the order and must include prescriber's last name, credentials, the date and the time of the order.

Based on observation, interview and record review, the facility failed to provide adequate supervision for one resident, Resident 1, who eloped (a patient leaving a healthcare facility without proper authorization or staff awareness)from the facility late at night, was unlocatable by the facility for nearly 14 hours, and sustained a fall while away from the facility. This failure had the potential for Resident 1 to suffer serious injury. Findings: According to a report filed to the Department by Adult Protective Services (APS): On 6/2/25, the police department Psychiatric Emergency Response Team ([NAME]) unit responded to a call for a missing person at risk. During investigation, a clinician learned that Licensed Nurse (LN) 1 knew that Resident 1 left the facility at approximately 1:30 AM and never returned. LN 1 did not report this until shift change at 7:30 AM. A phone call was made to the police at 8:17 AM. The police department filed a missing person at risk report. An unannounced visit was conducted at the facility on 6/3/25 at 12:15 PM. The Director of Nursing (DON) stated Resident 1 returned to the facility on 6/2/25 after 4 PM. The total time Resident 1's whereabouts were unknown was approximately 14 hours. A review of Resident 1's admission Record indicated he was admitted to the facility on [DATE] with diagnoses that included unsteadiness on feet. A review of Resident 1's admission orders indicated that there were no orders for Resident 1 to go out of the facility without supervision. On 6/3/25 at 12:50 PM an interview with the DON and concurrent record review of Resident 1's fall risk assessment dated [DATE] indicated a score of 14 which was moderate risk for fall. The evaluation did not include the antihypertensive medication Resident 1 took for seven days prior to the date of the evaluation. A review of Resident 1's fall risk assessment dated [DATE] after return to the facility indicated a score of 16 which was high risk for falls. The evaluation did not include the antihypertensive medication Resident took for seven days prior to the date of the evaluation. The DON stated the Medication Administration Record (MAR) indicated Resident 1 received the ordered antihypertensive medication for seven days preceding both fall risk evaluations, the evaluations were not accurate and the risk level should have been higher. A review of Resident 1's care plans indicated, substance abuse. This care plan was initiated on 5/8/25. Interventions included, Assess for the risk of leaving the facility without notification. On 6/3/25 at 1250 an interview with the DON and concurrent review of Resident 1's care plans indicated, Resident is a smoker. This care plan was initiated on 5/10/25. Interventions included, supervision provided while resident is smoking. The DON stated, The care plan is a template. Accompanying the resident outside to smoke safely is in the care plan but no one accompanied him. On 6/3/25 at 1:57 PM a telephone interview was conducted with Licensed Nurse (LN) 1 who stated, It's not the first time he got out like that. He goes down at night to smoke. I got busy, I was preoccupied and didn't notice he didn't return. I didn't notice until around 4 AM because he was not in bed. I did ask a senior nurse because I'm a new nurse, I wasn't sure what to do. He told me I could call the DON when she's awake. He said we don't want to wake someone for that. He said we could call the police and the DON after 7 AM. (Resident 1) didn't return during my shift. A review of a physician progress note dated 6/3/25 at 3:52 PM indicated, The patient returned the same day, at (3:17 PM), with an abrasion (an injury caused by scraping resulting in wearing away the surface of the skin) noted on the left side of his face.the patient would need . an x-ray of his face, and his wound cleaned and dressed. A review of Resident 1's x-ray report dated 6/3/25 indicated, There is a moderate suprapatellar effusion (excess fluid above the knee joint). A review of Resident 1's physician progress note dated 6/4/25 indicated, .patient was found many blocks away. He reported that he got lost. Noted with abrasions over face and left knee.Patient reported falling off his wheelchair. On 6/4/25 at 3:56 a telephone interview was conducted with LN 2 who stated he was the nursing supervisor of the third floor. LN 2 stated, I told (LN 1) to let Security (look for Resident 1), they come in later at about 5:30 AM. A patient who is a fall risk or with any level of cognitive impairment should not go outside the facility without staff. We would notify our supervisor about an issue, but we don't have a floor supervisor at night. I said you can wait and notify (the DON) at the beginning of the shift. I didn't look at his chart to see if the information the other nurse gave me was accurate because I was too busy doing my own work. If I don't know what to do in a situation I would talk to the DON. On 6/3/25 at 12:44 PM an observation and interview were conducted with Resident 1 who was noted to have a triangle shaped gauze dressing loosely taped over the left side of his face with ability to visualize scrapes and skin breaks from above his left temple to below his left cheekbone. There was a small amount of bright red blood noted. Resident 1's upper lip was noted with broken skin and a small amount of bright red blood and moderate swelling. Resident 1 stated, I went over a curb and fell out of the wheelchair. Resident 1 did not recall the time he went outside but stated, It was dark out. My knee is very painful when I walk, it's swollen and scraped up. Someone called the building for me because I don't know what I'm doing (Resident 1 held up a cell phone in his right hand). I couldn't find my way back, I was lost. A request was made to the Medical Records staff, DON, and Director of Staff Development (DSD ) for the facility's smoking policy. No policy was provided to ensure residents were supervised while smoking.

Based on observation, interview, facility document and policy review, the facility failed to follow the prepared menu for residents who received diets with mechanical soft or ground meat for 30 of 183 residents who resided in the facility and failed to follow the prepared menu for residents who received diets with pureed meat for 21 of 183 residents who resided in the facility. Findings included: An undated facility policy titled, Menus, indicated, Menus are developed and prepared to meet resident choices including religious, cultural and ethnic needs while following established national guidelines for nutritional adequacy. The policy revealed the section titled, Policy Interpretation and Implementation, included, 6. Menus must be followed. Deviations from posted menus are recorded (including the reason for the substitution and/or deviation) and archived. Further review revealed, 8. Menus provide a variety of foods from the basic daily food groups and indicate standard portions at each meal. The facility's Spring Cycle Menus, revealed that the planned lunch meal on 05/13/2025 included a 3-ounce (oz) portion of barbeque (BBQ) chicken for regular diets. The menus revealed the mechanical soft diet included a #10 (3.2 oz) scoop of ground moist BBQ chicken, and the pureed diet included a #8 (4 oz) scoop of pureed BBQ chicken. Observations on 05/13/2025 beginning at 10:40 AM revealed [NAME] #3 serving the mechanical soft BBQ chicken with a #12 (2.67 oz) scoop. [NAME] #3 served pureed BBQ chicken with a #12 (2.67 oz) scoop. During an interview on 05/13/2025 at 1:41 PM, [NAME] #3 stated she looked at the menus to know what size portion scoops to use for serving meals. [NAME] #3 confirmed she had used a #12 scoop to serve the mechanical soft and pureed chicken. [NAME] #3 reviewed the menu and confirmed that the portion size should have been a #10 portion scoop for the mechanical soft BBQ chicken and a #8 portion scoop for the pureed BBQ chicken. During an interview on 05/13/2025 at 3:42 PM, Dietary Director (DD) #2, the former Dietary Director who was assisting with training the current Dietary Director, stated her expectation was that the cook should check the menu spreadsheet before starting the meal service. DD #2 stated it was important to serve the correct portion sizes to ensure residents received adequate nutrition. During an interview on 05/13/2025 at 3:45 PM, DD #1, the current Dietary Director, stated her expectation was that they served the correct portion sizes. DD #1 stated it was important to serve the correct portions to ensure residents received the right nutrients. During an interview on 05/14/2025 at 3:16 PM, the Registered Dietitian (RD) stated it was important to serve the correct portion sizes to ensure residents received adequate nutrition and protein. During an interview on 05/15/2025 at 8:45 AM, the Director of Nursing (DON) stated she expected staff to follow the correct portion sizes because that was what the doctor ordered. During an interview on 05/15/2025 at 8:49 AM, the Administrator stated his expectation was that staff should follow the menu and portion sizes.

Based on observation, interview, record review, and facility policy review, the facility failed to provide timely podiatry services for 1 (Resident #388) of 3 sampled residents reviewed for activities of daily living. Findings included: A facility policy titled, Podiatry Services revised 02/2023, indicated, It is the policy of this facility to ensure residents receive proper treatment and care within professional standards of practice and state scope of practice, as applicable, to maintain mobility and good foot health. The policy specified, 5. The social worker or designer will assist residents in making appointments and arranging transportation to obtain needed services. An Admission Record revealed the facility admitted Resident #388 on 04/14/2025. According to the Admission Record, the resident had a medical history that included diagnoses of muscle weakness and dorsalgia (back pain). An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/21/2025, revealed Resident #388 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident required partial/moderate assistance with personal hygiene. Resident #388'sOrder Summary Report which contained active orders as of 05/14/2025, revealed an order dated 04/14/2025, for podiatry evaluation and treatment as indicated for mycotic toenails every 90 days and as needed. Resident #388's Social Service Note dated 04/16/2025, indicated the resident was referred to podiatry. Resident #388Nurse's Note written by the Assistant Director of Nursing and dated 04/26/2025, revealed social services was contacted by the ADON to please add the resident to the podiatrist list as soon as possible for an ingrown toenail. During a concurrent observation and interview on 05/12/2025 at 11:40 AM, Resident #388 stated they had an ingrown toenail and had been told that the podiatrist would come in and see them, but it had not been done. Resident #388 stated their toenail hurt and that pain medication did not help. Resident #388 removed the sock from their right foot, and it was noted that the toenail on their big toe on the right foot was about 1 inch long, above the top of the toe, and the nail was thick. During an interview on 05/14/2025 at 8:54 AM, Certified Nursing Assistant (CNA) #8 stated she was assigned to Resident #388, Resident #388 needed to see podiatrists, and was on the list. Per CNA #8, the podiatrist came into the facility on ce per month. During an interview on 05/14/2025 at 8:59 AM, Registered Nurse #9 stated that she was assigned to Resident #388 and the resident made complaints of ingrown toenails and pain for at least one and a half weeks. During an interview on 05/14/2025 at 9:08 AM, Licensed Vocational Nurse (LVN) #10 stated Resident #388 had been asking to be seen by the podiatrist and had pain that was managed by pain medication given for generalized pain. LVN #10 stated that the podiatrist company had come in the facility for urgent matters but had not come in for Resident #388. Per LVN #10, the resident was scheduled to be seen by the podiatrist on 05/15/2025. During an interview on 05/14/2025 at 9:30 AM, the Social Service Director (SSD) stated that residents were referred to podiatry by nursing or a resident would let social services (SS) know that they needed to be seen. The SSD stated the podiatrist came in every 90 days; if there was an emergent need they would do a special visit. Per the SSD, if the podiatrist was unable to come in for an emergent visit then the resident would be sent out for services. The SSD stated that the podiatrist was expected to come to the facility on [DATE] and would stay for three days to do each floor. The SSD stated that Resident #388 was currently on the list; a referral was sent out to the vendor on 05/09/2025 to cut the resident's toenails. During an interview with the Director of Nursing (DON) and the Administrator on 05/15/2025 at 10:40 AM, the DON stated that her expectation was that as soon as the resident had concerns with their toenails, social services would contact the podiatrist right away and make sure that the resident got the care needed. The Administrator stated that his expectation was the same expectation as the DON, and that he expected the floor staff report to appropriate channels and forward to social services.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure staff followed a physician's order for supervision during meals for 1 (Resident #30) of 7 residents reviewed for nutrition. Findings included: A facility policy titled, Assistance with Meals, revised 03/2022, specified, Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. The policy revealed the section titled, Policy Interpretation and Implementation, included, 2. Facility staff will serve resident trays and will help residents who require assistance with eating. An Admission Record revealed the facility admitted Resident #30 on 02/25/2013. According to the Admission Record, the resident had a medical history that included hemiplegia and hemiparesis (partial weakness on one side of the body) following a cerebral infarction (stroke), dysphagia (difficulty swallowing), and functional quadriplegia. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/06/2024, revealed Resident #30 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. The MDS indicated Resident #30 required supervision or touching assistance with eating. Resident #30's Order Summary Report, with active orders as of 05/14/2025, included an order dated 03/10/2025, for a regular diet with pureed texture and thin liquids consistency, and that specified one-on-one supervision with meals. Resident #30's Care Plan Report, included a focus area initiated 03/31/2025, that revealed Resident #30 had moderate oropharyngeal dysphagia, which impeded safe swallowing. The Care Plan Report included a focus area revised on 03/31/2025, that revealed Resident #30 had a self-care deficit and required assistance with activities of daily living (ADLs), and they needed to be supervised while eating. Resident #30's Visual/Bedside Kardex Report, dated 05/14/2025, revealed Resident #30 required supervision during meals. Resident #30's Wednesday Breakfast and Wednesday Lunch tray ticket revealed Resident #30 required one-on-one supervision during meals. An observation of meal service on 05/14/2025 at 9:01 AM revealed Resident #30 received their breakfast tray. At 9:13 AM, Resident #30 was observed in their bed consuming their breakfast. No staff were in the room supervising Resident #30. Resident #30 continued to consume their breakfast until they were done with their meal. An observation of meal services on 05/14/2025 at 1:52 PM revealed Certified Nursing Assistant (CNA) #12 delivered Resident #30 their lunch tray, set up the tray (uncovered food and drinks) for Resident #30 to eat, and exited the room. Resident #30 was observed eating their meal and drinking their milk and juice. There were no staff in the room supervising Resident #30. During an interview on 05/14/2025 at 2:03 PM, CNA #12 stated he did not know that Resident #30 needed to be supervised while eating. He stated he would get the information (related to the resident's required assistance with meals) from a coworker and if they did not provide the information he needed, he would look in the Kardex or look in the resident's health record. CNA #12 stated that not supervising someone that needed to be observed while eating could lead to that resident choking or aspirating. During an observation of meal services on 05/15/2025 at 9:01 AM, Resident #30 was observed in their bed, eating their breakfast. There was no staff supervising Resident #30. During a concurrent interview with Resident #30, they stated that no one had been in their room during the meal. During an interview on 05/15/2025 at 9:08 AM, CNA #13 stated she did know Resident #30 needed to be supervised during meal service. She stated she left Resident #30 while they were eating to answer a call light. CNA #13 acknowledged that when a resident needed to be supervised during meals, the staff member needed to stay during the entire meal. During an interview on 05/15/2025 at 9:53 AM, the Speech Language Pathologist (SLP) stated Resident #30 needed to be supervised while eating to remind them to take a bite and to take small bites. She added Resident #30 needed to be supervised for the entire meal, every meal. During an interview on 05/15/2025 at 11:06 AM, the Administrator stated that if there was a clinical recommendation, it needed to be followed. The Administrator stated that if the recommendation was not followed it could have led to choking. During a concurrent interview, the Director of Nursing (DON) stated that staff needed to do what was ordered.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a care plan was followed for 1 (Resident #30) of 7 residents reviewed for nutrition. Findings included: A facility policy titled, Assistance with Meals, revised 03/2022, specified, Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. An Admission Record revealed the facility admitted Resident #30 on 02/25/2013. According to the Admission Record, the resident had a medical history that included hemiplegia and hemiparesis (partial weakness on one side of the body) following a cerebral infarction (stroke), dysphagia (difficulty swallowing), and functional quadriplegia. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/06/2024, revealed Resident #30 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. The MDS indicated Resident #30 required supervision or touching assistance with eating. Resident #30's Care Plan Report, included a focus area initiated 03/31/2025, that revealed Resident #30 had moderate oropharyngeal dysphagia, which impeded safe swallowing. The Care Plan Report included a focus area revised on 03/31/2025, that revealed Resident #30 had a self-care deficit and required assistance with activities of daily living (ADLs), and they needed to be supervised while eating. An observation of meal service on 05/14/2025 at 9:01 AM revealed Resident #30 received their breakfast tray. At 9:13 AM, Resident #30 was observed in their bed consuming their breakfast. No staff were in the room supervising Resident #30. Resident #30 continued to consume their breakfast until they were done with their meal. An observation of meal services on 05/14/2025 at 1:52 PM revealed Certified Nursing Assistant (CNA) #12 delivered Resident #30 their lunch tray, set up the tray (uncovered food and drinks) for Resident #30 to eat, and exited the room. Resident #30 was observed eating their meal and drinking their milk and juice. There were no staff in the room supervising Resident #30. During an interview on 05/14/2025 at 2:03 PM, CNA #12 stated he did not know that Resident #30 needed to be supervised while eating. He stated he would get the information (related to the resident's required assistance with meals) from a coworker and if they did not provide the information he needed, he would look in the Kardex or look in the resident's health record. CNA #12 stated that not supervising someone that needed to be observed while eating could lead to that resident choking or aspirating. During an observation of meal services on 05/15/2025 at 9:01 AM, Resident #30 was observed in their bed, eating their breakfast. There was no staff supervising Resident #30. During a concurrent interview with Resident #30, they stated that no one had been in their room during the meal. During an interview on 05/15/2025 at 9:08 AM, CNA #13 stated she did know Resident #30 needed to be supervised during meal service. She stated she left Resident #30 while they were eating to answer a call light. CNA #13 acknowledged that when a resident needed to be supervised during meals, the staff member needed to stay during the entire meal. During an interview on 05/15/2025 at 9:53 AM, the Speech Language Pathologist (SLP) stated Resident #30 needed to be supervised while eating to remind them to take a bite and to take small bites. She added Resident #30 needed to be supervised for the entire meal, every meal. During an interview on 05/15/2025 at 11:06 AM, the Administrator stated that if there was a clinical recommendation, it needed to be followed. The Administrator stated that if the recommendation was not followed it could have led to choking.

Based on interview, record review, and facility policy review, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 2 (Resident #77 and Resident #185) of 38 residents whose MDSs were reviewed. Findings included: A facility policy titled, Resident Assessments, revised 10/2023, revealed the section titled, Policy Interpretation and Implementation, included, 11. All persons who have completed any portion of the MDS resident assessment form must sign the document attesting to the accuracy of such information. 12. Information in the MDS assessments will consistently reflect information in the progress notes, plans of care and resident observations/interviews. 1. An Admission Record indicated the facility admitted Resident #185 on 01/21/2025. According to the Admission Record, the resident had a medical history that included diagnoses of multiple rib fractures, a history of falling, and dementia. A discharge MDS, with an Assessment Reference Date (ARD) of 02/12/2025, revealed Resident #185 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated the resident had severe cognitive impairment. The MDS indicated Resident #185 had been discharged to a short-term general hospital. Resident #185's Care Plan Report, included a focus area initiated 01/22/2025, that indicated the resident had a need for assistance with discharge planning. Interventions directed staff to assess the resident for the appropriate level of care and make recommendations, coordinate referrals to outside resources, and educate the resident and family regarding home care needs. Resident #185's Order Summary Report, with active orders as of 02/12/2025, included an order dated 02/11/2025 to discharge the resident home per request with home health. During an interview on 05/15/2025 at 10:28 AM, MDS Coordinator #14 stated he obtained information for the MDS assessment from visiting with residents to make observations, reviewing hospital records, obtaining information from nursing, and reviewing progress notes. MDS Coordinator #14 stated a resident's discharge location was documented on the MDS assessment. He stated that the Social Services Director (SSD) had completed the discharge section of the MDS for Resident #185. MDS Coordinator #14 confirmed that according to Resident #185's progress notes, the resident had discharged with their personal belongings to home, but the SSD had coded on the MDS assessment that the resident went to the hospital. He stated the SSD should have documented that Resident #185 was discharged home. During an interview on 05/15/2025 at 10:52 AM, the SSD confirmed that the discharge summary for Resident #185 indicated the resident had discharged home with their family member. The SSD stated the MDS revealed Resident #185 was discharged to a short-term hospital but should have shown that the resident went home. The SSD stated she must have gotten confused with where the resident was admitted from. During an interview on 05/15/2025 at 11:06 AM, the Administrator stated he expected the MDS, including the discharge destination, to be accurate. During a concurrent interview, the Director of Nursing (DON) stated the MDS should be correct. 46258 2. An Admission Record revealed the facility admitted Resident #77 on 09/19/2018. According to the Admission Record, the resident had a medical history that included diagnoses of major depressive disorder, psychotic disorder, bipolar disorder, and generalized anxiety disorder. An annual MDS, with an Assessment Reference Date (ARD) of 09/06/2024, revealed Resident #77 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. The MDS indicated Resident #77 did not have a Preadmission Screening and Resident Review (PASRR). Resident #77's Care Plan Report, included a focus area revised 06/23/2023, that indicated Resident #77 had episodes of bipolar disorder exhibited by angry outbursts. The Care Plan Report included a focus area initiated 03/21/2025 that indicated the resident was at risk for psychosocial well-being and adjustment issues, emotions distress and ineffective coping skills, poor impulse control, and adverse effects on function, mental, physical, social, or spiritual wellbeing related to a diagnosis of depression. A letter from the State of California Health and Human Services Agency Department of Health Care Services, dated 06/05/2023, revealed Resident #77's PASRR Level II evaluation was completed on 06/04/2023. During an interview on 05/15/2025 at 10:28 AM, MDS Coordinator #14 confirmed that the PASRR was not coded correctly. He further stated the person that was signing off on the section of the MDS for PASRRs did not ensure accuracy, just that it was completed. He also stated that the Social Services Director (SSD) was responsible for the section for the PASRR. During an interview on 05/15/2025 at 10:53 AM, the SSD revealed she did not know Resident #77 had a PASRR Level II. She further confirmed that the MDS was not accurate. During an interview on 05/15/2025 at 11:06 AM, the Administrator revealed that the MDS should have been accurate. During a concurrent interview, the Director of Nursing (DON) stated the MDS should have been coded right.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a dignified dining experience for 1 (Resident #92) of 6 sampled residents reviewed for nutrition. Findings included: A facility policy titled, Dignity revised 02/2021, indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. The policy specified, 5. When assisting with care, residents are supported in exercising their rights. For example, residents are: a. groomed as they wish to be groomed; b. encouraged to attend activities of their choice, including religious, political, civic, recreational, or social activities; c. encouraged to dress in clothing that they prefer; d. allowed to choose when to sleep, eat and conduct activities of daily living; and e. provided with a dignified dining experience. A facility policy titled, Assistance with Meals revised 03/2022, indicated, Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. An Admission Record revealed the facility admitted Resident #92 on 10/07/2023. According to the Admission Record, the resident had a medical history that included diagnoses of amyotrophic lateral sclerosis (ALS, a nervous system disease that weakened muscles and impacted physical function), dysphagia (difficulty swallowing), contracture, muscle wasting and atrophy, and need for assistance with personal care. A significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/02/2025, revealed Resident #92 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS indicated that the resident was dependent on staff for eating. Resident #92's Care Plan Report included a focus area initiated 10/09/2023, that indicated the resident was at risk for an activity of daily living/mobility decline and required assistance related to diagnoses that included ALS. Interventions directed staff to provide substantial/maximal assistance with eating (initiated 10/09/2023). During a concurrent interview and observation on 05/13/2025 at 8:26 AM, Resident #92 was observed lying in bed. It was noted that the resident's breakfast meal tray was on an overbed table near the bottom of their bed and out of the resident's reach. Resident #92 stated their breakfast meal tray was delivered to their room at 8:15 AM. At 8:48 AM, Certified Nursing Assistant (CNA) #5 entered Resident #92's room and fed the resident's roommate their breakfast meal. During an interview on 05/13/2025 at 9:05 AM, CNA #5 stated that she was assigned to Resident #92; however, the resident was usually their breakfast and lunch meal by a restorative nursing assistant (RNA). During a concurrent interview and observation on 05/13/2025 at 9:07 AM, RNA #6 entered Resident #92's room and spoke with the resident. At 9:17 AM, RNA #6 brought another breakfast meal tray to the resident's room and received assistance from another staff member to reposition Resident #92 in their bed. At 9:21 AM, RNA #6 placed Resident #92's dentures in their mouth and then proceeded to feed the resident at 9:21 AM. RNA #6 stated Resident #92 was in the restorative dining program and he usually fed the resident around 9:00 AM. During a concurrent interview and observation on 05/14/2025 at 8:22 AM, , Resident #92 was observed lying in bed. It was noted that the resident's breakfast meal tray was on an overbed table near the bottom of their bed and out of the resident's reach. Resident #92 stated their meal tray was delivered to their room at 8:15 AM. According to Resident #92, staff always brought their meal tray early, laid it down out of their reach and no one came back for a long time to feed them. Resident #92 stated they did not like having to wait to be fed, while they watched their meal tray and their roommate being fed. During a concurrent interview and observation on 05/14/2025 at 8:22 AM, Resident #92 was being fed their breakfast meal by RNA #6. RNA #6 stated he started to fed the resident at 9:00 AM. RNA #6 stated Resident #92 saw when their meal was placed in their room and they knew when it was there, but having the meal sit was not typical. During an interview on 05/15/2025 at 9:42 AM, Licensed Vocational Nurse #7 stated Resident #92 required total assistance from staff and was fed breakfast and lunch by an RNA. During an interview on 05/15/2025 at 9:50 AM, the Infection Control Nurse (ICN) stated she supervised the restorative program. The ICN stated meal carts came at different times to unit based on who was assigned to the program. According to the ICN, Resident #92 was on the feeding program, an RNA was scheduled to feed the resident their meal dependent on when the tray arrived, and that the resident was to be fed immediately. During an interview with the Administrator and Director of Nursing (DON) on 05/15/2025 at 10:40 AM, the DON stated the expectation was that the RNA who was assigned to feed each resident should feed the resident at the time that the tray was distributed. The Administrator stated his expectations were the same expectation as the DON, that once all trays were delivered then the RNAs were to come back and deliver the assigned tray and feed the resident at that time so that the food did not get cold. The Administrator stated residents should never be able to see someone else eat and not have their food. The DON stated both residents in a room should be fed at the same time for a dignified meal experience.

Based on interviews and record review, the facility failed to protect a resident (Resident 1) with suicidal ideation (SI, when you think about, consider or feel preoccupied with the idea of death and suicide) tendency from harm, when staff did not: 1. Supervise Resident 1 with known SI tendencies to harm herself with overdosing on medications and cut herself with a butter knife, 2. Follow through on a provider ' s recommendations (five opportunities) for SI safe monitoring of Resident 1, 3. Developed of interdisciplinary and core staff communication for the planning, monitoring and evaluating Resident 1 ' s plan of care related to overdosing self, to ensure Resident 1 did not have access to medications for her safety and well-being, and, 4. Fully account for Resident 1 ' s belongings including medications from home. As a result, these failures provided Resident 1 an opportunity to harm herself by overdosing on her medications from home and cutting herself with a metal butterknife on 1/20/25. Resident 1 was transported from the facility to a GACH (General Acute Care Hospital). Resident 1 was admitted to the ICU (Intensive Care Unit), was placed on life support and underwent hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) for treatment and recovery. Findings: A record review was conducted of Resident 1. Resident 1 was readmitted to the facility on [DATE], with diagnoses which included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or the inability to move on one side of the body), per the facility ' s Admission Record. A record review was conducted of Resident 1. Resident 1's History and Physical (H & P), dated 10/17/24, indicated the attending physician (AP) documented Resident 1 was admitted to the facility for rehabilitation and Resident 1 had the capacity to make medical decisions. Per the H & P, Resident 1 was right-handed and had left sided weakness. A record review was conducted of Resident 1. Resident 1's minimum data set (MDS - a federally mandated resident assessment tool), dated 10/17/24, indicated Resident 1's brief interview for mental status (BIMS, ability to recall) score was 15/15 (a score of 13 to 15 suggests the patient is cognitively [process of acquiring knowledge and understanding] intact, 8 to 12 suggests moderately impaired and 0 to 7 suggests severe impairment). A review of Resident 1 ' s psychiatric assessment completed by Nurse Practitioners (NPs 1 and 2) was conducted. The NPs documented Resident 1 was assessed for suicidal risk on the following dates: 11/29/24, 12/5/24, 12/26/24, 1/2/25, and 1/16/25 - for the question Have you wished you were dead or wished you could go to sleep and not wake up? Resident 1 answered Yes. For the question Have you actually had any thoughts of killing yourself? Resident 1 answered Yes. For the question Have you been thinking about how you might do this? Yes - patient reports thinking about overdosing on medication. For 11/29/24 notes, NP 1 documented Resident 1 was at moderate risk for SI and recommended monitoring of Resident 1. NP 1 documented Resident 1 had Major Depressive Disorder (MDD, a mood disorder that causes a persistent feeling of sadness and loss of interest) and was placed on trazodone (anti-depressant) medication for Resident 1. For 12/5/24 notes, NP 1 documented Resident 1 had suicide attempt one month ago by overdosing herself on pills. The NP documented Resident 1 was at high risk for SI written in bold letters. The NP recommended monitoring of Resident 1. The NP added sertraline (anti-depressant) medication for Resident 1. For 12/26/24 notes, NP 2 documented Resident 1 required closely monitoring. Per the NP note, NP 2 saw Resident 1 on 12/12/24 and 12/19/25 with the same recommendation to monitor Resident 1. For 1/2/25 notes, NP 2 documented Resident 1 required closely monitoring. For 1/16/25 notes, NP 2 documented Resident 1 required closely monitoring. A review of Licensed Nurse (LN) progress notes dated 1/20/25 at 12:29 P.M. was conducted. LN 1 documented At 1000, the resident was seen in her room attempting self-harm by cutting her wrist with a butter knife and reporting she had ingested approximately 90 metformin pills that she had in her possession from her daughter bringing them to her from the [name of pharmacy]. She also reported taking a ziplock bag with other unidentified pills. Empty metformin bottle and an empty ziplock found in residents' possession .The butter knife was removed from the patient's possession and secured. Laceration and bleeding noted on resident's left wrist with a scant amount of bleeding noted at the time of intervention . On 1/23/25 at 2:21 P.M., an interview with Certified Nursing Assistant (CNA) 1 was conducted. CNA 1 stated Resident 1 was alert and knew what was going on. CNA 1 stated Resident 1 did not seem to be depressed. CNA 1 stated there was no communication reported related to monitoring Resident 1. CNA 1 stated the staff did not know Resident 1 had pills on her belongings. On 1/23/25 at 1:27 P.M., an interview with LN 1 and a joint review of Resident 1 ' s clinical record was conducted. LN 1 stated on 1/20/25, LN 4 called him to check Resident 1 in her room because she was cutting her wrist. Per LN 1, Resident 1 was actively cutting herself with a metal butter knife. Per LN 1, while taking the metal butterknife from Resident 1, Resident 1 was bleeding and LN 1 noticed an empty bottle of home medication containing metformin pills (antidiabetic medication). Per LN 1, he asked Resident 1 what she did, and Resident 1 told him she ingested 90 pills of metformin and some pills from a plastic bag. LN 1 stated he did not know what other medications Resident 1 ingested. LN 1 stated Resident 1 did not verbalize her depression. LN 1 stated the psychiatrist NP placed Resident 1 on anti-depressant medications. LN 1 stated he was not aware there was a note from the provider indicating Resident 1 needed monitoring. LN 1 stated they (staff) were not aware Resident 1 had suicidal ideation. LN 1 stated NP 1 saw Resident 1 on 11/29/24. LN 1 stated, I see the notes from the psychiatrist, I don ' t know about this note, this is the first time I saw the notes. We don ' t monitor [name of resident 1]. LN 1 stated he was not sure if the other LN knew about Resident 1 ' s SI. LN 1 stated there was no communication related to Resident 1 ' s SI and monitoring. On 1/23/25 at 3:27 P.M., an interview with LN 2 and a joint review of Resident 1 ' s clinical record was conducted. LN 2 stated she would sometimes worked as a charge nurse and one responsibility of the charge nurses was to check the laboratory results from the fax machine and relay the results to the attending physician. LN 2 stated she did not receive a report related to Resident 1 ' s SI and monitoring. LN 2 stated she was not aware of the psychiatrist notes and recommendations. LN 2 stated, With nursing standpoint, gets order for medication. LN 2 stated she was not aware Resident 1 had SI. LN 2 stated the facility ' s protocol was to monitor residents with SI. LN 2 stated they (staff) were not aware Resident 1 had history of overdosing herself with medications. LN 2 was shaking her head when she was reading NP 1 ' s notes indicating Resident 1 had a SI and the plan was to overdose herself with medications, LN 1 stated This is the first time I am reading this. LN 2 stated the protocol was when a resident was assessed with SI, the staff would have to closely monitor the resident. LN 2 stated there was no care plan developed related to monitoring Resident 1 of any behavior and or safety. On 1/23/25 at 5:11 P.M., an interview with LN 3 and a joint review of Resident 1 ' s clinical record was conducted. LN 3 stated NP 1 saw Resident 1 on 11/29/24 and she gave an order of trazodone for Resident 1. LN 3 stated, I have not seen the psych notes that she had passive SI. This is my 1st time seeing this note. On 3/6/25, a telephone interview with CNA 2 was conducted. CNA 2 stated she had Resident 1 on 1/20/25. CNA 2 stated Resident 1 did not eat all her meals which she usually did. CNA 2 stated there was no communication of monitoring Resident 1 related to her SI. CNA 2 stated for resident inventories, the staff did not go to the nightstand of the residents who were continent. CNA 2 stated, We did not know she had some medications there, we don ' t check. On 3/6/25 at 2:28 P.M., a telephone interview with NP 1 was conducted. NP 1 stated she saw Resident 1 on 11/29/24 and alerted the charge nurse that Resident 1 was moderate to high risk on suicide risk assessment and needed close monitoring. NP 1 stated the facility staff should be communicating with each other since Resident 1 was at moderate to high risk of suicidal ideation. NP 1 stated Resident 1 should have been closely monitored meaning for residents with SI, they should be placed on one-on-one monitoring. NP 1 stated the other biggest factors was Resident 1 had access to medications and butterknife and no one knew she had those. NP 1 stated Resident 1 had a diagnosis of MDD because she met the criteria of having a recurrent thought of death or trying to harm herself. NP 1 stated she did not communicate to the social services but informed the charge nurse of the facility. A review of the message of NP 1 to the facility was conducted. The message dated 12/5/24 at 9:46 P.M. indicated, NP 1 informed the facility that Resident 1 was at moderate to high risk of suicide, to ensure there were not medications or weapons in the resident ' s room and that the staff would have to checked Resident 1 more often. A review of hospital records was conducted. The psychiatry (psych) consults notes dated 1/20/25 at 1:19 P.M., indicated the interview with Resident 1 was limited due to lethargy (decrease in consciousness), nausea and vomiting. Per psych notes, Resident 1 endorses a month of worsening depressed mood and SI. Per the psych notes, Resident 1 had symptoms of depressed mood, insomnia, hopelessness, decreased energy, and worsening suicidal ideation. A review of hospital records was conducted. The emergency department (ED) physician notes dated 1/21/25 at 2:06 P.M., indicated Resident 1 had worsening SI over the past month and planned to end her life. The ED notes indicated that while Resident 1 was in the ED, Resident 1 ' s vital signs were significant with tachycardia (heart rate over 100 beats per minute) in addition to tachypnea (rapid, shallow breathing). The ED notes indicated Resident 1 ' s lab results were abnormal, and Resident 1 became more agitated, somnolent (a state of strong desire for sleep, or sleeping for unusually long periods) and altered mental status. The ED notes indicated Resident 1 was admitted to the ICU in critical condition and to proceed forward with hemodialysis. On 3/20/25 at 12:28 P.M., a telephone interview with the Director of Nursing (DON) was conducted. The DON stated no one alerted her on the message from NP 1. The DON stated the LNs should have informed her about the message to ensure she knew what was happening in the facility and ensure resident safety. The DON stated the expectation was to make sure there would be no repeated incident. A review of the facility ' s policy titled Safety and Supervision of Residents, revised July 2017, indicated, .Resident safety and supervision and assistance to prevent accidents are facility-wide priorities .2. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes .Individualized Resident centered Approach to Safety .2. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents, 3. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision . A review of the facility ' s policy titled, Care Plans, Comprehensive Person-Centered, revised March 2022, indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident .

Based on interviews and record review, the facility failed to communicate and develop a baseline care plan (detailed plan with information about a patient's treatment, goal, and interventions) related to a resident ' s (Resident 1) suicidal ideation (SI, when you think about, consider or feel preoccupied with the idea of death and suicide) tendency for one of one sampled resident. As a result, the lack of communication among facility staff related to Resident 1 ' s SI and a resident centered care plan with specific interventions to monitor Resident 1 from harming herself with overdosing of medications and cutting herself with a butter knife on 1/20/25. Findings: A record review was conducted of Resident 1. Resident 1 was readmitted to the facility on [DATE], with diagnoses which included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or the inability to move on one side of the body), per the facility ' s Admission Record. A record review was conducted of Resident 1. Resident 1's History and Physical (H & P), dated 10/17/24, indicated the attending physician (AP) documented Resident 1 was admitted to the facility for rehabilitation and Resident 1 had the capacity to make medical decisions. Per the H & P, Resident 1 was right handed and had left sided weakness. A review of Resident 1 ' s psychiatric assessment completed by Nurse Practitioners (NPs 1 and 2) was conducted. The NPs documented Resident 1 was assessed for suicidal risk on the following dates: 11/29/24, 12/5/24, 12/26/24, 1/2/25, and 1/16/25 - for the question Have you wished you were dead or wished you could go to sleep and not wake up? Resident 1 answered Yes. For the question Have you actually had any thoughts of killing yourself? Resident 1 answered Yes. For the question Have you been thinking about how you might do this? Yes - patient reports thinking about overdosing on medication. For 11/29/24 notes, NP 1 documented Resident 1 was at moderate risk for SI and recommended monitoring of Resident 1. NP 1 documented Resident 1 had Major Depressive Disorder (MDD, a mood disorder that causes a persistent feeling of sadness and loss of interest) and was placed on trazodone (anti-depressant) medication for Resident 1. For 12/5/24 notes, NP 1 documented Resident 1 had suicide attempt one month ago by overdosing herself on pills. The NP documented Resident 1 was at high risk for SI written in bold letters. The NP recommended monitoring of Resident 1. The NP added sertraline (anti-depressant) medication for Resident 1. For 12/26/24 notes, NP 2 documented Resident 1 required closely monitoring. Per the NP note, NP 2 saw Resident 1 on 12/12/24 and 12/19/25 with the same recommendation to monitor Resident 1. For 1/2/25 notes, NP 2 documented Resident 1 required closely monitoring. For 1/16/25 notes, NP 2 documented Resident 1 required closely monitoring. A review of Licensed Nurse (LN) progress notes dated 1/20/25 at 12:29 P.M. was conducted. LN 1 documented At 1000, the resident was seen in her room attempting self-harm by cutting her wrist with a butter knife and reporting she had ingested approximately 90 metformin pills that she had in her possession from her daughter bringing them to her from the [name of pharmacy]. She also reported taking a ziplock bag with other unidentified pills. Empty metformin bottle and an empty ziplock found in residents' possession .The butter knife was removed from the patient's possession and secured. Laceration and bleeding noted on resident's left wrist with a scant amount of bleeding noted at the time of intervention . On 1/23/25 at 2:21 P.M., an interview with Certified Nursing Assistant (CNA) 1 was conducted. CNA 1 stated Resident 1 was alert and knew what was going on. CNA 1 stated Resident 1 did not seem to be depressed. CNA 1 stated there was no communication reported related to monitoring Resident 1. CNA 1 stated the staff did not know Resident 1 had pills on her belongings. On 1/23/25 at 1:27 P.M., an interview with LN 1 and a joint review of Resident 1 ' s clinical record was conducted. LN 1 stated on 1/20/25, LN 4 called him to check Resident 1 in her room because she was cutting her wrist. Per LN 1, Resident 1 was actively cutting herself with a metal butter knife. Per LN 1, while taking the metal butterknife from Resident 1, Resident 1 was bleeding and LN 1 noticed an empty bottle of home medication containing metformin pills (antidiabetic medication). Per LN 1, he asked Resident 1 what she did, and Resident 1 told him she ingested 90 pills of metformin (antidiabetic medication) and some pills from a plastic bag. LN 1 stated he did not know what other medications Resident 1 ingested. LN 1 stated Resident 1 did not verbalize her depression. LN 1 stated the psychiatrist NP placed Resident 1 on anti-depressant medications. LN 1 stated he was not aware there was a note from the provider indicating Resident 1 needed monitoring. LN 1 stated they (staff) were not aware Resident 1 had suicidal ideation. LN 1 stated NP 1 saw Resident 1 on 11/29/24. LN 1 stated, I see the notes from the psychiatrist, I don ' t know about this note, this is the first time I saw the notes. We don ' t monitor [name of resident 1]. LN 1 stated he was not sure if the other LN knew about Resident 1 ' s SI. LN 1 stated there was no communication related to Resident 1 ' s SI and monitoring. On 1/23/25 at 3:27 P.M., an interview with LN 2 and a joint review of Resident 1 ' s clinical record was conducted. LN 2 stated she would sometimes worked as a charge nurse and one responsibility of the charge nurses was to check the laboratory results from the fax machine and relay the results to the attending physician. LN 2 stated she did not receive a report related to Resident 1 ' s SI and monitoring. LN 2 stated she was not aware of the psychiatrist notes and recommendations. LN 2 stated, With nursing standpoint, gets order for medication. LN 2 stated she was not aware Resident 1 had SI. LN 2 stated the facility ' s protocol was to monitor residents with SI. LN 2 stated they (staff) were not aware Resident 1 had history of overdosing herself with medications. LN 2 was shaking her head when she was reading NP 1 ' s notes indicating Resident 1 had a SI and the plan was to overdose herself with medications, LN 1 stated This is the first time I am reading this. LN 2 stated the protocol was when a resident was assessed with SI, the staff would have to closely monitor the resident. LN 2 stated there was no care plan developed related to monitoring Resident 1 of any behavior and or safety. On 1/23/25 at 5:11 P.M., an interview with LN 3 and a joint review of Resident 1 ' s clinical record was conducted. LN 3 stated NP 1 saw Resident 1 on 11/29/24 and she gave an order of trazodone for Resident 1. LN 3 stated, I have not seen the psych notes that she had passive SI. This is my 1st time seeing this note. On 3/6/25, a telephone interview with CNA 2 was conducted. CNA 2 stated she had Resident 1 on 1/20/25. CNA 2 stated Resident 1 did not eat all her meals which she usually did. CNA 2 stated there was no communication of monitoring Resident 1 related to her SI. CNA 2 stated for resident inventories, the staff did not go to the nightstand of the residents who were continent. CNA 2 stated, We did not know she had some medications there, we don ' t check. On 3/6/25 at 2:28 P.M., a telephone interview with NP 1 was conducted. NP 1 stated she saw Resident 1 on 11/29/24 and alerted the charge nurse that Resident 1 was moderate to high risk on suicide risk assessment and needed close monitoring. NP 1 stated the facility staff should be communicating with each other since Resident 1 was at moderate to high risk of suicidal ideation. NP 1 stated Resident 1 should have been closely monitored meaning for residents with SI, they should be placed on one-on-one monitoring. NP 1 stated the other biggest factors was Resident 1 had access to medications and butterknife and no one knew she had those. NP 1 stated Resident 1 had a diagnosis of MDD because she met the criteria of having a recurrent thought of death or trying harm herself. NP 1 stated she did not communicate to the social services but informed the charge nurse of the facility. A review of the message of NP 1 to the facility was conducted. The message dated 12/5/24 at 9:46 P.M. indicated, NP 1 informed the facility that Resident 1 was at moderate to high risk of suicide, to ensure there were not medications or weapons in the resident ' s room and that the staff would have to checked Resident 1 more often. A review of hospital records was conducted. The psychiatry (psych) consults notes dated 1/20/25 at 1:19 P.M., indicated the interview with Resident 1 was limited due to lethargy (decrease in consciousness), nausea and vomiting. Per psych notes, Resident 1 endorses a month of worsening depressed mood and SI. Per the psych notes, Resident 1 had symptoms of depressed mood, insomnia, hopelessness, decreased energy, and worsening suicidal ideation. A review of hospital records was conducted. The emergency department (ED) physician notes dated 1/21/25 at 2:06 P.M., indicated Resident 1 had worsening SI over the past month and planned to end her life. The ED notes indicated that while Resident 1 was in the ED, Resident 1 ' s vital signs were significant with tachycardia (heart rate over 100 beats per minute) in addition to tachypnea (rapid, shallow breathing). The ED notes indicated Resident 1 ' s lab results were abnormal, and Resident 1 became more agitated, somnolent (a state of strong desire for sleep, or sleeping for unusually long periods) and altered mental status. The ED notes indicated Resident 1 was admitted to the ICU in critical condition and to proceed forward with hemodialysis. On 3/20/25 at 12:28 P.M., a telephone interview with the Director of Nursing (DON) was conducted. The DON stated no one alerted her on the message from NP 1. The DON stated the message should have been communicated and a care plan developed to ensure resident safety. A review of the facility ' s policy titled, Care Plans, Comprehensive Person-Centered, revised March 2022, indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident .

Based on observations, interviews, and record review, the facility failed to protect Resident 1 from abuse when the facility failed to ensure the building was secured at night. As a result, Resident 1 was sexually assaulted, sustained a right arm fracture, required two emergency hospital visits, was subjected to an examination by sexual assault forensic examiners, required [MEDICAL CONDITION] (STD) testing, and developed bacterial vaginosis (vaginal infection), which required antibiotic treatment. Resident 1 also experienced physical pain from the fractured arm, requiring narcotic medication. These failures increased Resident 1's risk for further psychosocial distress, and put all residents residing in the facility on 10/27/19 at risk for abuse. In addition, Resident 2 did experience psychosocial distress as result of the incident. Findings: An unannounced visit was made to the facility on [DATE] to investigate a report from the facility that Resident 1's roommate alerted staff to a naked man under Resident 1's bed. The facility was observed to be located two blocks from a public park, where a large homeless population are known to reside. The facility is a four story building with the main entrances on the first floor. The public access the facility from the front door, which faces East to the street and enters into the lobby. Employees access the facility from the South entrance door, located by an employee parking lot, and enters into a bank of two elevators. The elevators on the first floor provide the main access to resident rooms located on the second, third, and fourth floors. On the right (West) of the elevators on each resident floor is the dining room, and a short hallway to an alarmed emergency exit. On the left (East) of the elevators on each resident floor is the nursing station, and a long hallway with most of the resident rooms. There are three resident rooms between the nursing station and the dining room. At the time of the incident, Resident 1's room was observed to be located on the second floor, between the dining room and the nursing station. The resident resided in a three bed-room with two other residents. Resident 1 was in the C bed near the window, the farthest from the room's door. Resident 2 resided in the middle (B) bed in the same room with Resident 1. Resident 1, an [AGE] year-old female, was admitted to the facility on [DATE] with diagnoses, which included heart failure, muscle weakness, and age-related [MEDICAL CONDITION] (weak and brittle bones), per the facility's Admission Record. According to a review of Resident 1's Minimum Data Set assessment (MDS - a resident assessment tool), dated 8/7/19, a Brief Interview for Mental Status (BIMS), Resident 1's score was a 3, which indicated severe cognitive impairment. Resident 1 was not interviewed due to her cognitive impairment. According to a review of Resident 2's MDS assessment, dated 9/24/19, Resident 2's BIMS score was 13, which indicated the resident was cognitively intact. During an interview with Resident 2, on 10/30/19 at 11:35 [NAME]M., the resident stated she was awakened in the middle of the night on 10/27/19 by Resident 1 screaming. Resident 2 stated she heard noises behind the curtain between her and Resident 1, and heard Resident 1 yelling, .You're breaking my arm. Resident 2 stated she pulled back the curtain between their beds and saw a naked man on top of Resident 1. Resident 2 stated she started yelling at the man, Get out of here, you don't belong here, and called staff for help. Resident 2 stated the naked man got up and slid under Resident 1's bed. Resident 2 stated as the nurses were coming into the room, the naked man grabbed his clothes and ran past the nurses and out of the room. Resident 2 stated since the incident she felt safe at the facility during the day, but sometimes at night she felt anxious. Resident 2 stated she had spoken to a psychologist since the incident. During an interview with licensed nurse (LN) 28 on 10/30/19 at 12:55 P.M., LN 28 stated at approximately 3:30 [NAME]M. on 10/27/19 she heard Resident 2 screaming. LN 28 stated when she went to the room, Resident 2 had a terrified look on her face, and LN 28 was afraid to go into the room. LN 28 asked a male CNA (CNA 14), who had just come off the elevator, to go in the room with her, because Resident 2 was yelling that a naked man was under the bed. LN 28 stated she followed CNA 14 into the room and when the CNA moved the curtain the man ran past them out of the room. LN 28 stated the man was naked, covering his groin with his clothes. During an interview with certified nursing assistant (CNA) 23 on 11/1/19 at 4:44 P.M., CNA 23 stated she was assigned to care for Resident 1 on 10/27/19. CNA 23 stated she was just returning from her break at approximately 3:30 [NAME]M., when she saw a naked man run out of Resident 1's room. CNA 23 stated the man ran down the hallway and exited through the second floor south emergency exit. CNA 23 stated after the man was gone she went into the room and saw Resident 1 was lying on her bed, completely naked. CNA 23 stated she stayed with the resident and held her hand while waiting for the paramedics to arrive. CNA 23 stated, She was scared . Her arm didn't look right and she screamed when she moved it, and said she had pain everywhere. According to a review of Resident 1's acute care hospital Emergency Department Record, dated 10/27/19 at 8:15 [NAME]M., .Clinical Impression: 1. Sexual assault by bodily force by person unknown to victim. 2. Other closed displaced fracture of distal end of right humerus (broken right upper arm bone) . Resident 1 was discharged from the acute care hospital at 5:08 P.M. on 10/27/19 and returned to the facility. During interview and facility tour with the administrator (admin) on 10/30/19 at 10:30 [NAME]M., the admin stated the first floor lobby door was locked at 5:30 P.M., and the South entrance door by the employee parking lot was locked at 9 P.M. A small camera was observed outside above the upper right corner of the door of the South entrance. There was a doorbell on the left side of this door. The admin stated this was the only camera in the facility, which provided a live-feed to a monitor at the second floor nursing station. There was also a switch at the second floor nursing station where the staff could release the locked door to allow entrance to the facility, for pharmacy deliveries, emergency transfer access, or staff, without having to go down to the first floor and unlock the door. On 10/30/19 at 1:05 P.M., LN 28 stated she was the nursing supervisor for the night shift on 10/27/19 (11 P.M. 10/26/19 to 7 [NAME]M. 10/27/19). LN 28 stated at the beginning of her shift at approximately 11:30 P.M., she checked all doors in the building to ensure they were closed and secured. LN 28 stated these included the lobby door, South entrance by the employee parking lot, and North side kitchen door on the first floor, and the second floor employee breakroom exit door. During an interview with LN 27 on 11/6/19 at 7:39 [NAME]M., LN 27 stated he was not aware that anyone was assigned to check the doors. LN 27 stated he checked the North side kitchen door whenever he was on the first floor. LN 27 stated he did not check the other first floor doors because the front lobby door was always locked, and the South entrance door by the employee parking lot was usually open at night. During an interview with LN 18 on 11/15/19 at 6:28 [NAME]M., LN 18 stated the South entrance door on the first floor was supposed to be locked at night. LN 18 stated she did not get any instruction regarding who was responsible to check and secure the first floor doors. During an interview with LN 19 on 11/15/19 at 6:36 [NAME]M., LN 19 stated everyone was responsible to ensure all doors were locked at night, and the nursing supervisor made rounds to ensure doors were locked. During an interview with the director of nursing (DON) on 11/15/19 at 7:17 [NAME]M., the DON stated she would expect it was the nursing supervisor on the evening shift who locked the South entrance door on the first floor. The DON stated she expected the nursing supervisor on the night shift to ensure the door was locked and remain locked on the night shift. During an interview with the DON on 11/15/19 at 8:17 [NAME]M., the DON stated there was no policy related to staff ensuring doors were locked on the night shift, and no mention of securing the facility in the list of duties for LNs. Night shift staff who worked the night of the incident were interviewed on 10/30/19 at 12:55 P.M., 11/1/19 at 3:49 P.M., 11/6/19 at 7:30 [NAME]M., 11/8/19 at 6:14 [NAME]M., and 11/15/19 at 6:01 [NAME]M. Of the 18 staff interviewed, 12 stated they left the building during their breaks, which ranged from 2 [NAME]M. to 3:30 [NAME]M. These 12 staff stated they entered and exited the facility by the South entrance next to the employee parking lot on their breaks. Five of 12 staff stated the South entrance was always unlocked when they returned from their break. Four of 12 stated the door was always locked and they had to press the doorbell or call the nursing station to return to the facility from their break. Three of 12 staff stated that sometimes the door was locked and sometimes it was unlocked. During an interview with CNA 17 on 11/15/19 at 6:20 [NAME]M., CNA 17 stated on the night of the incident, she took her break between 3 and 3:30 [NAME]M. CNA 17 stated she went out to her car for her break and when she returned through the South entrance the door was unlocked. During an interview with LN 18 on 11/15/19 at 6:50 [NAME]M., LN 18 stated the first floor South entrance door could be left ajar if people did not manually close it after they exited. During an interview with CNA 32 on 11/15/19 at 6:53 [NAME]M., CNA 32 stated he sometimes went out to his car during his break at 2:30 [NAME]M. CNA 32 did not recall if he went out on the night of the incident. CNA 32 stated the South entrance was usually locked when he returned from his break, but sometimes it was unlocked. CNA 32 stated, the door was unlocked, If someone didn't close the door all the way. During an interview with the DON on 11/15/19 at 8:20 [NAME]M., the DON stated the staff informed her the nursing staff secured the South entrance by the switch at the second floor nursing station and not with the key. During an observation of the monitor and lock switch at the second floor nursing station, on 11/15/19 at 8:28 [NAME]M., LN 33 demonstrated how the lock for the first floor South entrance worked. The lock switch looked like a regular light switch, labeled open and closed depending on which direction the switch was positioned. LN 33 positioned the switch to closed and instructed a CNA to go downstairs and exit the first floor South entrance. The CNA was observed on the monitor to exit the South entrance. The lock switch remained in the closed position when the CNA opened the door and came back into the facility. LN 33 stated the CNA did not close the door all the way, which enabled her to reenter the facility without staff at the nursing station changing the switch to the open position. At 8:30 [NAME]M., LN 33 went downstairs and was observed to exit out the South entrance and push the door closed after exiting. LN 33 was then unable to open the door until the switch was changed to the open position. During an interview with LN 33 on 11/15/19 at 8:33 [NAME]M., LN 33 stated when the switch was in the closed position, the door was not locked unless the door was fully closed. During an interview with the DON on 11/15/19 at 8:42 [NAME]M., the DON stated unless the South entrance door was shut tightly, like LN 33 demonstrated, the door would not lock even with the switch in the closed position. The DON stated, The staff could have thought the door was locked when it actually was unlocked. During an interview with the DON on 11/15/19 at 8:44 [NAME]M., the DON stated there was no policy related to building security. During an observation with the DON and the maintenance supervisor (MS) on 11/15/19 at 8:49 [NAME]M., the MS used the key to lock the South entrance door from the outside. The door was released to close by itself, visually the door appeared closed, but the door did not latch and the door was able to be opened. The door required another push to ensure the door latched and was locked. The MS explained when either the key or the second floor switch was used to place the door in the locked position, a mechanism on top of the door latched to the door frame and locked the door. During an interview with the DON on 11/15/19 at 8:55 [NAME]M., the DON stated it was not safe if the door to the facility was unlocked at night. During an interview with the MS on 11/15/19 at 2:15 P.M., the MS stated he routinely checked all exterior access doors monthly to ensure they properly closed and latched. The MS stated no one had reported to him that there was any issue with the South entrance door not latching properly. According to a review of the facility's annual Life Safety Code (a set of fire protection requirements designed to provide a reasonable degree of safety from fire) re-certification survey on 3/9/19, .The facility failed to maintain their self-closing doors. This was evidenced by doors which failed to self-close and latch . According to a review of the Plan of Correction for this deficiency, dated 3/20/19, .The Environmental Service Director or Designee will . do random checks to ensure all doors close and latch properly . According to a review of the facility's document titled Door Safety Lock Checklist 1st Floor 2019, the first floor doors were checked monthly. Prior to the incident on 10/27/19, the South entrance door was last checked on 9/19/19. During an interview with the MS on 11/15/19 at 5:01 P.M., the MS stated random checks were not done on any doors, just the monthly checks, which were documented on the first floor checklist. According to a review of the facility's policy, titled Safety of Employees, dated 1/08, Policy Statement- As part of our efforts to provide a safe and healthful environment for all employees, residents, and visitors, the facility shall comply with applicable governmental health and safety requirements. Policy Interpretation and Implementation- 1. The facility shall verify compliance with all federal, state, and local health and safety regulations and shall take steps to correct any violations thereof . During an interview with the admin on 11/20/19 at 2:29 P.M., the admin stated the facility did not have a security policy. The admin stated, The supervisors know they have to secure the doors at night. The admin stated he expected the doors to be checked and secured, and to remain locked during the night. On 10/30/19, the Facility Assessment was reviewed (a comprehensive assessment of the facility to ensure all resources are available necessary to care for all residents, and includes a facility-based and community-based risk assessment). There were no specific entries in the Facility Assessment regarding safety or security of residents. During an interview and facility tour with the admin on 10/30/19 at 10:36 [NAME]M., a small garage was observed at the front of the building, north of the lobby entrance. The admin stated they had to install a gate at the garage entrance because homeless people used to sleep in the garage at night. During an interview and facility tour with the admin on 10/30/19 at 10:53 [NAME]M., the admin stated in addition to the alarmed emergency exits on the resident floors, there was a door on each floor that exited to outside stairs on the North-West side of the building. The third and fourth floor doors exited the activities and medical record departments, and those doors were not accessible for entrance only exit. The second floor door had a key pad lock that entered into the employee breakroom. During an interview with the MS on 11/15/19 at 2:15 P.M., the MS stated the code for the key pad lock to the exterior second floor employee breakroom had been the same for years. This would enable anyone who no longer worked at the facility to access the building through the employee breakroom. During an interview with the DON on 11/15/19 at 2:37 P.M., the DON stated she was not aware of any policy related to key lock codes, such as who had access to codes or how often they should be changed. During an interview with the admin on 11/20/19 at 2:28 P.M., the admin stated there was no facility policy related to key lock codes, and information related to who had access to the code, and when they were changed or what should have been communicated to staff. During an interview with CNA 35 on 11/20/19 at 1:20 P.M., CNA 35 stated Resident 1 would state, it hurts, sometimes while she was eating, or when she woke up. CNA 35 stated the resident complained of pain either her whole body, arm, or occasionally her leg. According to a review of Resident 1's Medication Administration Record, [REDACTED]. Resident 1's pain level after the incident ranged between eight and10, which required the resident to receive more narcotic pain medication. During an interview with LN 36 on 11/20/19 at 1:34 P.M., LN 36 stated Resident 1 called out for help but was not always able to verbalize where she hurt. LN 36 stated sometimes she would say, vagina, or shoulder. According to a review of Resident 1's nursing progress notes, dated 11/11/19, the resident was transferred to the acute care hospital at 3:18 P.M., with a complaint of vaginal pain. According to a review of Resident 1's acute care hospital Emergency Department Record, dated 11/11/19 at 4:42 P.M., the resident was seen for a complaint of vaginal pain, approximately two weeks after a sexual assault at her skilled nursing facility. This document indicated the resident had symptoms of a bacterial vaginal infection, was prescribed antibiotics, and was tested for STDs. This document also indicated, .Clinical Impression: 1. Acute vaginitis (vaginal infection). 2. Vaginal pain. 3. Sexual assault of adult, subsequent encounter . Resident 1 returned to the facility on [DATE] at 7:30 P.M., with a new physician order [REDACTED].

Based on observation, interview and record review, for 2 of 3 sampled residents (1,2), the facility failed to: 1. Analyze and address reoccurring high levels of pain documented on the Electronic Medication Administration Record [REDACTED] 2. Re-evaluate the resident's pain management goals and revise an effective pain management care plan with the resident and members of the healthcare team. 3. Address the consulting pharmacist's recommendations in a timely manner. 4. Report to the physician in a timely manner when pain medication was ineffective. As a result, Resident 1 experienced uncontrolled pain which affected his emotional and mental status and his approach to life. Severe pain affected Resident 1's ability to progress in physical therapy (therapy for the restoration of movement and physical function-PT) which caused the discontinuation of physical therapy services. Resident 2 experienced uncontrolled pain which resulted in his inability to get out of bed, use a bed pan (equipment used for relieving bowels or bladder while in bed) or receive a shower. Findings: 1. Resident 1's medical record was reviewed. Resident 1 was admitted to the facility on [DATE], following a hospitalization for an [MEDICAL CONDITION] (a collection of pus and germs in the spine), [DIAGNOSES REDACTED] (inflammation), and discitis (infection in the discs between vertebrae), per the facility's Admission Record. A review of the hospital Transfer Summary, dated 10/5/18, indicated Resident 1 had a laminectomy (a surgical operation which removed one or more backbones to relieve pressure on the spinal nerves) and he had been given [MEDICATION NAME] (a pain medication) and [MEDICATION NAME] (a pain medication) for back pain. The hospital notes indicated pain medication given to Resident 1 at the hospital had improved his pain. A review of the Minimum Data Set (an assessment tool- MDS), dated [DATE], indicated Resident 1 had a BIMS of 15 (a BIMS of 13-15 indicated a person is mentally intact). The MDS pain assessment indicated Resident 1 had a pain scale of 4 (on a pain scale of 0-10 with 0 being no pain and 10 being the worst pain). Per the MDS notes, Resident 1's pain had not limited his activities and the intensity of Resident 1's pain was left blank. Resident 1's care plan interventions for back pain, dated 10/5/18, indicated Resident 1 should have been assessed for the effectiveness of pain medication and licensed nurses (LN's) were to notify the physician if pain was unrelieved. A review of physician orders, dated 10/5/18, indicated Resident 1's physician ordered: 1. [MEDICATION NAME] 15 milligrams (mg) every night before bed. 2. [MEDICATION NAME] 5/325 (5 mg of [MEDICATION NAME] and 325 mg of [MEDICATION NAME]) mg every 6 hours as needed for severe pain. 3. [MEDICATION NAME] 10/325 (10 mg of [MEDICATION NAME] and 325 mg of [MEDICATION NAME]) mg every 6 hours as needed for breakthrough pain (pain which had not been relieved with another medication). On 10/6/18, LN's documented in the nursing notes that Resident 1 had pain unrelieved by medication and the physician was contacted. The physician discontinued the [MEDICATION NAME], and [MEDICATION NAME] and ordered: 1. [MEDICATION NAME] (a pain medication) 5 mg every 4 hours as needed for moderate pain 2. [MEDICATION NAME] 10 mg every 4 hours as needed for severe pain. Per the facility policy, titled Pain Management, dated (MONTH) (YEAR), LNs were to assess Resident 1's pain, document the assessment, administer pain medication per the physician's orders [REDACTED]. If pain was unrelieved, nurses were to notify the physician. According to the EMAR, dated 10/1-10/31/18, LN's documented Resident 1's pre-medication pain assessment pain scale was never less than 6. No nursing documentation was found indicating the licensed nurses had notified Resident 1's physician when Resident 1's pain medication was ineffective from 10/7/18 through 10/23/18. According to the Weekly Summary, dated 10/23/18, the Assistant Director of Nursing (ADON) documented Resident 1 verbalized his pain medication was not effective. On 10/24/18 LN 4 documented Resident 1's physician ordered a pain consultation (physician who specializes in treating pain). On 10/29/18, the LNs documented Resident 1 was sent to the hospital. When Resident 1 returned to the facility on [DATE], the pain consultation was not re-ordered. On 11/11/18, the LN's documented in the nursing notes that Resident 1's pain increased and the physician was notified. Resident 1's physician ordered [MEDICATION NAME] 20 mg, every 4 hours as needed, and discontinued the previous [MEDICATION NAME] orders. Per the physician's orders [REDACTED]. According to Resident 1's EMAR, dated 11/16/18 through 11/18/18, LNs documented Resident 1's pain medication was ineffective 5 times. There was no documentation indicating the LNs notified Resident 1's physician the pain medication was ineffective during that time. Per the notes of the pain consultant dated 11/19/18, Resident 1 was examined and no changes were made to his medications. According to the EMAR, dated 11/23/18 through 11/28/18, LNs documented Resident 1's pain medication was ineffective 7 times. There was no documentation found indicating the LNs notified Resident 1's physician the pain medication was ineffective from 11/23/18 to 11/28/18. On 12/20/18, at 10:42 A.M., an observation and interview was conducted with Resident 1. Resident 1 was lying in bed. Resident 1 stated from the day of admission on 10/5/18, until 12/10/18, his pain was horrible, the pain medication did not work even a little and he had been absolutely miserable. Resident 1 stated the pain made him feel irritated, frustrated and he had given up and did not care anymore. Resident 1 stated from 10/5-12/10/18, he had experienced tremendous pain in his back every time his brief (an adult diaper) was changed, during transfer from bed to wheelchair and when he had been moved by staff. Resident 1 stated, during physical therapy (therapy for the restoration of movement and physical function), he told the staff he had pain and the staff had not changed his position or provided pain medication. Resident 1 stated when he had complained about severe pain during his physical therapy, his sessions ended. Resident 1 further stated he had experienced so much pain that he could not sleep, could not lay flat and suffered constant burning, stabbing pain in his back and nothing alleviated it. Resident 1 stated I would have tried anything to get pain relief. Resident 1 stated from 10/5-12/20/18, his pain had never been below a 6. Resident 1 stated he had never reported a pain level of zero to the nurses. Resident 1's record was reviewed. Per the physician's orders [REDACTED]. Per Resident 1's EMAR, LN's documented Resident 1's pain levels each shift as follows: 11/1-11/30/18, a 0 was entered 36 times. 12/1-12/10/18, a 0 was entered 43 times. Resident 1's EMARs, dated 10/1/18- 11/30/18, indicated LNs documented Resident 1's pre-medication pain levels were never less than 6. Resident 1's EMAR, dated 12/1-12/10/18 indicated LNs documented Resident 1's pre-medication pain assessment pain scale was never less than 5. Per the EMAR, the re-assessment of Resident 1's pain, after pain medication was given, was documented by the LNs as follows: 10/1-10/31/18, a 0 was entered 100 times. 11/1-11/30/18, a 0 was entered 71 times. 12/1-12/10/18, a 0 was entered 37 times. On 12/20/18 at 11:20 A.M., an interview with LN 4 was conducted. LN 4 stated the pain specialist visited the facility weekly and any resident in the facility could have been added to his list to be seen. On 12/26/18, at 11:10 A.M, a joint interview and record review was conducted with LN 1. LN 1 reviewed Resident 1's EMAR pre-medication pain assessment, dated 12/26/18, at 10 A.M. LN 1 stated she had recently documented a zero for Resident 1's pain scale. LN 1 further stated she documented Resident 1's pain scale as a zero because the pain medication was routine. On 12/26/18, at 3:15 P.M., an interview was conducted with Resident 1. Resident 1 stated, on 12/26/18, he told the medication nurses his pain level was a 7 at 10 A.M., and a 7.5 at 2 P.M. On 12/26/18, at 3:34 P.M., an interview and joint record review was conducted with LN 2. LN 2 reviewed Resident 1's EMAR dated 12/26/18, at 2 P.M., and stated Resident 1 had told him his pain was a 7.5. LN 2 further stated I documented a zero. On 1/3/19, at 4 P.M., a telephone interview was conducted with FAM 1. FAM 1 stated, following Resident 1's admission to the facility, he had sounded sad, not upbeat like usual. FAM 1 stated Resident 1 said he had given up and I quit due to the pain. FAM 1 stated she had observed he had been uncomfortable lying in bed. FAM 1 stated she had observed Resident 1 reporting his pain to direct care staff during care and when transferred out of bed. On 1/11/19, at 8:35 A.M., an interview and joint record review was conducted with the DOR. The DOR reviewed the Occupational Therapy (therapy for self-care skills-OT) and Physical Therapy (PT) notes for Resident 1, dated 10/8-10/11/18. The DOR stated Resident 1 had experienced severe pain during therapy and prevented Resident 1 from fully participating in therapy. The DOR stated there was no documentation indicating nursing or Resident 1's physician had been notified of Resident 1's pain. The DOR stated he had not reported Resident 1's pain to the physician. The DOR reviewed the OT and PT weekly evaluations for Resident 1, dated 10/16-10/24/18. The DOR stated Resident 1 had complained of low back and rib pain during therapy. The DOR stated Resident 1 had been given pain medication prior to therapy and still experienced pain at a level that required modification of exercises or ending therapy sessions. The DOR stated on 11/24/18, due to severe pain limiting Resident 1's progress during therapy sessions, his Physical Therapy and Occupational Therapy was discontinued. On 1/11/19, at 2:20 P.M., an interview was conducted with LN 3. LN 3 stated she had been responsible for administering Resident 1's pain medications and he had usually reported that his pain scale was an 8. LN 3 stated she had not noticed Resident 1's pain medication was ineffective. LN 3 stated she had not analyzed previous LNs documentation regarding Resident 1's pain medication effectiveness, because it was difficult to retrieve and view the data within the computer system. LN 3 stated if a resident continued to have severe pain, the physician should have been notified. On 1/11/19, at 3:43 P.M., an interview was conducted with the Pharmacist (Pharm 1). Pharm 1 stated Resident 1's pain medications were reviewed on 10/26/18. Pharm 1 stated he notified the DON Resident 1's pain needed to be reassessed, because Resident 1 had taken PRN (as needed) pain medication around the clock and continued to have high levels of pain. Pharm 1 stated he was aware the facility failed to follow up or take action on his recommendations for two months. On 1/17/19, at 10:12 A.M., an interview was conducted with the DON. The DON stated the LNs did not correctly analyze the pain information gathered from each shift for Resident 1. The DON stated the nurses did not consistently report to Resident 1's physician when the pain medication was not effective. The DON further stated the facility did not anticipate the resident's pain management needs and instead waited for the resident's to report high levels of pain. The DON stated the pain management program had not been revised in a timely manner for Resident 1 and as a result, Resident 1 experienced uncontrolled pain. The DON stated the team had discussed Resident 1's pain but failed to follow the facility's policy to provide an effective pain management program. The DON further stated she failed to address the pharmacist's recommendations on 10/26/18, to re-evaluate Resident 1's pain medication and interventions, until December. On 1/18/19, at 4:10 P.M., an interview was conducted with the Medical Director (MD). The MD stated Resident 1's severe pain had not been resolved quickly. The MD stated the LNs had not performed an analysis of pain assessments for Resident 1. The MD stated the LNs had not consistently communicated with Resident 1's physician when pain medication had been ineffective. The MD stated the facility's pain management program needed to be improved. On 1/18/19, at 4:40 P.M., an interview was conducted with the ADM. The ADM stated members of the healthcare team needed to meet with the MD more frequently to address and evaluate resident's pain management programs in a timely manner. Per the facility's policy, dated (MONTH) (YEAR), titled Pain Management, Purpose, the purpose of this procedure is to assess the resident's pain level and provide optimal comfort through a pain control plan which is mutually established with the resident, family and members of the health care team. General Guidelines .3. Continuing assessment of the pain management program will occur daily and will focus on the effectiveness of the program and the comfort level of the resident. Procedure .9. If pain is . not relieved with current medication, the physician will be notified for review of medication .10. Acceleration of interventions will be reflected in the resident's care plan 2. Resident 2's medical record was reviewed. Resident 2 was admitted on [DATE], with [DIAGNOSES REDACTED]. Per the hospital ICU Admission H&P (History and Physical), Resident 2's pain was managed with [MEDICATION NAME] (a pain medication) and [MEDICATION NAME]es (a pain medication delivered through the skin on a patch). According to physical therapy and occupational therapy notes, dated 5/28/18 through 7/4/18, Resident 2 had been evaluated by orthopedic surgeons for surgical repair of the [MEDICAL CONDITION] and had not received the surgical procedure yet. Resident 2's care plan interventions for hip pain, dated 5/28/18, indicated Resident 2 was to be assessed for pain medication effectiveness, and to notify the physician if pain was unrelieved through nursing interventions or medications. According to the Order Summary Report, signed 11/2/19, Resident 2 had physician's orders [REDACTED].>1. [MEDICATION NAME]es to be applied to both hips daily. 2. [MEDICATION NAME] (a pain medication) 5 milligrams (mg) every four hours as needed for moderate pain 3. [MEDICATION NAME] 7.5 mg every 4 hours as needed for severe pain Per the facility policy, titled Pain Management, dated (MONTH) (YEAR), LNs were to assess the resident's pain, document the assessment, give pain medication per the physician's orders [REDACTED]. If pain was unrelieved, nurses were to notify the physician. According to the Nursing Weekly Summary, dated 11/5/18, Resident 2 continued to wait for the surgeon to approve and arrange surgical repair of the two [MEDICAL CONDITION]. The LN documented Resident 1 stated he was looking forward to the day when he will be able to walk again without being in pain. According to the Electronic Medication Administration Record [REDACTED].M., and 2:30 P.M. No documentation was found that LNs notified Resident 2's physician. According to the nursing notes, dated 11/13/18, the LNs documented Resident 2 had been encouraged to get out of bed and he had stated he could not get out of bed due to pain. On 11/15/18, the LNs documented Resident 2 could not shower or be weighed due to pain. No new care plan interventions were documented by the LN's addressing Resident 1's inability to complete self-care due to pain. According to the nursing notes, dated 11/16/18, the LNs documented an attempt had been made to transfer Resident 2 out of his bed and the transfer was unsuccessful due to pain. The LNs documented Resident 2 had been given pain medication prior to the attempted transfer. The LNs documented Resident 2 would be seen by the pain specialist (physician who specializes in treating pain) on 11/16/18. According to a later entry, Resident 2's pain specialist visit did not occur until 11/19/18. On 11/19/18, the Pain Consultant (physician who specializes in treating pain) assessment stated Resident 2 had Chronic pain due to .bilateral (both sides) femur (leg bone) fractures, chronic low back pain, chronic neck pain, chronic bilateral hip pain, failed back syndrome, (and) failed neck syndrome (unsuccessful surgical procedure on the back or neck leading to chronic pain). The pain consultant documented Resident 2's hips were very tender to touch. According to the Consultant Pharmacist's Medication Regimen Review, dated 11/27/18, the consulting pharmacist recommended Resident 2's physician re-evaluate Resident 2's pain due to frequent use of pain medication. On 11/30/18, LNs documented in the nursing notes that Resident 2's physician was notified of the pharmacist's recommendations and no changes were made. On 12/20/18, at 9:50 A.M., an observation and interview was conducted with Resident 2. Resident 2 was lying in bed. Resident 2 stated he could not get out of bed due to pain. Resident 2 stated staff attempted to get him out of bed with a mechanical lift (an assistive device that allows patients with limited mobility to be transferred out of bed) and despite having taken pain medication ahead of time, he could not tolerate being moved due to the pain. Resident 2 stated the staff tried a second time but he could not tolerate being moved due to pain. On 12/20/18, at 11:05 A.M., an interview was conducted with CNA 5. CNA 5 stated when Resident 2 complained of pain, she reported it to the nurse. CNA 5 further stated after the nurses gave Resident 2 his pain medication, he would call and say he was still in pain. On 12/26/18, at 10:13 A.M, an interview was conducted with The Director of Rehabilitation (DOR). The DOR stated Resident 2 had a lot of pain all the time and refused therapy due to pain. The DOR stated Resident 2 would agree to therapy, and when he tried to move Resident 2, he yelled Lay me back down! The DOR stated he attempted to transfer Resident 2 on 11/16/18 and Resident 2 screamed in pain. On 12/26/18, at 10:31 A.M., an interview was conducted with CNA 6. CNA 6 stated Resident 2 experienced pain when he was moved and had stayed in bed all of the time due to pain. On 1/11/19, at 10:55 A.M., an interview was conducted with CNA 2. CNA 2 stated Resident 2 had asked for a shower. CNA 2 stated while transferring Resident 2 out of bed, Resident 2 had a lot of pain and clenched his teeth due to pain throughout the shower. CNA 2 stated Resident 2 could not tolerate getting up for showers after that, due to pain. On 1/11/19, at 11:30 A.M., an interview was conducted with CNA 3. CNA 3 stated resident 2 was always in pain. CNA 3 stated Resident 2 was continent of bowels (able to control bowel movements) and was unable to use a bed pan because of the pain. CNA 2 further stated Resident 2 had to have bowel movements on a disposable pad while lying in bed. On 1/17/19, at 10:12 A.M., an interview was conducted with the DON. The DON stated the nurses did not consistently report to Resident 2's physician when the pain medication was not effective. The DON further stated the facility did not anticipate the resident's pain management needs and instead waited for the resident's to report high levels of pain. The DON stated the pain management care plan had not been revised in a timely manner for Resident 2 and as a result, Resident 2 experienced episodes of uncontrolled pain. The DON stated the team had discussed Resident 2's pain but failed to follow the facility's policy to provide an effective pain management program for Resident 2. On 1/18/19, at 4:10 P.M., an interview was conducted with the Medical Director (MD). The MD stated Resident 2's severe pain had not been resolved quickly. The MD stated the LN's had not communicated with Resident 2's physician when pain medication had been ineffective. The MD stated the pain management program needed improvement. On 1/18/19, at 4:40 P.M., an interview was conducted with the ADM. The ADM stated members of the healthcare team needed to meet with the MD more frequently to address and evaluate Resident 2's pain management in a timely manner. Per the facility's policy, dated (MONTH) (YEAR), titled Pain Management, Purpose, The purpose of this procedure is to assess the resident's pain level and provide optimal comfort through a pain control plan which is mutually established with the resident, family and members of the health care team. General Guidelines .3. Continuing assessment of the pain management program will occur daily and will focus on the effectiveness of the program and the comfort level of the resident. Procedure .9. If pain is . not relieved with current medication, the physician will be notified for review of medication .10. Acceleration of interventions will be reflected in the resident's care plan

Based on observation, interview, and record review, the facility failed to ensure that timely medical interventions were provided to 1 of 24 sampled residents (162). physician's orders [REDACTED]. Findings: A closed record review was conducted for Resident 162. According to the facility's Discharge sheet, Resident 162 died on [DATE]. Resident 162 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the nurses progress notes, indicated that on [DATE] at 10:12 P.M., Resident 162 complained of right leg pain ,[DATE] (5 out of 10, with 10 being the highest level). Per the same note, the resident grimaced and was not able to perform her baseline activities of daily living. Per the same note, the resident leaned on her left side. A review of the nurse's progress notes, dated [DATE], indicated that at 6:09 A.M., Resident 162 complained of generalized body pain at ,[DATE]. Per the same note, the resident was medicated with [MEDICATION NAME]/[MEDICATION NAME] (pain medication) ,[DATE] milligrams (mg). Further review of the nurse's progress notes indicated that on [DATE] at 1:10 P.M., Resident 162 had episodes of shaking, increased confusion, and a temperature of 102.9 Fahrenheit. The nurse's notes indicated that the resident's physician was informed about the resident's condition and gave orders for STAT (immediately) BNP (Brain natriuretic peptide test - a blood test that measures levels of protein made by your heart and blood vessels), STAT x-ray, and STAT doppler ultrasound. Further review of the nurse's progress notes, dated [DATE], indicated that at 11:53 P.M., the ordered STAT doppler ultrasound was pending. A review of the nurse's progress notes, dated [DATE], indicated that at 7:27 A.M., Resident 162 vomited one time. Per the same note, at 8:22 A.M., the resident vomited a large amount of green watery substance, and a message was left with the resident's physician. Per the same note, at 9:07 A.M., the resident complained of nausea with episodes of green projectile vomiting. Further review of Resident 162's nurse's progress notes, dated [DATE], indicated that at 10 A.M., the nurse practitioner (NP) 1, who worked with the resident's physician, called back. NP 1 ordered [MEDICATION NAME] (a medication to help with nausea and vomiting) 4 mg and D5 ([MEDICATION NAME])-,[DATE] NS (normal saline) 70 ml (milliliters)/hour. The nurse's note also indicated that the result of the doppler ultra sound was reported to NP 1. Per the nurse's notes, NP 1 ordered [MEDICATION NAME] (a medication used to treat or prevent a type of blood clot) and [MEDICATION NAME] (a medication used to prevent [MEDICAL CONDITIONS], and blood clots in veins and arteries). A review of Resident 162's Ultrasound Report, dated [DATE], indicated that the resident had thrombus (blot clot) in the right femoral (thigh), right posterior tibial (back side of the lower leg), and right anterior tibial (front side of the lower leg) veins. A review of Resident 162's Medication Administration Record [REDACTED]. A review of Resident 162 nurse's progress notes, dated [DATE], indicated that at 3:15 P.M., the resident was lethargic and weak. With SOB (shortness of breath) at this time. PRN (as needed) O2 (oxygen) @ (at) 2 LPM (liters per minute) via nasal cannula (a device used to deliver supplemental oxygen) initiated. Per the same nurse's notes, at 4 P.M., Resident 162 complained of a headache at ,[DATE]. The nurse's notes indicated that at 4:25 P.M., When CNA (certified nursing assistant) transferred resident from bed to wheelchair, noted resident pale, cold, and clammy not responding to shaking and painful stimuli. Reported to LN (licensed nurse), vital signs taken, not appreciated (could not register). POLST (Provider Orders for Life-Sustaining Treatment - encourages providers to speak with patients and create specific medical orders to be honored by health care workers during a medical crisis) checked with other LN 3 times, resident is full code. CPR (cardiopulmonary resuscitation - a procedure to support and maintain breathing and circulation ) initiated and called 911 paramedics. At 4:30 P.M., the paramedics took over and continued to provide Resident 162 CPR. The nurse's notes indicated that at 4:52 P.M., Per 911 paramedics, (name of physician) from (name of hospital) pronounced that resident passed away at 4:52 P.M. An interview with Resident 57, Resident 162's roommate, was conducted on [DATE] at 4:25 P.M. Resident 57 stated that Resident 162 complained of a headache for 3 days. Resident 57 also stated that Resident 162 complained of pain in her right leg. Resident 57 stated that Resident 162 was in pain the whole night of [DATE]. Resident 57 also stated that Resident 162 refused to take pain medication. An interview and joint record review with the director of nursing (DON) and assistant director of nursing (ADON) was conducted on [DATE] at 7:40 A.M. The DON stated that she and the administrator were not in the facility on [DATE], when Resident 162 died . The DON stated that the ADON was in the facility. The ADON stated she heard a code blue announced via the overhead paging system. The ADON stated that when she got to Resident 162's room, CPR was already initiated. The ADON stated that she was informed by the unit nurse supervisor that Resident 162 had episodes of vomiting that day. An interview with the unit nurse supervisor (UNS) and the director of nursing (DON) was conducted on [DATE] at 8:31 A.M. The UNS stated that he was informed on [DATE] at approximately 9 or 10 A.M. that Resident 162 had episodes of vomiting. The UNS stated that he did not assess Resident 162 until approximately 12:30 to 1 P.M. The UNS stated that the licensed vocational nurses (LVN)s in the unit were competent to assess the resident's condition. The DON stated that, She (Resident 162) should have been re-assessed sooner. An interview and joint record review with the DON was conducted on [DATE] at 9:15 A.M. The DON read Resident 162's nurse's progress notes. The DON was not able to say when the STAT doppler ultrasound was done for Resident 162. The DON stated that NP 1 ordered IV fluids for Resident 162 on [DATE] at 10 A.M., but this was not carried out. The DON stated that the IV fluids should have been provided to Resident 162, who had episodes of vomiting. An interview and joint record review with the assistant director of nursing (ADON) was conducted on [DATE] at 2 P.M. The ADON provided this writer a copy of the Radiology Ultrasound Requisition, dated [DATE]. Per the requisition, the ultrasound was completed on [DATE] at 9:28 A.M., 20 hours and 18 minutes after the STAT order was given. The ADON stated that the STAT order was not done as ordered. The ADON stated that a STAT order should be done within 4 hours of the order being given. The ADON also stated that there was no evidence in the record that the ordering physician was informed that the STAT order for ultrasound was not done as ordered. A phone interview with Physician 1, Resident 162's attending physician, was conducted on [DATE] at 2:40 P.M. Physician 1 stated that she was dependent on what the nurses reported to her. Physician 1 stated that base on what the nurse reported to her, she ordered STAT x-ray and STAT doppler ultrasound for Resident 162. Physician 1 stated that STAT orders meant that the order will be done within 4 hours. Physician 1 also stated that she wanted to rule out [MEDICAL CONDITION] ([MEDICAL CONDITION] - the formation of a blood clot (thrombus) within a deep vein, most commonly the legs). Physician 1 stated that if a [MEDICAL CONDITION] was found in the ultrasound, she would start Resident 162 on [MEDICATION NAME] and [MEDICATION NAME]. Physician 1 stated that she was not aware that the STAT doppler ultrasound was not done for Resident 162. Physician 1 stated that she was not aware that the order given by NP 1 for IV fluids and [MEDICATION NAME] were not given to Resident 162. Physician 1 stated that the [MEDICATION NAME] should have been given immediately because the resident had blood clots. A phone interview with Physician 2, physician covering for the Medical Director, was conducted on [DATE] at 3:34 P.M. This writer informed Physician 2 regarding Resident 162's delayed care, based on staff interviews and record review. Physician 2 stated, It should not have happened. A phone interview with licensed nurse (LN) 3 was conducted on [DATE] at 9:15 A.M. LN 3 stated that she worked the PM shift (,[DATE] shift) on [DATE]. LN 3 stated that the she was informed, during the change of shift report on [DATE], that a STAT order for a doppler ultrasound was still pending for Resident 162. LN 3 stated that a STAT order had to be done within 2 to 4 hours. LN 3 stated that she called diagnostic lab to follow up and was told that they were coming. LN 3 stated that she also called the resident's physician to inform her that the STAT doppler ultrasound had not been carried out. LN 3 stated that she forgot to document the call she made to the physician. LN 3 was informed by this writer that Physician 1 denied being informed about the STAT doppler ultrasound not being carried out. LN 3 did not provide a response. LN 3 stated that she worked the PM shift on [DATE]. LN 3 stated that she was informed, during the change of shift report on [DATE], that an IV line needed to be started on Resident 162. LN 3 stated that she was not aware that the order for the IV fluids was given at 10 A.M. that morning due to vomiting. LN 3 stated that the IV line should have been started sooner in order to provide the resident IV fluids. A phone interview with NP 1 was conducted on [DATE] at 10:03 A.M. NP 1 stated she was informed about Resident 162's [MEDICAL CONDITION]. NP 1 stated that she ordered [MEDICATION NAME] and [MEDICATION NAME]. NP 1 stated that the first dose of [MEDICATION NAME] was supposed to be given immediately. NP 1 stated that she was not aware that Resident 162 did not receive the ordered IV fluids and the [MEDICATION NAME]. NP 1 also stated that she was not aware that the doppler ultrasound, that was done on [DATE], was a STAT order from the day before ([DATE]). NP 1 stated that, This is not a Laissez-Faire (attitude of letting things take their own course, without interfering) type of condition. A review of the facility's policy and procedure titled STAT Response Time/Report Turnaround Time, dated [DATE], was conducted. The policy indicated, Purpose: To provide prompt delivery of service when a STAT ultrasound is requested, as indicated by clinical urgency, in order to expedite patient medical management. The policy also indicated, . Venous exams to rule out Thrombus will take priority over other STAT requests. The policy did not provide clear guidance related to the timeframe of when the STAT order should be completed. A review of the facility's policy and procedure titled Change in a Resident's Condition or Status, revised ,[DATE], was conducted. The policy indicated, . The nurse supervisor/charge nurse will notify the resident's attending physician or on-call physician when there has been: .e. A need to alter the resident's medical treatment significantly. The facility did not have a written policy related to following physician's orders [REDACTED]. An interview with the DON was conducted on [DATE] at 10:40 A.M. The DON stated that the STAT doppler ultrasound for Resident 162 should have been done as ordered. The DON stated that the ordering physician should have been informed when the STAT order was not carried out. The DON stated that Resident 162 should have been provided with IV fluids as ordered by the nurse practitioner. The DON stated that the [MEDICATION NAME] should have been given immediately. The DON also stated that if the order was unclear, the nurse should have clarified with the nurse practitioner when the [MEDICATION NAME] should be given, especially if it was already known that Resident 162 had [MEDICAL CONDITION] in three areas of her body.

Based on observations, interviews, and record reviews, the facility failed to implement a comprehensive systemic approach, to ensure that acceptable parameters of nutritional status were maintained for 5 of 25 sampled residents (58, 13, 17, 48, 35) and 3 of 5 extended sampled residents (151, 143, 51) when: 1. The facility failed to address unplanned slow gradual progressive weight loss prior to becoming an unplanned significant weight loss for Resident 58, 151, 13, 17, 48, 35, 51. 2. The facility failed to identify and address an unplanned significant weight loss (loss of body weight greater than 5% in month) for Residents 151, 13, 17, 35, 143. The facility's system was not effective at identifying and addressing slow gradual progressive weight changes prior to the weight changes becoming significant. The facility's interdisciplinary team, aside from the director of nursing (DON) and the registered dietitian (RD), were not involved in identifying, analyzing, and addressing unplanned slow gradual weight changes. The above cited systems failures had a potential to negatively impact and compromise the medical status of all residents residing in the facility. Elderly patients with unintentional weight loss are at higher risk for infection, depression and death. (American Family Physician, February 15, 2002/Volume 65, Number 4) Findings: 1. Resident 58 was re-admitted to the facility on [DATE] per the Resident Admission Record. A review of the History and Physical, dated 1/15/15, indicated that the resident had [DIAGNOSES REDACTED]. An observation and interview with Resident 58 was conducted on 8/4/15 at 9:00 A.M. Resident 58 sat in her bed with the over bed table in front of her. The resident's breakfast tray was on top of the over bed table. The resident ate all of the oatmeal, half of the egg dish, none of the toast, and none of the juice. The glass of milk was full with a quarter of milk left in the carton. According to the resident, she took sips of the milk. An interview with certified nursing assistant (CNA) 41 was conducted on 8/4/15 at 9:15 A.M. CNA 41 stated that Resident 58 usually ate 50-60% of her meals. CNA 41 stated that if a resident ate 50% or less of their meal, the resident would be offered a nourishment. A review of Resident 58's weight record indicated the following weights: 1/14/15 - 131 lbs (pounds) 1/15/15 - 130.4 lbs 1/17/15 - 129.4 lbs 1/18/15 - 131.4 lbs 1/19/15 - 131.7 lbs 1/20/15 - 130.8 lbs 1/21/15 - 131.2 lbs 1/22/15 - 130.6 lbs 1/23/15 - 131.4 lbs 1/24/15 - 130.9 lbs 1/25/15 - 132 lbs 1/26/15 - 132.6 lbs 1/31/15 - 132 lbs 2/7/15 - 130.6 lbs 2/14/15 - 128.9 lbs 2/22/15 - 127.1 lbs 2/28/15 - 124.7 lbs 3/7/15 - 127.2 lbs 3/14/15 - 126.2 lbs 3/21/15 - 124 lbs 3/28/15 - 126.6 lbs 4/4/15 - 124.4 lbs 4/11/15 - 124.3 lbs 4/18/15 - 124.8 lbs 4/25/15 - 125.6 lbs 5/2/15 - 122.8 lbs 6/6/15 - 120.2 lbs 7/4/15 - 118 lbs 7/13/15 - 115.6 lbs 7/18/15 - 114.8 lbs 7/25/15 - 115.7 lbs 8/1/15 - 114.6 lbs An interview and joint record review with licensed nurse (LN) 41 was conducted on 8/5/15 at 7:50 A.M. LN 41 was asked regarding the facility's process in identifying resident weight loss. LN 41 stated a weight loss or gain of 3 lbs in a week and 5 lbs in a month were reported to the director of nursing (DON) and the registered dietitian (RD). LN 41 did not know the facility's process for weight changes that did not meet the criteria of 3 lbs in a week and 5 lbs in a month. LN 41 reviewed Resident 58's weights from 1/14/15 to 8/1/15. LN 41 stated that the resident had gradual weight loss that started in 2/2015, which was later identified as significant weight loss in 7/2015. LN 41 reviewed the resident's records, and stated that she could not find documented evidence that interventions were implemented to address the resident's gradual weight loss. LN 41 further stated that the gradual weight loss should have been identified and addressed by the licensed nurses and the other interdisciplinary team (IDT). An interview and joint record review with the RD was conducted on 8/5/15 at 9:55 A.M. The RD stated that nurses notified her and the DON for weight changes of 3 lbs in a week and 5 lbs in a month. The RD stated that residents with significant weight changes were referred to the Weight Variance (changes) Committee. The RD stated that she and the DON met weekly to look at all the residents' weights. The RD stated that she became aware of the resident's weight loss on 4/8/15, when she conducted a quarterly assessment on the resident. However, the RD confirmed that the resident's gradual weight loss started in 2/2015. The RD stated that the resident's weight loss on 4/8/15 was not significant and confirmed that she did not implement any nutritional interventions, other than lowering the resident's weight goal from (128 -136 lbs) to (124 - 127 lbs). The RD stated that she lowered the resident's weight goal because the resident was holding stable at 124 lbs for one month. When asked whether the resident's weight loss was desirable or beneficial for the resident, the RD stated, I'm not going to say it's beneficial the resident is stable in that weight. The RD was asked if she informed the resident's physician regarding lowering the resident's weight goal, the RD stated that she did not. The RD further stated, RDs can make their own decision. The RD stated that the resident continued to have gradual weight loss from 4/2015 to 7/2015. The RD confirmed that she did not implement any nutritional interventions in response to the resident's continued gradual weight loss. The RD stated that there was no documented evidence that the cause of the resident's weight loss was looked at by anybody. The RD stated that on 7/4/15, the resident's weight was at 118 lbs, a weight loss of 13 lbs (10% unplanned significant weight loss) from 1/14/15 to 7/4/15. An interview and joint record review with the DON was conducted on 8/5/15 at 11:05 A.M. The DON stated that nursing staff notified her and the RD for weight changes of 3 lbs in a week and 5 lbs in a month. The DON stated that she and the RD met weekly to look at all the residents' weights and all the weight changes. The DON stated that she relied on the RD's expertise when reviewing the weight changes and implementation of nutritional interventions. A phone interview with Resident 58's responsible party (RP) was conducted on 8/5/15 at 3:30 P.M. The RP stated that she was informed about the resident's weight loss 2 weeks ago. The RP stated that she was not aware of the resident's weight loss prior to being informed 2 weeks ago. The RP also stated she had noticed that the resident's voice was softer and that the resident was not as spunky or energetic as she was, months ago. A review of Resident 58's care plan #3 titled Potential for Altered Nutrition R/T (related to) Dx (diagnoses): advanced dementia ., dated 1/13/15, was conducted. There were no documented evidence that interventions were initiated to address the resident's gradual weight loss. A phone interview with Resident 58's physician (Physician 41) was conducted on 8/6/15 at 9:15 A.M. Physician 41 stated that nursing staff informed him about the resident's significant weight loss but did not recall being informed about the resident's gradual weight loss. Physician 41 stated that he was not aware whether or not the resident had poor appetite. Physician 41 stated that the IDT should have identified and addressed Resident 58's gradual weight loss. Physician 41 stated that he relied on the RD's clinical judgement, but also stated that the RD should have informed him when the RD lowered the resident's weight goal. A review of Resident 58's CNA Flowsheet from 2/2015 to 8/2015 was conducted on 8/6/15 at 9:45 A.M. The flowsheets indicated the following: 2/2015 - 27 episodes of eating 50% or less and only 2 documented evidence that nourishment was offered. 3/2015 - 24 episodes of eating 50% and no documented evidence that nourishment was offered. 4/2015 - 22 episodes of eating 50% or less and 2 documented evidence that nourishment was offered. 5/2015 - 49 episodes of eating 50% or less and no documented evidence that nourishment was offered. 6/2015 - 36 episodes of eating 50% or less and no documented evidence that nourishment was offered. 7/2015 - 54 episodes of eating 50% or less and 3 documented evidence that nourishment was offered. 8/2015 - 7 episodes of eating 50% and no documented evidence that nourishment was offered. An interview with the director of staff development (DSD) was conducted on 8/6/15 at 10:30 A.M. The DSD stated that CNAs offered nourishments to residents who ate 50% or less of their meals. The DSD also stated that the CNAs documented the offered nourishment on the back of the CNA flowsheet, as well as, the amount of nourishment taken by the resident. Upon review of the CNA flowsheet, the DSD confirmed that there was a lack of documented evidence that Resident 58 was consistently offered nourishment when her meal intake was 50% or less. An interview with the DON was conducted on 8/10/15 at 2:25 P.M. The DON stated that after reviewing Resident 58's medical record with the RD and a consultant RD, the DON acknowledged that the resident's gradual weight loss should have been identified, analyzed, and addressed by the IDT prior to becoming an unplanned significant weight loss. The DON stated that she relied on the RD's expertise. The DON also stated that the facility's policy did not address gradual weight loss. An interview and joint record review with the RD was conducted on 8/10/15 at 4:00 P.M. A review of Resident 58's Nutritional Assessment, dated 1/19/15, indicated that the RD calculated the resident's required total calorie as, 60 kilograms (kg) x 25-30 cal/kg (calorie per kilogram) = 1500-1800 calories. However, a review of Resident 58's Nutritional Assessment, completed by the RD on 7/14/15, after the RD identified the resident's significant weight loss, indicated that the RD calculated the resident's required total calorie (calories needed to maintain body weight) as, 54 kg x 25-30 cal/kg = 1350-1620 calories, lower than the initial nutritional assessment. The RD was asked to explain why, that in spite of Resident 58's significant weight loss, the calculated required calorie for the resident was lower than the initial assessment. The RD stated that she made a mistake. The RD stated that she should have increased her calculations to, 54 kg x 35-40 cal/kg =1890-2160 calories. The RD acknowledged that, after she spoke to the RD consultant, interventions should have been implemented to address Resident 58's gradual weight loss prior to it being significant. The RD also acknowledged that she should not have lowered the resident's weight goal when the resident was experiencing a weight loss, unless the weight loss was planned and discussed with the IDT and the resident's RP. 2. A record review of Resident 151's medical record was conducted on 8/10/15 at 7:38 A.M. Resident 151 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 151's weight record indicated the following weights: 4/20/15 - 175.4 lbs (pounds) 4/25/15 - 163.8 lbs 5/2/15 - 161 lbs 5/9/15 - 159.6 lbs 5/16/15 - 157.9 lbs 5/23/15 - 155.7 lbs 5/30/15 - 149.5 lbs 6/6/15 - 148.3 lbs 6/13/15 - 147.8 lbs 6/20/15 - 145.3 lbs 6/27/15 - 144.2 lbs 7/4/15 - 141.4 lbs 7/11/15 - 139.2 lbs 7/18/15 - 144.4 lbs 7/25/15 - 143.6 lbs 8/1/15 - 145.8 lbs 8/10/15 - 144.2 lbs A review of Resident 151's Nutritional Assessment, dated 4/23/15, indicated that the resident was 6 feet 1 inch tall, with an admission weight of 175.4 lbs. The assessment also indicated that the resident's goal body weight was 165-175 lbs. A review of the nursing progress notes, dated 4/26/15 at 10:58 A.M., indicated that Resident 151 had a weight loss of 11.6 lbs (175.4 to 163.8 lbs) in 5 days (4/20/15 to 4/25/15). Per the same progress notes, the resident's physician (Physician 42), the registered dietitian (RD), the resident and the resident's responsible party (RP) were informed of the resident's weight loss. The progress notes also indicated that the resident's physician gave no orders to address the weight loss. A review of the RD progress note, dated 4/29/15 at 8:39 A.M., indicated that Resident 151 lost 11.6 lbs in 5 days. The progress note indicated that the RD discussed with resident possible ways to add calories to diet but resident wants to keep weight stable. The progress note indicated that the resident would be monitored. According to Resident 151's weight record, the resident continued to have gradual weight loss from 4/25/15 to 5/30/15. An interview was conducted with the DON on 8/11/15 at 8:55 A.M. The DON acknowledged that there was no documented evidence that the gradual weight loss was identified and addressed by the interdisciplinary team (IDT). A review of the nursing progress note, dated 5/31/15 at 9:14 P.M., indicated that Resident 151 consumes 17%-67% of the meal and lost 6.2 lbs. (155.7 lbs. to 149.5 lbs) in a week (5/23/15 to 5/30/15). The progress note also indicated that Physician 42 and the RP were informed about the weight loss. The progress note indicated that Physician 42 gave no orders to address the weight loss. A review of the RD progress note, dated 6/5/15 at 12:12 P.M., indicated that Resident 151's current weight was at 149.5 lbs. The progress note indicated that the resident declines nutrition supplement at this time. Will monitor upcoming weekly wt (weight). No current labs. Will adjust wt goal to 148-155 lbs. and monitor. There was no documented evidence that the RD discussed the plan of care with the RP and Physician 42. The resident lost 25.9 lbs (175.4 to 149.5 lbs) from 4/20/15 to 5/30/15, a 14% unplanned significant weight loss in 40 days. There was no documentation that indicated that the resident's significant weight loss was identified and addressed by the IDT. There were no documented evidence that the resident was referred to the Weight Variance (changes) Committee at this time. An interview with Resident 151's RP was conducted on 8/10/15 at 9:05 A.M. The RP stated that he was the resident's Durable Power of Attorney (legal decision maker) and had been the resident's decision maker since the resident was admitted to the facility. The RP stated that he was aware of Resident 151's weight loss, but was unsure what the facility did for the resident when the weight loss started. However, the RP stated that he was not sure what the facility did about it, when the resident started to lose weight. The RP stated that he was not aware that the RD spoke with the resident about weight goals. The RP also stated that he was not aware of the RD's conversation with the resident, when the resident refused nutritional supplements. The RP stated, I should be informed. According to Resident 151's weight record, the resident continued to have gradual weight loss from 6/6/15 to 6/27/15. However, there were no documented evidence that the continued gradual weight loss was identified and addressed by the IDT. A review of the nursing progress note, dated 6/30/15 at 11:50 A.M., indicated that Resident 151 developed an open area on his coccyx (tailbone area). Per the progress note, the resident consumes 33-100% of his meal with episodes of refusals. The progress note also indicated that Physician 42, the RD, and the RP were informed about the open area. A review of the RD progress note, dated 6/30/15 at 12:18 P.M., indicated that Resident 151 had a Stage II pressure ulcer (partial thickness loss of skin layer presenting as a shallow open ulcer with a red pink wound bed) on the coccyx area. Per the progress note, the resident's current weight was at 144.2 lbs. and the RD recommended fortified (food with extra nutrients added) diet, BMP (Basic Metabolic Panel - a blood test that measures your sugar level, fluid balance, and kidney function), [MEDICATION NAME] (a blood test to see whether you are getting enough nourishment, such as protein, from your diet), two Cal (nutritional supplement) 120 ml (milliliters) TID (three times a day) with med (medication) pass, and Vitamin C. A review of the laboratory result, dated 7/2/15, indicated that Resident 151's [MEDICATION NAME] level was low at 12 mg/dl (milligram per deciliter) with normal range at 17 - 34 mg/dl. An interview and joint record review with the RD was conducted on 8/10/15 at 4:20 P.M. The RD acknowledged that nutritional interventions were not implemented for Resident 151, until a pressure ulcer was identified. The RD stated that the facility's policy and procedure did not address gradual weight loss. A phone interview with Physician 42 was conducted on 8/11/15 at 9:58 A.M. Physician 42 stated that he would order supplements and blood tests for residents with weight loss concerns. When asked to explain why Resident 151 was not ordered blood tests and supplements prior to the development of the pressure ulcer, Physician 42 stated that he was informed about the resident's weight loss 2 weeks ago. 3. Resident 13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 13 has the capacity to understand and make decisions per Resident 13's History and Physical, dated 4/13/15. A concurrent observation and interview was conducted of Resident 13 on 8/6/15 at 8:50 A.M. Resident 13 sat in a wheelchair in her room, and looked out the window. Resident 13 stated she used to weigh about 123 pounds (lbs) and wanted to gain more weight. Resident 13 stated I was heavier before and stated she has lost a lot of weight since she was at the facility. A concurrent meal observation was conducted with certified nursing assistant (CNA) 2 and Resident 13 on 8/6/15 at 12:00 P.M. CNA 2 stated Resident 13 ate 60% of her breakfast (3 out of 5 items). A review of Resident 13's documented weights from 4/10/15 to 7/11/15 was conducted. This document indicated Resident 13 had weights as follows (in pounds): 4/10/15- 129.5 4/11/15 - 128.6 4/18/15- 122.8 4/25/15- 123.0 5/2/15 - 125.2 5/9/15- 123.2 5/16/15- 122.8 5/23/15- 115.2 5/30/15- 115.2 6/7/15 - 116.2 6/13/15 - 113.8 6/20/15 - 112.4 6/27/15 - 112.2 7/4/15 - 112.0 7/11/15 - 111.4 Resident 13 lost 7.8 pounds (lbs), 6.34% (percent), of her weight between 4/25/15 and 5/23/15 (28 days) and lost 18.1 lbs, 13.9% of her weight, from 4/10/15 to 7/11/15 (92 days). These percentages were greater than 5% in 30 days and greater than 7.5% in 90 days, indicating a significant weight loss for Resident 13. An interview was conducted with licensed nurse (LN) 1 on 8/5/15 at 12:10 P.M. LN 1 stated resident weights were obtained by the facility's restorative nursing aides (RNAs) on a weekly or monthly basis based on the physician order. If there is a difference of 3 lbs in a week or 5 lbs in a month, the RNA will give a slip to the charge nurse. The charge nurse will then notify the doctor and do an assessment for [MEDICAL CONDITION] and depression. LN 1 also stated dietician referrals were not necessary because the dietician also received the slip of paper from the RNAs and looked at all resident weights. LN 1 stated nursing did not look for trends in weight changes and if it is not 5 lbs or more in a month or 3 lbs or more in a week, it (a resident's weight) is not a problem. An interview was conducted with RNA 1 on 8/5/15 at 12:41 P.M. RNA 1 stated RNAs weighed residents weekly or monthly based on the physician's orders [REDACTED]. If weights met the criteria, RNAs filled out a paper and this paper was given to the charge nurse. RNA 1 stated this paper was not given to the registered dietician (RD). A review of Resident 13's nursing Resident Progress Notes, dated 4/18/15, 4/19/15, 4/21/15, 4/23/15, 5/24/15, and 6/4/15 was conducted. This document indicated: 4/18/15 - Resident noted with weight loss of 5.8 lbs in one week . No [MEDICAL CONDITION] (swelling) noted . Resident on NAS, (no added salt) NCS (no concentrated sweets) puree diet with nectar thick liquids. Average PO (by mouth) meal intake of 50-100%. MD (doctor) made aware, still awaiting response. 4/19/15 - No new order received from (name of Resident 13's physician) for weight loss of 5.8 lbs in one week. 4/21/15 - Resident noted with +4 (degree of swelling, on a scale of 1 to 4 with 4 being most severe) [MEDICAL CONDITION] to BLE (bilateral lower extremities) . Left a message for (name of Resident 13's physician). Awaiting response at this time. 4/23/15 - Pedal (foot) [MEDICAL CONDITION] resolved. 5/24/15 - Noted with weight loss of 7.6 lbs in 1 week. No s/s (signs and symptoms) of dehydration, expected due to poor PO intake, intake is only 50% most meals, also resident +4 [MEDICAL CONDITION] to BLE now resolved. (name of Resident 13's physician) made aware, with no new order . 6/4/15 - Noted resident weight loss of 7.6 lbs in a week. meal intake 50-100%. no [MEDICAL CONDITION] noted current snack and supplement order consuming well, RP (responsible party) and MD notified and also order obtained from MD. RD (registered dietician) recommendations: fortified (extra calories and nutrients) diet to add to current diet, increase house nourishments to TID (three times daily) between meals and increase snack to BID (twice daily) 10 am and HS (evening). order noted and carried out . This document indicated nursing and Resident 13's physician had been aware of Resident 13's gradual weight loss since 4/18/15 but no interventions had been implemented until 6/4/15. Resident 13 lost 6.34% of her weight between 4/25/15 and 5/23/15 (28 days) indicating a significant weight loss. A review of Resident 13's (Facility name) Nutritional Assessment, dated 4/13/15, was conducted. This document indicated Resident 13's IBWR (ideal body weight range) as 113-138# (pounds) with a GBW (goal body weight) as 126-138#. Additionally, this document indicated, Spoke with resident. Noted with significant wt loss in 90 days. Wt reported at 140# 2-3 months ago . Resident denies any decrease in po intake. Wt (weight) loss likely r/t (related to) dx of PNA (pneumonia - lung infection). Current wt within IBWR. Resident accepting of wt goal range 126-136#, reports being ok at current wt. Accepting of house nourishment for additional nutrition .REC (recommendation) 1. house nourishment 1x daily at 10am. This document also indicated a calculation for total protein, calories and fluids that met the needs of Resident 13. This calculation utilized Resident 13's admission weight, 58 kg (kilograms), and not the usual weight reported by the resident 2-3 months ago (140 lbs or 63 kg) as indicated in the (Facility name) Nutritional Assessment. The documented nutrition calculations were as follows: 58 kg x 25-30 cal/kg = 1450-1740 calories 58 kg x .8-1.1 g/kg = 46-64 g protein 58 kg x 25-30 ml/kg = 1450-1740 ml fluid If the RD had utilized Resident 13's usual body weight for nutrition calculations instead of the resident's admission weight (a significant weight loss as indicated by the (Facility name) Nutritional Assessment), the calculations for calories, protein and fluids would be increased as follows: 63 kg x 25-30 cal/kg = 1575-1890 calories 63 kg x .8-1.1 g/kg = 50.4-69.3 g protein 63 kg x 25-30 ml/kg = 1575-1890 ml fluid A review of all Resident 13's dietary Resident Progress Notes, dated 4/10/15 to 6/16/15, were conducted. These documents indicated: 5/28/15 - Resident noted with a 7.6# wt loss this week. Current wt at 115.2#. Noted with a 6.3% loss in 30 days. Wt had been trending between 122-125# over past month. Was admitted in April with a wt of 128#. Reported wt of 140# back in Jan and Feb. IBWR 113-138#. Resident continues to report a good appetite, likes the food served. Meal intake 50-100%, most > (greater than) 75% looking over past 7 days. Resident does report to be a slow eater, nursing confirms this. She denies and problems with self feeding. Order for house nourishment 1 x daily at 10am, consuming well per resident and nursing. Also gets HS (evening) snack daily. Noted with 4+ [MEDICAL CONDITION] to BLE on 4-1-15 and now resolved per nursing. ST (speech therapy) approved m/soft (mechanical soft - easy to chew) snacks on 5/7/14. REC (recommendations) 1. fortify diet 2. increase house nourishment to tid (3 times daily) between meals 3. increase snacks to bid (twice daily) 10 am and continue with HS. 6/16/15 - Start resident in weight variance (changes) d/t weight loss. There was no intervention or monitoring of Resident 13's weight by the RD until 5/28/15 and the order for the interventions recommended by the RD was not obtained until 6/4/15. This documentation also indicated Resident 13 had 4+ [MEDICAL CONDITION]. A review of the nursing progress notes indicated Resident 13 had 4+ [MEDICAL CONDITION] for 3 days (4/21/15 to 4/23/15). In addition, Resident 13 continued to lose weight and was not followed by the Weight Variance Committee until 6/16/15, 63 days after Resident 13 started losing weight and after significant weight loss had already occurred. A review of Resident 13's Medication Flowsheet, dated 4/21/15 to 5/21/15, was conducted. This document indicated an X or - in the ml (milliliters) box next to House nourishment Once a Day. There was no evidence indicating the volume of the house nourishment Resident 13 had consumed from 4/21/15 to 5/21/15. This documentation indicated no monitoring had been consistently implemented by nursing or the RD to evaluate the effectiveness of the intervention recommended by the RD on 4/13/15. A review of Resident 13's CNA (certified nursing assistant) Flowsheet, dated April - June 2015 was conducted. These documents indicated N (No) or NA (Not Applicable) next to AM (morning) Snack Taken for June 1-30. This document also indicated N or NA next to HS Snack Taken for April 9-30 and May 1-31, indicating Resident 13 had not consistently received AM or HS snacks which contradicted the RDs note on 5/28/15. The RDs recommendation on 5/28/15 to increase snacks to bid 10 am and continue with HS was not implemented when the documentation indicated Resident 13 had not received an AM snack from June 1-30 and had not been consistently receiving HS snacks since 4/10/15. A review of Resident 13's CNA Flowsheet, dated April - June 2015 was conducted. This document indicated average meal intake percentages for Resident 13 as follows: April 2015: Breakfast - 63%, Lunch - 56%, and Dinner - 62% May 2015: Breakfast - 86%, Lunch - 61%, and Dinner - 84% June 2015: Breakfast - 77%, Lunch - 63%, and Dinner - 71% This documentation indicated Resident 13 did not consistently consume 75% or more of her meals as indicated by the RD. An interview was conducted with CNA 2 on 8/6/15 at 7:35 A.M. CNA 2 stated Resident 13 eats slow and sometimes eats a little snacks. CNA 2 stated she had worked with Resident 13 since Resident 13 had been at the facility and stated, she does not complain about the food and sometimes she eats a little and sometimes she eats a lot. A review of Resident 13's care plan titled, Potential for dehydration due to weight loss, dated 4/18/15 to 7/20/15, was conducted. This document indicated interventions to be implemented for Resident 13. These interventions included, RD consult PRN (as needed) and Update food preferences. Both of these interventions were initiated on 4/18/15. A review of Resident 13's IDT (interdisciplinary team) Assessment of Significant Weight Change (weight variance committee), dated 6/16/15 was conducted. This document indicated IDT recommendations to address Resident 13's continued weight loss as follows: Update Preferences and Consider hospice consult for worsening dementia 6-8-15. The intervention of update preferences had previously been implemented on Resident 13's care plan on 4/18/15. Consider hospice consult for worsening dementia 6-8-15 was the only new intervention recommended by the IDT for Resident 13's continued weight loss. In addition, the IDT did not identify that Resident 13 had received snacks as ordered and the nourishment intake monitoring had not been documented. A review of Resident 13's physician Resident Progress Notes, dated 4/16/15 to 6/9/15 was conducted. There was no documentation related to the resident's weight loss, nor interventions implemented to address the resident's gradual weight loss. A telephone interview was conducted with Resident 13's physician on 8/11/15 at 10:00 A.M. Resident 13's physician stated it was his practice to address any reversible issues that may have contributed to a resident's weight loss when a weight change was reported to him by nursing staff. Resident 13's physician stated, if weight loss is reported, I address it. Resident 13's physician acknowledged Resident 13's weight loss should have been addressed sooner, before the weight loss was significant. An interview was conducted with LN 2 on 8/6/15 at 2:10 P.M. LN 2 stated she was the charge nurse for Resident 13. LN 2 stated nursing should notify the doctor and RD for weight loss trends and these trends should be monitored by nursing and the Registered Dietician (RD). LN 2 stated I expect that my LNs look at weight history to identify slow weight loss and gain when they complete their weekly summaries. LN 2 further stated the RD, nursing and the physician should have implemented interventions and monitored Resident 13's weight loss before it became significant. LN 2 further stated she was unsure of the criteria needed for a resident to be referred to the Weight Variance Committee. An interview was conducted with LN 3 on 8/6/15 at 2:58 P.M. LN 3 stated she was the LN for Resident 13 and completed her weekly summary. LN 3 stated LNs do not look at past weights during completion of the weekly summary. That's the dietician's job. LN 3 stated LNs focus on weight loss of 3 lbs in a week and 5 lbs in a month. LN 3 acknowledged earlier interventions should have implemented and weight loss monitored for Resident 13. An interview was conducted with the RD on 8/6/15 at 3:55 P.M. The RD stated the DON and RD reviewed each resident and decided to add them or remove them from the Weight Variance Committee. These additions and exclusions were based on the DON and RD's opinions. The RD acknowledged there was no criteria utilized for resident referral to the Weight Variance Committee. An interview was conducted with the DON on 8/10/15 at 2:41 P.M. The DON stated the RD received a weight list weekly and assessed residents according to the list. Nursing staff did not need to notify the RD of weight changes because the RD had access to all weights for monitoring. The DON stated she expected all interactions between the RD and residents to be documented in the medical record. The DON acknowledged LNs identified significant weight changes and gradual weight changes were identified by the DON and the RD. The DON acknowledged no nutritive interventions had been implemented for Resident 13 from 4/10/15 to 6/4/15 to address Resident 13's weight loss. In addition, there was no evidence of the volume consumed for the morning house nourishment by Resident 13 for 4/21/15 to 5/20/15 and no evidence Resident 13 had been receiving snacks between meals and in the evening as