Every finding on record at Bowerston Hills Nursing & Rehabilitation

Based on medical record review, observation, interviews, and facility policy review, the facility failed to ensure current advance directives were implemented for one resident, (Resident #1), out of seven residents reviewed for advanced directives. The facility census was 21.Findings Include:Review of Resident #1's medical record revealed an admission date [DATE] with diagnoses including but not limited to Congestive Heart Failure (CHF), Chronic Obstructive Pulmonary Disease (COPD), high blood pressure, and anxiety.Review of Resident #1's quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 had intact cognition with a Brief Interview Mental Status (BIMS) score of 13 out of possible 15 and required assistance from staff to complete Activities of Daily Living (ADL) tasks.Review of Resident #1's DNR order form dated [DATE] revealed Resident #1's advanced directive was for Do Not Resuscitate Comfort Care - Arrest (DNRCC-A) no intubation.Review of Resident #1's physician orders revealed an order dated [DATE] for DNRCC-A no intubation.Review of Resident #1's advance directive care plan dated [DATE] revealed Resident #1's advance directive was for DNRCC-A.Observation on [DATE] at 2:03 P.M. revealed Resident #1's medical record chart located in a cabinet at the nurse's desk. On the spine of the chart there was a blue dot and inside the chart there was no DNR form or any other type of form indicating what Resident #1's advance directive had been requested or ordered.An interview on [DATE] at 3:45 P.M. with Licensed Practical Nurse (LPN) #206 revealed the blue dot on Resident #1's medical record chart indicated Resident #1's advance directive request was for a full code, (meaning Cardio-Pulmonary Resuscitation CPR would be performed with possible intubation). LPN #206 stated if Resident #1 was a DNRCC-A the dot would be yellow and Resident #1's completed DNR form would be in the front of the chart. During a code situation the staff would look at the colored dot on the spine of the chart and also check for the any form indicating the advance directive in the front of the chart.An interview on [DATE] at 3:50 P.M. with the Director of Nursing (DON) confirmed Resident #1's advance directive physician order dated [DATE] for DNRCC-A did not match the blue dot on Resident #1's medical record chart, which indicated Resident #1 was a full code and there was no DNR form in the front of Resident #1's medical record chart.Review of the facility's policy titled Code Status Interpretation Full Code/Don Not Resuscitation/ DNRCC-A dated 05/2016 revealed in accordance with the state of Ohio DNR Comfort Care Protocol the facility will ensure a resident's wishes are carried out as they desire. Every effort to maintain a resident's wishes and dignity will be carried out as requested by the resident and/or responsible party.

Based on observations, review of the medical record, interview with staff, and review of the facility policy, the facility failed to ensure fall interventions were in place as ordered for Resident #7. This affected one resident (Resident #7) of two observed for fall interventions. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE]. Diagnoses included major depressive disorder, restlessness and agitation, hyperlipidemia, hyperparathyroidism, chronic fatigue, Alzheimer's disease, generalized anxiety disorder, and diabetes. Review of the plan of care dated 03/04/25 revealed Resident #7 was at risk for falls related to memory impairment and neuropathy. Interventions included encourage to wear non-skid socks when out of bed, keep bed in the lowest position when in occupied, keep call light within reach, left assist bar to the bed, night light on at night, and therapy screen as needed. Review of the April 2026 physician's orders revealed Resident #7 had an order for the bed to be in the low position when the resident was in bed dated 02/27/26. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #7 had severely impaired cognition, was dependent for all activities of daily living, had a prognosis of less than six months, and had no falls since the last assessment. Review of the Fall Risk assessment dated [DATE] revealed Resident #7 was at moderate risk for falls. Observation on 04/29/26 at 9:45 A.M. revealed Resident #7 was in watching television in bed and the bed was not in the lowest position. An interview at this time with Certified Nursing Assistant #222 verified Resident #7's bed was not in the lowest position and she proceeded to lower the bed into the lowest position with the remote control device. Review of the facility policy titled, Post Fall Protocol Policy and Procedure, dated 01/22/26 revealed the purpose of the policy was to provide guidelines for nursing staff for protocol post fall of a resident.

Based on observation, interview, record review, review of the facility water management plan and policy review the facility failed to ensure infection control measures were implemented during a dressing change. This affected one resident (Resident #4) observed for dressing change during wound care. The facility also failed to follow their written water management plan for Legionella. This had the potential to affect all residents. Findings include: 1. Record review revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure, muscular dystrophy, dysphagia, unspecified protein-calorie malnutrition, anxiety disorder, dependence on ventilator status, major depressive disorder, gastrostomy status, and attention to tracheostomy. Record review revealed an order for enhanced barrier precautions (EBP) ordered on 11/01/24 due to wounds, a tracheostomy, and gastrostomy (feeding) tube. Further review of the physician orders revealed to cleanse the left and right buttock open areas with normal saline, apply collagen and cover with a dry, sterile, dressing (DSD) every evening. Review of the Minimum Data Set (MDS) Assessment completed on 03/01/25 revealed the resident had intact cognition. Observation on 04/09/25 at 10:45 A.M. of a dressing change for Resident #4 revealed the resident was in enhanced barrier precautions. Nurse Practitioner (NP) #888 was wearing a gown and gloves and Licensed Practical Nurse (LPN) #19 was assisting with the dressing change and was also wearing a gown and gloves. NP #888 removed the old dressings for two areas on Resident #4 buttocks. The NP was not observed to remove her gloves or perform hand hygiene NP #888 cleansed the right side wound with saline and gauze and proceeded to cleanse the left wound with gauze and saline without hand hygiene or a glove change. The wounds measured (right and left wound) measure to be 0.1 centimeters (cm) by (x) 0.1 cm each. The left wound with serosanguinous (clear, blood tinged) drainage, the right wound with serous (clear) drainage. No hand hygiene or glove change performed before skin prep and collagen was applied to both wound beds. NP #888 continued to wear the same gloves as when she started the procedure. NP #888 opened border foam dressings and applied one to each wound. No hand hygiene or glove change was completed. Resident #4 was then repositioned in bed and NP #888's moved Resident #4's bedside table while still wearing the gloves that were initially applied upon entrance to the resident's room. Then NP #888 removed the soiled gloves and gown, discarded the items and used alcohol based hand rub for hand hygiene. Interview with NP #888 on 04/09/25 at 11:13 A.M. confirmed hand hygiene and glove changes should have been performed during the dressing change for Resident #4 and she did not perform hand hygiene by washing or using an ABHR. NP #888 confirmed gloves were not changed during the dressing change. Review of facility policy named Hand Hygiene revision date August 2019 revealed hands should be washed with soap and water or an antiseptic agent used before and after providing routine care, after contact with a resident's intact skin, after contact with body fluids or excretions, mucous membranes, non-intact skin, or wound dressings. Use of gloves include being easily accessible and worn in situations such as changing gloves after removing wound dressing and before placing new dressing. 2. Review of the facility's water management program dated 10/27/24 revealed water temperatures would be gathered weekly at each of the facility's water heaters to ensure water was being maintained at 140 degrees Fahrenheit. Review of the water temperature log with weekly water temperatures checked at each of the facility's six hot water tanks revealed temperature between 100 degrees Fahrenheit and 119 degrees Fahrenheit from 11/07/24 through 03/25/25. Interview on 04/09/25 with Maintenance Director #11 revealed he obtained the weekly temperatures for the water management program from the faucets, not from each of the facility water heaters as directed in the facility water management plan.

Based on interviews and record reviews the facility failed to ensure Resident #13 was assisted out of bed on the weekends per resident preference. This affected one (Resident #13) of one residents reviewed for resident rights. Findings include: Record review revealed Resident #13 was admitted to the facility on [DATE] with diagnoses including major depressive disorder, insomnia, weakness, constipation, and cerebral palsy. Review of the Minimum Data Set (MDS) Assessment completed 02/13/25 revealed a brief interview for mental status score of 12 out of a possible 15, indicating moderate cognitive impairment. Section D for mood and behavior revealed Resident #13 did have little interest or pleasure in doing things, during six days Resident # 3 felt down, depressed, or hopeless, had trouble falling or staying asleep, or sleeping too much, felt tired or had little energy, and moving or speaking so slowly that other people could have noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual. This resulted in a total severity score of 10. Section G of the MDS for activities of daily living (ADL) revealed Resident #13 was an extensive two plus person assist for bed mobility - how the resident moved to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture. Total dependence two plus person physical assist for transfer - how the resident moved between surfaces including to or from: bed, chair, wheelchair, standing position. Two plus extensive physical assist for toilet use, how the resident used the toilet room, commode, bedpan, or urinal; transferred on/off toilet; cleansed self after elimination; changed pad; managed ostomy or catheter; and adjusted clothes. Review of Resident #13's care plan completed on 02/13/25 revealed Resident #13 was at risk for decline in ADL function related to cerebral palsy, weakness, and hypertension. Goals included Resident #13 would maintain current range of motion and the residents ADL's would be met. Interventions included to allow time for rest breaks, encourage resident participation while performing Activates of daily living (ADL), notify nursing of any complaints of pain or discomfort, provide necessary adaptive equipment to meet daily needs, staff to anticipate needs and assist as needed, encourage activity during daily care, encourage to attend activities and assist as needed, monitor decline in care and report to clinical staff as needed, and notify therapy of any decline in condition. Review of Resident #13's care plan completed on 02/13/25 revealed Resident #13 had potential for activity deficit related to decreased mobility. Interventions and goals included Resident #13 would participate in activities of choice, assist resident to activities as needed, encourage resident to come to group activities, provide resident access to activity calendar, staff to provide one to one as needed. Review of tasks for transferring from bed to chair and from chair to bed revealed Resident #13 did not get out of bed on Saturday 03/15/25, Saturday 03/29/25, Sunday 03/30/25, Saturday 04/05/25, and Sunday 04/06/25. Review of task for bowel movements (BM) revealed Resident #13 on Saturday 03/15/25 had one BM , Saturday 03/29/25 had four BM's, Sunday 03/30/25 had no BM's, Saturday 04/05/25 Resident #13 had no BM's , and Sunday 04/06/25 Resident #13 had one BM. Review of progress notes and resident record revealed no documentation as to why Resident #13 was not transferred out of bed or refusal to get out of bed on Saturday 03/15/25, Saturday 03/29/25, Sunday 03/30/25, Saturday 04/05/25, and Sunday 04/06/25. Interview on 04/07/25 at 10:06 A.M. with Resident #13 stated on the weekends she stayed in bed because the staff don't want to put her in her wheelchair . Resident #13 stated she was unsure why she couldn't get out of bed, but she would like to get into her chair on the weekends. Interview on 04/09/25 at 1:01 P.M. with Certified Nursing Assistant (CNA) #210 revealed Resident #13 required Hoyer assistance to get out of bed. CNA #210 stated Resident #13 had good range of motion (ROM) with her arms. She stated that on the weekends there were two aides and one nurse for all shifts except midnight shift had one CNA. CNA #210 stated, at times, Resident #13 would refuse to get out of bed. She stated that about a month or so ago, the resident was having a lot of loose stools, so she was staying in bed more often. Interview on 04/09/25 at 1:17 P.M. with CNA #76 stated Resident #13 required a hoyer lift to get out of bed. CNA #76 stated if Resident #13 had diarrhea, she would stay in bed. CNA #76 shared that on the weekends, Resident #13 would sometimes choose to stay in bed. Interview on 04/09/25 at 1:26 P.M. with Licensed Practical Nurse (LPN) #19 stated Resident # 13 would refuse to get out of bed on the weekends at times if she didn't like the activities. If Resident #13 was having bowel movements, she would stay in bed because getting in and out of bed with the hoyer lift took a lot of her energy.

Based on review of the medical record, interview, and review of facility policy, the facility failed to ensure the comprehensive care plan for Resident #1 was revised after a fall and change in elopement risk. This affected one resident (Resident #1) of 13 residents with care plans reviewed The facility census was 19. Findings include: Review of the medical record for Resident #1 revealed an admitted [DATE] with diagnoses including parkinsonism, calculus of gall bladder with acute cholecystitis, conversion disorder with seizures or convulsions, altered mental status, glaucoma, chronic hepatitis, unspecified lack of coordination, diffuse traumatic brain injury, and dementia with behavioral disturbances. Review of the annual Minimum Data Set (MDS) 3.0 assessment revealed Resident #1 had severely impaired cognition and exhibited no behaviors, including rejection of care or wandering behaviors. Further review of the MDS revealed Resident #1 had experienced one fall with injury since the previous comprehensive assessment which was completed on 10/08/24. Review of the progress notes revealed the following On 09/19/24 at 9:31 A.M. a nursing note indicated the nurse had updated the physician that Resident #1 was no longer capable of elopement and was incapable of physically getting himself to exit areas. On 11/18/24 at 6:45 A.M. a nursing note revealed Resident #1 sustained an unwitnessed fall in his room and was found on his floor with a puddle of blood noted under his head. The note further revealed that Resident #1 received first aid and was transported by squad to the emergency room for evaluation and treatment. On 11/18/24 at 9:30 A.M., the nursing note revealed Resident #1 returned to the facility with a laceration to the top right side of his head, a skin tear to his right elbow, and scattered bruising to his right side. On 11/19/24 at 9:40 A.M., the nursing note revealed that the laceration to Resident #1's right elbow had steri-strips in place and the right head laceration had required sutures. Review of all progress notes from 11/07/24 through 12/07/24 revealed no concerns related to Resident #1 wandering or at risk for elopement and no evidence of an interdisciplinary team (IDT) meeting to review the fall risk care plan interventions for continued appropriateness or need for revision. Review of the clinical assessments titled Elopement Risk Screen between 09/04/24 and 03/08/25, which included screenings dated 09/04/24, 09/19/24, 12/05/24, and 03/08/25, revealed Resident #1 was no longer at risk for elopement. Review of the care plan dated 06/18/18 (last reviewed 01/09/25) revealed Resident #1 had a care plan focus related to being at risk for wandering and elopement secondary to dementia, confusion, and a previous traumatic brain injury (TBI). The elopement risk care plan was initiated on 02/22/21 and the last revision was made on 09/19/24. The care plan also revealed Resident #1 was at risk for falls and fall related injury secondary to seizures, glaucoma, weakness, and TBI. Further review of the fall risk care plan revealed the fall Resident #1 sustained on 11/18/24 was not added to the care plan and no new interventions were added after the 11/18/24 fall. However, the resident was moved closer to the nurses' station for closer observation. Review of the fall investigation initiated 11/18/24 revealed a fall incident report, the progress note dated 11/18/24 at 6:14 A.M., and the post fall risk assessment completed on 11/18/24. None of the documents provided included any post-fall follow-up information, such as injuries sustained, or newly added interventions. Interview with the Director of Nursing (DON) on 04/09/25 at 1:30 P.M. confirmed the paperwork she provided was all she had available regarding the investigation into Resident #1's fall on 11/18/24 because the chart had been thinned, and she would have to search in medical records for any additional information surrounding the fall. No additional information had been provided by the end of the survey on 04/10/25. Interview on 04/09/25 at 3:47 P.M. with MDS Coordinator #27 confirmed Resident #1's last elopement risk assessments revealed he no longer was high risk for elopement and that she had not caught up with updating the care plan because she had not seen the assessments. MDS Coordinator #27 further confirmed she did not attend quarterly resident care conferences. Review of the fall policy last revised 11/04/22 revealed the facility was to implement an intervention based off the fall investigation to prevent a similar fall, update the care plan with the new intervention(s), and communicate the new intervention(s) to direct care staff. The policy further revealed the IDT would meet to discuss the fall, review statements, determine the root cause, implement new interventions based on the determined root cause, and the resident's care plan was to be updated immediately upon completion of the fall investigation. Review of the Care Plan Policy and Procedure dated December 2019 revealed the comprehensive care plan was to be updated quarterly and as needed to ensure accuracy and ongoing appropriateness of interventions.

Based on interview and record review the facility failed to implement antibiotic stewardship regarding antibiotic use. This affected one (Resident #70) of one resident reviewed for antibiotics. Findings include: Record review revealed Resident # 70 admitted to the facility on [DATE] with diagnoses including dementia, hypertension, benign prostatic hyperplasia without lower urinary tract symptoms, obesity, type 2 diabetes, schizoaffective disorder, auditory hallucinations, cataracts, hypothyroidism, depression, chronic obstructive pulmonary disease. Review of the minimum data set (MDS) completed 04/02/25 revealed the resident had severe cognitive impairment. Review of Resident #70's care plan completed on 04/04/25 revealed the resident is exhibiting signs and symptoms of a urinary tract infection (UTI). Goals included the resident will be free from signs and symptoms of a UTI after completion of antibiotics. Interventions included to administer antibiotic as ordered, encourage resident to increase fluids, monitor for pain and medicate as ordered, monitor for signs of increased risk for falls related to possible confusion, monitor vital signs for increase in temperature, notify physician and family of a change in condition, obtain urine for urinalysis and culture & sensitivity as ordered. Review of Resident #70 electronic medical record revealed a progress note dated 04/02/25 at 12:41 P.M. by Licensed practical nurse (LPN) #98 stating Resident #70 was being sent to the emergency department for evaluation due to low blood pressure, lethargy, and blood-tinged urine, not responding as he normally does, and ambulance is here at this time to transport resident. Review of Resident #70 progress note revealed a note by LPN #98 dated 04/02/25 at 5:50 P.M. stated Resident #70 was admitted to the hospital with a urinary tract infection (UTI). Record review revealed Resident # 70 was sent to the emergency department on 04/02/25 for altered mental status (AMS) by emergency medical services (EMS) from the facility stating over the last few days he had not been eating or drinking and had a decreased mental status, blood was also noted in his urine by nurses, he was hypotensive at 80/60 millimeters of Mercury (mm Hg) (normal blood pressure 120/60 mm Hg), dry mucous membranes, confused upon arrival to the emergency department, urinalysis showed cloudy urine with moderate bacteria. Blood cultures and urine cultures were pending at the time of hospital discharge on 04/03/25. Resident # 70 was discharged from the hospital on 04/03/25 with an order for cefdinir (antibiotic) 300 mg oral capsule give one capsule by mouth twice a day for seven days. Record review revealed an order placed on 04/03/25 for cefdinir oral capsule 300 milligram (MG) give one capsule by mouth two times a day for UTI until 04/11/25. Review of Resident #70 progress note revealed a note by LPN #19 dated 04/03/25 at 5:32 P.M. stating Resident #70 had returned from the hospital. Review of Resident #70 progress note dated 04/04/25 at 2:59 P.M. stating Resident #70 was being transported to the hospital. Review of Resident #70 progress note dated 04/05/25 at 2:10 P.M. stating Resident #70 returned from the hospital with a diagnosis of altered mental status and UTI. Awaiting pending urine culture and blood cultures. Orders for Keflex were received. Review of Resident #70 progress note dated 04/05/25 at 4:55 P.M. stating Medical Director #737 wished to cancel Keflex (antibiotic) order and continue cefdinir that was already ordered. Record review revealed no evidence of any documentation of receiving blood cultures or urine culture and sensitivity for the hospitalization on [DATE] through 04/03/25 or documentation of hospital discharge, urinalysis or urine culture and sensitivity for the emergency department visit on 04/04/25 through 04/05/25. Record review revealed one attempt by LPN #19 to receive urine culture and sensitivity from the hospital via fax on 04/07/25. Further review of the medical record revealed a fax received from a local hospital dated 04/09/25 at 8:53 A.M. that showed Resident #70's urine culture collected on 04/04/25 and resulted on 04/07/25 showed no bacterial growth. Record review revealed a fax dated 04/09/25 at 11:40 A.M. from the other hospital that indicated Resident #70's urine culture collected 04/02/25 and resulted on 04/04/25, after 36 hours, showed no bacterial growth. Interview on 04/09/25 at 8:17 A.M. revealed licensed practical nurse (LPN) #19 faxed a request for the urine and blood culture results on 04/07/25 but she was unsure if it came in. LPN #19 stated Resident #70 was currently on antibiotics. LPN #19 stated they would like to have the culture results before continuing the antibiotics, but Medical Director #737 wanted to continue the cefdinir. Interview on 04/09/25 at 8:34 A.M. with the director of nursing (DON) revealed no urine or blood culture results had been received from either hospital for Resident #70. Interview on 04/09/25 at 10:05 A.M. with LPN #19 revealed Resident #70 urine culture results were negative and she would call the physician to discontinue the antibiotic.

Based on record review, interview and policy review the facility failed to ensure an influenza vaccination was administered to one (Resident #70) resident per request/signed consents. This affected one (Resident #70) of five residents reviewed for vaccinations. Findings include: Record review revealed Resident # 70 admitted to the facility on [DATE] with diagnoses including dementia, hypertension, obesity, type 2 diabetes, schizoaffective disorder, auditory hallucinations, hypothyroidism, depression, and chronic obstructive pulmonary disease. Further medical record review revealed a signed consent form for the administration of the influenza vaccine signed by Resident #70's appointed representative and dated 03/30/25. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed a brief interview for mental status (BIMS) score of 03 (out of a possible 15) indicating cognitive impairment. Review of Resident #70's March 2025 and April 2025 medication administration record (MAR) and treatment administration record (TAR) revealed no documentation Resident #70 had received the influenza vaccination. Record review revealed no documentation that Resident #70's representative, who gave consent for Resident #70 to receive the influenza vaccine, was notified that the vaccination was not given or not available for administration. Interview on 04/10/25 at 11:05 A.M. with the Director of Nursing (DON) revealed residents are offered vaccinations on admission and will receive them if they consented to administration. The DON shared influenza vaccinations are completed annually, if the facility runs out of vaccinations they will put in an order from the pharmacy and they typically receive the vaccine within two to four business days. The DON stated Resident #70 had not received his influenza vaccine and there was no documentation of Resident #70's representative being notified of this. The DON stated the influenza vaccine was not administered to Resident #70 because the facility ran out of the vaccine and no one at the facility notified her of this. Review of the undated Influenza Policy revealed between October 1st and March 31st or as otherwise indicated per the Centers for Disease Control (CDC) each year, the influenza vaccine shall be offered to residents unless the vaccine is medically contraindicated or the resident has already been immunized. Residents admitted between October 1st and March 31st shall be offered the vaccine within five (5) working days of the resident's admission to the facility. For those who receive the vaccination the date of the vaccination, lot number, expiration date, person administering and the site of the vaccination will be documented in the resident's medical record. A resident's refusal of the vaccine shall be documented on the Informed Consent for Influenza Vaccine and placed in the resident's medical record.

Based on observation, interview and record review the facility failed to have the Resident's rights posted in the facility or evidence resident rights are reviewed with the residents outside of admission. This had the potential to affect 21 of 21 residents. The facility census was 21. Findings include: Observation of the facility during the survey on the days of 02/21/23, 02/22/23, and 02/23/23 revealed there were no postings of resident's rights available for the residents, in the facility. On 02/22/23 at 10:39 A.M. interview with Residents #7, #13, #14, and #15 at the Resident Council interview revealed the resident rights are not reviewed at the resident council meeting and none of the residents were aware of the rights being posted in the facility. The residents also stated they were unaware of what their rights were despite being residents of the facility. On 02/23/23 at 1:05 P.M. phone interview with Activities Director #116 revealed she schedules the Resident Council meetings, reminds the residents of the meeting day and time, and reviews the minutes for the previous month (including outcomes of the concerns). Resident's rights are not reviewed at council meetings unless the residents voice a concern. She is not aware of rights being posted anywhere in the facility, but she would get a copy to give a resident if they voiced a concern. On 02/23/23 at 2:25 P.M. interview and tour of the facility with Administrator #117 revealed Resident Rights are not posted in the facility. Record review of both the current admission packet and resident handbook revealed the resident rights are to be given to the resident on admission and reviewed regularly. Record review of resident council meeting minutes from 01/22 to 02/23 revealed no information was provided to residents on resident's rights.

Based on observations, interviews, and record review, the facility failed to ensure information was available for residents and their representatives on how to file a grievance and who the facility designated as a Grievance Official. This had the potential to affect 21 of the 21 residents in the facility. Facility census was 21. Findings include: Observation of the facility during the survey on the days of 02/21/23, 02/22/23, and 02/23/23 revealed there were no postings of how to file a grievance available for the residents, in the facility. On 02/22/23 at 10:39 A.M. interview with Residents #7, #13, #14, and #15 at the Resident Council interview revealed the residents did not know how to file a grievance. All residents present stated they would just tell someone they had a concern and it usually was addressed. Most of the time they are happy with the resolution but not always. Resident #14 stated he had not received his glasses that were ordered last year. The resident stated he had asked multiple staff but no one informed him of the situation with his glasses. On 02/23/23 at 11:35 A.M. interview with Licensed Practical Nurse (LPN) #104 revealed the grievance forms are not at the nurse's station as stated in the admission packet and the Resident Handbook. LPN#104 stated if a resident asked to file a complaint or grievance, she would refer the resident to the Director of Nursing (DON) or the Administrator. On 02/23/23 at 11:37 A.M. interview with the DON revealed if the residents have a concern someone from administration or the activities director, who coordinates Resident Council, works with the resident to address the concern or fill out the grievance form. On 02/23/23 at 1:05 P.M. phone interview Activities Director #116 revealed she schedules the Resident Council meetings, reminds the residents of the meeting day and time, and review the minutes for the previous month (including outcomes of the concerns). She does not fill out the grievance forms but refers the residents to the Administrator or DON if concerns are not resolved. On 02/23/23 at 2:25 P.M. interview with Administrator #117 revealed the grievance process instructions were not posted in the facility. The forms are at the nurse's station and in the administration office. Most of the residents would need help filling out the form so the grievance process is addressed as concerns are raised by the residents. Review of the current resident handbook revealed a resident with a concern may complete a concern form which should be available at the Nursing Stations, Business office or Administrative office. There is also a Grievance Committee comprised of the Facility's staff, Residents, sponsors, or outside representatives in a ratio of not more than one staff member to every two Residents, sponsors, or outside representatives. Procedures are reviewed at least annually by the Facility with the advice of Residents, their sponsors, or both. Record review of resident council meeting minutes from 01/22 to 02/23 revealed no information provided to residents on how to file a grievance, no information that confidentiality will be maintained if a grievance is filed, and no information that the procedures have been reviewed with Resident input.

Based on medical record review and interview, the facility failed to ensure the Minimum Data Set (MDS) assessments accurately reflected diuretic medication use and psychotropic medication use. This affected four residents (#5, #7, #10 and #21) of 15 residents reviewed for assessments. Findings include: 1. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE]. Diagnoses included coronavirus (COVID-19), anemia, major depressive disorder, psychoactive substance abuse, opioid addiction, protein-calorie malnutrition, and chronic viral hepatitis. Review of the Minimum Data Set (MDS) quarterly assessment, dated 10/27/22, inaccurately revealed that Resident #7 received diuretics for zero days during the look-back period. Review of a physician order, dated 10/15/21, revealed the order for Furosemide 20 milligrams (mg) one tablet, two times per day. Review of the Medication Administration Record (MAR) revealed that Resident #7 received Furosemide 20 mg, one tablet, two times per day, from 10/21/22 through 10/27/22. Interview on 02/22/23 at 9:45 A.M. with the Director of Nursing (DON) verified the MDS quarterly assessment, dated 10/27/22, contained an inaccurate assessment of Resident #7's diuretic use. 2. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE]. Diagnoses included dementia, diabetes mellitus, psychotic disorder with delusions, major depressive disorder, chronic obstructive pulmonary disease, and hypertension. Review of the MDS annual assessment, dated 12/12/22, inaccurately revealed that Resident #5 received diuretics for zero days during the look-back period. Review of a physician order, dated 10/21/22, revealed the order for Bumex one milligram (mg), one tablet, two times per day. Review of the MAR revealed that Resident #5 received Bumex one mg, one tablet, two times per day, from 12/06/22 through 12/12/22. Interview on 02/22/23 at 9:45 A.M. with the DON verified the MDS quarterly assessment, dated 10/27/22, contained an inaccurate assessment of Resident #5's diuretic use. 22653 3. Review of Resident #10's medical record revealed diagnoses including convulsions and hypertension. Review of the January 2023 Medication Administration Record (MAR) revealed Resident #10 received Furosemide (diuretic) 20 milligrams (mg) every morning for congestive heart failure between 01/06/23 and 01/12/23. A quarterly MDS dated [DATE] did not reflect the use of a diuretic over the seven day assessment period. On 02/22/23 at 9:43 A.M., during interview, the Director of Nursing (DON) verified the MDS was coded incorrectly, verifying Resident #10 had received a diuretic. 32799 4. Review of Resident #21's medical record revealed an admitted [DATE] with diagnoses including anxiety, major depressive disorder and insomnia. Review of the physician orders revealed medications including ambien (hypnotic) 10 milligrams (mg) daily at bedtime, venlafexine (antidepressant) extended release 75 mg twice a day; buspar (antianxiety) 10 mg twice a day. Review of the Quarterly MDS dated [DATE] revealed the resident was cognitively intact but did not receive antianxiety, antidepressants or hypnotics during the assessment period. Review of the December 2022 Medication Administration Record (MAR) revealed the resident did receive the ordered medications during the assessment period, 12/21/22 through 12/27/22. On 02/23/23 at 11:34 A.M. interview with the DON verified the resident's MDS did not accurately reflect the medications the resident received.

Based on record review and interview, the facility failed to initiate a significant change Minimum Data Set (MDS) assessment, within 14 days, following a hospice admission. This affected one (#18) of one resident reviewed for hospice services. The facility census was 21. Findings include: Review of the medical record for Resident #18 revealed an admitted [DATE] with diagnoses including dementia, atherosclerotic heart disease, history of cerebral vascular infarction, and history of urinary tract infection. Review of the 5-Day Minimum Data Set (MDS) assessment, dated 01/31/23, indicated Resident #18's Brief Interview for Mental Status (BIMS) score was 04, which indicated severely impaired cognition. The resident did not have any hallucinations, delusions, physical or verbal behaviors, or rejection of care. This was the most current MDS assessment completed. Review of a physician order, dated 02/06/23, revealed the order to admit the resident to hospice services. Review of the Care Plan, dated 02/21/23, revealed Resident #18 received hospice services related to cerebral atherosclerosis. During interview on 02/22/23 at 2:45 P.M., the Director of Nursing (DON) confirmed the significant change MDS assessment was not timely initiated, within 14 days, following Resident #18's hospice admission.

Based on medical record review and interview, the facility failed to refer a resident with newly diagnosed serious mental disorder, for a Pre-Admission Screening and Resident Review (PASARR) re-evaluation. This affected one (#5) of 15 residents reviewed for PASARR. Findings include: Review of the medical record revealed Resident #5 was admitted to the facility on [DATE]. Diagnoses included dementia, diabetes mellitus, major depressive disorder, chronic obstructive pulmonary disease, and hypertension. Review revealed on 12/15/19, the resident was diagnosed with psychotic disorder with delusions. Review revealed a PASARR review, dated 12/28/15, which indicated there was no serious mental illness or developmental disability. Review of a psychiatric progress note, dated 04/19/22, revealed the resident had behaviors including delusions. Interview on 02/23/23 at 1:45 P.M., the Director of Nursing (DON) confirmed the last PASARR evaluation was completed on 2015 and there was not a re-evaluation completed following the resident's new diagnosis of psychotic disorder with delusions.

Based on medical record review and interview, the facility failed to ensure there was follow up to an optometrist visit recommending eye glasses for one (#14) of 14 residents interviewed regarding vision. The census was 21. Findings include: During an interview of Resident #14 on 02/21/23 at 12:40 P.M. he stated he had eye glasses ordered and he had not received them. Other residents who saw the eye doctor on the same day had received their eye glasses. Review of Resident #14's medical record revealed diagnoses including disorientation and type 2 diabetes mellitus. An annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #14 had adequate vision with corrective lenses. The assessment indicated Resident #14 was moderately cognitively impaired. Documentation from the facility's eye care provider revealed Resident #14 had an eye exam 09/22/22 which indicated he had a cataract of the right eye, pseudophakia (implant of an intraocular lens to replace a natural lens) of the left eye, hyperopia (nearby objects look blurred) and presbyopia (progressive loss of near focusing ability) of both eyes with no current prescription. The form indicated glasses were required and to encourage full time use for distance and reading. Glasses were recommended and were to be delivered upon approval. A care plan initiated 01/07/23 indicated Resident #14 was at risk for impaired vision related to use of magnifier/magnifier glass. Goals were for Resident #14 to be free of acute eye problems and maintain optimal quality of life within visual limits. Interventions included arranging consultation of an eye care practitioner as needed. On 02/22/23 at 11:13 A.M., during interview, the Director of Nursing (DON) stated Resident #14 never received eye glasses due to issues with his insurance. On 02/22/23 at 12:15 P.M., during interview, the DON stated she spoke to the eye doctor provider and was told insurance would send a denial letter. After the facility got the denial letter they would appeal. Resident #14 could choose to pay out of pocket for the eye glasses. On 02/22/23 at 1:08 P.M., during interview, the Vision Provider Representative #200 stated the information regarding the cost of the eye glasses was submitted to Resident #14's primary insurance provider and was informed they did not cover the cost of glasses. A letter was sent to the resident at the facility on 09/23/22. No other person was listed as the responsible party. On 02/22/23 at 1:22 P.M., during interview, Business Office Manager (BOM) #112 verified the census view of the medical record revealed Resident #14 had Medicaid coverage as of 09/16/22. On 02/22/23 at 1:54 P.M., during interview, the Ohio Medicaid Representative #205 indicated he could see Resident #14 had Medicaid which had back dated benefits as of 09/01/22. The case was not updated in the system until 11/25/22 so he would not have been in the system as covered until then. The DON indicated she would have the vision provider submit the bill for eye glasses to Medicaid. On 02/22/23 at 2:00 P.M., during interview, the DON stated she usually tracked when residents got glasses and who had not received them. The DON stated she thought because Resident #14 had a hospitalization , it slipped her mind.

Based on observation, record review, policy review, and interview, the facility failed to ensure a resident's oxygen flow rate was set as ordered and failed to ensure the oxygen tubing and humidifier bottle were changed weekly as ordered. This affected one (#7) of three residents reviewed for respiratory care. The facility identified seven residents receiving oxygen therapy. The facility census was 21. Findings include: Review of the medical record revealed Resident #7 was admitted to the facility on [DATE]. Diagnoses included coronavirus (COVID-19), anemia, major depressive disorder, psychoactive substance abuse, opioid addiction, protein-calorie malnutrition, and chronic viral hepatitis. Review of the Minimum Data Set (MDS) quarterly assessment, dated 10/27/22, revealed Resident #7's Brief Interview for Mental Status (BIMS) score was 15, which indicated intact cognition. There were no behaviors or rejection of care. The resident received oxygen therapy. Review of the Care Plan, dated 01/07/23, revealed Resident #7 is at risk for altered respiratory status with the intervention to administer oxygen as ordered. Review of physician order, dated 12/19/19, revealed the order for oxygen at four liters per minute to be infused via nasal cannula as needed. Further review revealed the physician order, dated 06/19/21, to change the oxygen humidifier bottle and oxygen tubing weekly. Observations on 02/21/23 at 10:28 A.M. and at 12:05 P.M. revealed Resident #7's oxygen flow rate was set at 3.5 liters per minute via nasal cannula and the oxygen humidifier bottle and oxygen tubing were dated 02/12/23. During interview on 02/21/23 at 12:09 P.M., Licensed Practical Nurse (LPN) #104 confirmed Resident #7's oxygen flow rate was incorrectly infusing at 3.5 liters per minute and should be infusing at 4 liters per minute. LPN #104 further confirmed the oxygen humidifier bottle and oxygen tubing had not been changed weekly as ordered. Review of the facility's policy, Oxygen Administration, dated January 2020, revealed to review the physician's order for oxygen administration. Change tubing weekly.

Based on record review, policy review, and interview, the facility failed to provide an appropriate diagnosis for a resident receiving an antipsychotic medication and failed to indicate the duration (stop date) of a psychotropic medication ordered as needed (prn). This affected one (#18) of five residents reviewed for unnecessary medications. Findings include: Review of the medical record for Resident #18 revealed an admitted [DATE] with diagnoses including dementia, atherosclerotic heart disease, history of cerebral vascular infarction, and history of urinary tract infection. Review of the Minimum Data Set (MDS) assessment, dated 01/31/23, indicated Resident #18's Brief Interview for Mental Status (BIMS) score was 04, which indicated severely impaired cognition. The resident did not have any hallucinations, delusions, physical or verbal behaviors, or rejection of care. Review of the Care Plan, dated 01/31/23, revealed Resident #18 received antipsychotic medication related to dementia. Review of a physician order, dated 02/02/23, revealed the order for Lorazepam (Ativan) 0.5 milligrams (mg) by mouth or intramuscularly (IM), every four hours, as needed for anxiety, restlessness, or agitation. The order did not indicate a duration of time or stop date. Review of a physician order, dated 02/07/23, revealed the order for Quetiapine Fumarate (Seroquel) 25 milligrams (mg) by mouth at bedtime for restlessness/anxiety. Review of the Medication Administration Record (MAR), dated February 2023, indicated the resident received Quetiapine Fumarate 25 milligrams (mg) every night. During interview on 02/22/23 at 3:41 P.M., the Director of Nursing (DON) verified the resident is receiving Seroquel, which is an antipsychotic, without an appropriate diagnosis. The DON confirmed the physician order, dated 02/07/23, stated the indication for use was due to restlessness/anxiety. The DON further confirmed there was no stop date indicated on the physician order, dated 02/02/23 for Lorazepam 0.5 mg, every four hours, prn. Review of the facility's policy, Antipsychotic Medication Use, dated December 2016, revealed the residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. The need to continue prn orders for psychotropic medications beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the prn order will be indicated in the order.

Based on observations, record review, and interview, the facility failed to make timely referrals for dental services for two (#11 and #14) of 16 residents whose dental status was observed. The facility census was 21. Findings include: 1. Observations of Resident #11 on 02/21/23 at 10:58 A.M. revealed he had no natural teeth and no dentures in. On 02/21/23 at 3:47 P.M., during interview, Resident #11's son indicated Resident #11 had new dentures that had been missing. The facility had reported they were looking for them. Review of Resident #11's medical record reviewed diagnoses including Alzheimer's disease, type 2 diabetes mellitus, dysphagia (difficulty swallowing) and cerebrovascular disease. Between 06/07/21 and 11/07/22, Resident #11 had an order for a regular diet with regular texture. A nursing note dated 11/07/22 at 9:14 A.M. indicated the power of attorney and physician were updated that Resident #11's diet was changed to mechanical soft due to decreased appetite and difficulty chewing. An admission nursing assessment dated [DATE] indicated Resident #11 had full upper and full lower dentures that fit but did not wear them. There was no documentation indicating Resident #11's dentures were missing. Review of a Resident/Family/Staff concern form dated 07/21/22 indicated Resident #11's dentures were missing. Staff were unable to find the dentures in his room, the laundry, day room, dining room or in the chairs. Resident #11 was unable to state what he did with them. Resident #11 was known to take them out and leave them in random places. Resident #11 was added to a list to be seen at the next dental visit. It was unknown if the cost of the dentures would be covered. On 02/22/23 at 4:20 P.M., during interview, the Director of Nursing (DON) stated the facility assessed a resident with lost dentures to see if it affected their intake and if it did they reached out for emergency dental services. If not, the residents were seen with the next visit. The DON stated she would look for documentation regarding any referral for dental services after the dentures were lost. The DON stated the facility was still waiting on the next dental visit to be scheduled. On 02/22/23 at 4:42 P.M., during interview, the Administrator provided a list that was provided to the dental service on 12/20/22 indicating Resident #11's name was on the list to be seen. On 02/23/23 at 7:00 A.M., during interview, the DON verified there was no documentation revealing there was a referral for dental services within three days of the dentures being lost nor was there documentation of extenuating circumstances that led to the delay of dental services being provided. On 02/23/23 at 10:31 A.M., interview of Dental Services Representative #210 revealed dental services provided in the facility included x-rays, exams, cleanings, fillings, most extractions and dentures. The dental service automatically saw residents who had Medicaid services. Notices would be sent out for any private pay residents. The dental service would generally visit when residents were due to be seen. However there were only a few residents who were eligible to be seen at present so they would wait until most residents were due to be seen unless there was an emergency. Dental Services Representative #210 stated if a facility notified them of missing dentures they would seek approval for payment by Medicaid first or give the residents the option to pay privately. In that case, they would coordinate to visit the specific resident. Dental Services Representative #210 stated the facility called the dental service provider on 02/22/23 to schedule a visit. After reviewing the records for Resident #11, Dental Services Representative #210 stated the facility had not notified them that his dentures were missing. Dental Services Representative #210 stated Resident #11 had received dentures in 2022. Medicaid would only pay for dentures every eight years so new dentures would have to be paid for privately. 2. During an interview of Resident #14 on 02/21/23 at 12:40 P.M., Resident #14 was observed to have natural lower teeth but no upper teeth were observed. Review of Resident #14's medical record revealed diagnoses including disorientation, type 2 DM, and adult failure to thrive. An admission assessment dated [DATE] indicated Resident #14 had his own teeth but also indicated dentures fit. The assessment was silent as to the type of dentures Resident #14 had. A dietary note dated 12/16/22 at 10:29 A.M. indicated Resident #14 had lost dentures. Review of a Resident/Family/Staff concern form dated 12/09/22 indicated Resident #14's dentures were missing. Resident #14 stated he took them out in bed and did not know what happened to them. Staff searched the bedroom, laundry, and visible trash and were unable to find the dentures. Resident #14's name was placed on a list to be seen by the dentist. The facility was waiting on a date. On 02/22/23 at 11:11 A.M., during interview, Licensed Practical Nurse (LPN) #104 stated Resident #14 had upper dentures when he was admitted but they were unable to be located about 1-1.5 months prior to the survey. Staff had removed everything from the room in attempts to locate the dentures without success. Resident #14 had no difficulty eating. Resident #14 would be seen when the dentist visited next. On 02/22/23 at 4:20 P.M., during interview, the Director of Nursing (DON) stated the facility assessed a resident with lost dentures to see if it affected their intake and if it did they reached out for emergency dental services. If not, the residents were seen with the next visit. The DON stated she would look for documentation regarding any referral for dental services after the dentures were lost. The DON stated the facility was still waiting on the next dental visit to be scheduled. On 02/22/23 at 4:42 P.M., during interview, the Administrator provided a list that was provided to the dental service on 12/20/22 indicating Resident #14's name was on the list to be seen. On 02/23/23 at 7:00 A.M., during interview, the DON verified there was no documentation revealing there was a referral for dental services within three days of the dentures being lost nor was there documentation of extenuating circumstances that led to the delay of dental services being provided. On 02/23/23 at 10:31 A.M., interview of Dental Services Representative #210 revealed dental services provided in the facility included x-rays, exams, cleanings, fillings, most extractions and dentures. The dental service automatically saw residents who had Medicaid services. Notices would be sent out for any private pay residents. The dental service would generally visit when residents were due to be seen. However there were only a few residents who were eligible to be seen at present so they would wait until most residents were due to be seen unless there was an emergency. Dental Services Representative #210 stated if a facility notified them of missing dentures they would seek approval for payment by Medicaid first or give the residents the option to pay privately. In that case, they would coordinate to visit the specific resident. Dental Services Representative #210 stated the facility called the dental service provider on 02/22/23 to schedule a visit. After reviewing the records, Dental Services Representative #210 stated Resident #14 had not been seen by dental services yet and his initial visit would be with the next dental visit to the facility. The facility had not reported Resident #14's dentures were missing.

Based on observation, interview and record review the facility failed to ensure fingernails of four dependent residents, Resident #2, #5, #14, and #15, were cleaned/trimmed. This affected four of four residents reviewed for activities of daily living (ADLs). Findings include: 1. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the current plan of care dated 06/11/20 (re-used from a previous admission) revealed Resident #2 was at risk for a decline in ADL function related to weakness, obesity, and wounds on his legs. Interventions included: allow time for rest breaks, break tasks down so ADL's are easier for the resident to perform, encourage resident participation, provide necessary adaptive equipment to meet daily needs, and staff to anticipate needs and assist as needed. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had moderately impaired cognition and required extensive assistance from staff for ADLs. Review of the shower sheets dated 03/29/21 to 04/21/21 revealed no documentation Resident #2's fingernails were cleaned/trimmed. Observations on 04/19/21 at 10:05 A.M., 04/21/21 at 7:48 A.M. and 11:43 A.M. revealed Resident #2 had long, dirty fingernails. Interview on 04/21/21 at 11:30 A.M. with the Director of Nursing (DON) revealed resident fingernails were to be cleaned/trimmed on shower days. Interview on 04/21/21 at 11:43 A.M. with Management #300 verified the fingernails of Resident #2 were long and dirty. Review of the the facility policy, Resident Care Showers, dated 10/20, revealed the facility would provide resident care to promote the highest physical, mental and emotional well-being. Nails and skin would be observed during routine care and showering for care needs including shaving, nail trimming, and skin integrity. The resident should receive two showers a week. 2. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the plan of care dated 09/04/19 revealed Resident #5 required staff assistance with ADL performance. Interventions included staff to assist with bathing, dressing, toileting and personal hygiene. Review of the quarterly MDS assessment dated [DATE] revealed Resident #5 had intact cognition and required extensive assistant from staff for ADLs. Review of the shower sheets dated 03/04/21 to 04/21/21 revealed no documentation Resident #5's fingernails were cleaned/trimmed. Observations on 04/19/21 at 10:10 A.M. and 04/21/21 at 11:44 A.M. revealed Resident #5 had long dirty fingernails. Interview on 04/19/21 at 10:10 A.M. with Resident #5 revealed his fingernails had not been trimmed and he did not like them long. Interview on 04/21/21 at 11:30 A.M. with the DON verified resident's fingernails were to be cleaned/trimmed on shower days. Interview on 04/21/21 at 11:44 A.M. with Management #300 verified the fingernails of Resident #5 were long and dirty. Review of the the facility policy, Resident Care Showers, dated 10/20, revealed the facility would provide resident care to promote the highest physical, mental and emotional well-being. Nails and skin would be observed during routine care and showering for care needs including shaving, nail trimming, and skin integrity. The resident should receive two showers a week. 3. Review of the medical record revealed Resident #14 was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the plan of care dated 03/25/20 revealed Resident #14 was at risk for ADL functional decline related to right knee pain and his knee giving out at times, wearing a brace, weakness, Alzheimer's disease, hypertension, diabetes and cardiovascular accident. Interventions included: allow time for rest breaks, break tasks down so ADL's are easier for the resident to perform, encourage resident participation, provide necessary adaptive equipment to meet daily needs, and staff to anticipate and assist as needed. Review of the annual MDS assessment dated [DATE] revealed Resident #14 had severely impaired cognition and required staff supervision for personal hygiene. Review of the shower sheets dated 03/04/21 to 04/21/21 revealed no documentation Resident #14's fingernails were cleaned/trimmed. Observation on 04/19/21 at 10:00 A.M. revealed the fingernails of Resident #14 were long and dirty. Interview at that time revealed staff had not trimmed his fingernails in a while. Interview on 04/21/21 at 11:30 A.M. with the DON indicated resident fingernails were to be cleaned/trimmed on shower days. Interview on 04/21/21 at 11:46 A.M. with Management #300 verified the fingernails of Resident #14 were long and dirty. Review of the the facility policy, Resident Care Showers, dated 10/20, revealed the facility would provide resident care to promote the highest physical, mental and emotional well-being. Nails and skin would be observed during routine care and showering for care needs including shaving, nail trimming, and skin integrity. The resident should receive two showers a week. 4. Review of the medical record revealed Resident #15 was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the plan of care dated 11/29/17 revealed Resident #15 was at risk for a decline in ADL function related and alteration in ADL performance related to [CONDITION(S)], [CONDITION(S)], [CONDITION(S)] accident, hypertension, and diabetes. Interventions included: allow time for rest breaks, break tasks down so ADL's are easier for the resident to perform, encourage resident participation, provide necessary adaptive equipment to meet daily needs, and staff to anticipate and assist as needed. Review of the quarterly MDS assessment dated [DATE] revealed Resident #15 had severely impaired cognition and required total assistance from staff for all ADL's. Review of the shower sheets dated 03/04/21 to 04/21/21 revealed no documentation Resident #15's fingernails were cleaned/trimmed. Observation on 04/19/21 at 10:05 A.M. revealed the fingernails of Resident #15 were long and dirty. Interview on 04/21/21 at 11:30 A.M. with the DON indicated resident fingernails were to be cleaned/trimmed on shower days. Interview on 04/21/21 at 11:43 A.M. with Management #300 verified the fingernails of Resident #15 were long and dirty Review of the the facility policy, Resident Care Showers, dated 10/20, revealed the facility would provide resident care to promote the highest physical, mental and emotional well-being. Nails and skin would be observed during routine care and showering for care needs including shaving, nail trimming, and skin integrity. The resident should receive two showers a week.

Based on interview and record review the facility failed to ensure accurate assessments were completed related to falls and anticoagulant medication use for Resident #12. This affected one of 15 residents reviewed for assessments. The facility census was 20. Findings included: Resident #12 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Fall Incident Report dated 11/24/20 revealed Resident #12 fell from bed. The progress note dated 11/24/20 stated the nurse was called to the resident's room by the state tested nursing assistant (STNA) who opened the door to the room and observed him on the floor in front of his bed. The resident was assessed to have elevated blood pressure and pulse. The resident complained of right hip pain and was unable to move his right shoulder. His shoulder was painful when touched. The resident was transported to the hospital and returned to facility at 2:50 P.M. the same day. X-rays of the right humerus and right clavicle were negative. Contusion of his right shoulder and hip were noted. Review of the minimum data set (MDS) assessment dated [DATE] revealed Resident #12's fall on 11/24/20 was not reflected on this assessment. This assessment dated [DATE], the quarterly MDS assessment dated [DATE] and the quarterly MDS assessment dated [DATE], revealed no documentation of Resident #12 receiving the anticoagulant, [MEDICATION(S)], every day. Review of the medication administration records (MARs) for January, February, and March 2021 revealed Resident #12 received the [MEDICATION(S)] medication as prescribed. Interview with the Director of Nursing on 04/21/21 at 10:44 A.M. verified these assessments were inaccurate and did not accurately reflect Resident #12's fall or use of [MEDICATION(S)].

Based on record review, interview and policy review the facility failed to ensure pressure ulcer assessments were completed at least weekly and individualized pressure relieving interventions were initiated in a timely manner for Resident #2. This affected one of one resident reviewed for pressure ulcers. Findings include: Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facesheet indicated his original admitted was 05/01/20 and the initial admitted was 01/22/21. Review of the current plan of care dated 06/11/20 (date on this plan of care was listed as being from 2020) revealed Resident #2 was a risk for impaired skin integrity related to impaired circulation, impaired mobility, wound ulcers, obesity, diabetes, and peripheral vascular disease. Interventions included barrier cream after each incontinent episode as needed, encourage fluids, pad and protect the skin as needed, pillows for repositioning, and pressure reduction devices (no specific devices were listed). All of the interventions listed had an implementation date of 06/11/20 and were not specific and individualized to Resident #2's current physical condition, including his actual pressure ulcer. Review of the admission physician's orders dated 01/22/21 revealed Resident #2 was admitted to the facility with treatment orders to cleanse open areas on his right and left buttocks with normal saline, pat dry and apply a border foam dressing until healed. Review of the admission Skin Grid Pressure form dated 01/22/21 revealed Resident #2 was admitted with an unstageable pressure ulcer to the left buttock which measured 2.6 centimeters (cm) in length by 0.8 cm in width by 0.0 cm in depth. This document indicated the area was pressure related, had a scab over it and was unstageable. Review of the Admission Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #2 had moderately impaired cognition, required extensive assistance from staff for bed mobility, and had one unstageable pressure ulcer with slough. According to the National Pressure Ulcer Advisory Panel (NPUAP), unstageable pressure ulcers are ulcers with a full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, greenish or brown tissue) and/or eschar (tan, brown or black tissue). The base of the ulcer is used to denote the inability to determine the depth and stage of the ulcer since visualization of the wound bed is not possible due to slough/eschar. Review of the Skin Grid Pressure form dated 02/01/21, 10 days after the initial assessment, revealed Resident #2's pressure ulcer was now identified as a stage three sacral wound. The NPUAP defines a stage three pressure ulcer as a full-thickness tissue loss in which subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure depth of tissue loss and undermining and tunneling may be present. This assessment indicated the pressure ulcer had deteriorated and measured 5.0 cm in length by 5.0 cm in width by 1.0 cm in depth. There was 20 percent slough covering the wound, with a moderate amount of serosanguinous drainage. The peri-wound was discolored and macerated. The physician was notified but no new treatment orders were given. Review of the Skin Grid Pressure form dated 02/08/21 revealed Resident #2's sacral pressure ulcer declined again and now measured 8.0 cm in length by 8.0 cm in width by 0.2 in depth. This assessment indicated the pressure ulcer areas to the left and right buttock combined into one pressure ulcer at the sacral area with soft, yellowish-brown slough covering most of the wound, a foul odor was present, and a moderate amount of serosanguinous drainage. The treatment order was changed this date and directed nurses to cleanse the open area to the sacrum with normal saline, apply calcium alginate silver (a highly absorbent gel-like covering with silver which promotes wound healing and assists in killing bacteria), cover with a border foam to be changed two times a week and as needed. Review of the Skin Grid Pressure form dated 03/01/21 revealed the open areas to the right and left buttocks had combined into one pressure ulcer which measured 6.0 cm in length by 5.0 cm in width by 3.0 cm in depth. The ulcer edges were dark brown in color and there was a very foul odor. The pressure ulcer was wound was now a Stage 3 pressure ulcer. The assessment indicated the pressure ulcer had declined. Review of the Skin Grid Pressure form dated 03/08/21 revealed Resident #2's sacral pressure ulcer had declined and measured 6.0 cm in length by 5.0 cm in width by 4.0 cm in depth with tunneling present at 12 o'clock which was 5.0 cm deep. The treatment was changed this date for nursing staff to apply a negative pressure wound vacuum to the sacral pressure ulcer with continuous pressure at 125 millimeters of mercury (mmHg). They were to cleanse the wound with normal saline, apply foam to the wound bed, cover with clear transparent dressing, change the dressing twice weekly and indicated the foam should never touch the intact surrounding skin. Review of physician orders dated 03/18/21 revealed new orders for Resident #2 to have an alternating air mattress to his bed and for him to be referred to Union Hospital Wound Clinic. Review of the Skin Grid Pressure form dated 04/19/21 revealed the sacral wound of Resident #2 was a Stage 3 pressure wound which measured 5.0 cm in length by 3.0 cm in width by 4.1 cm in depth with tunneling at 12 o'clock which was 2.7 cm deep. There was a large amount of bloody drainage with no odor. Observation of the wound could not be completed as Resident #2 continued to be treated with the wound vacuum and it was only changed three times a week. The resident left the faciity on [DATE] at 1:45 P.M. to go to a physician's appointment and the wound vacuum was reapplied there. Interview on 04/22/21 at 10:15 A.M. with the DON verified Resident #2 had no specific, individualized pressure relieving interventions in place until 03/18/21 when the alternating air mattress was ordered, weekly pressure ulcer assessments were not completed from 01/22/21 to 02/01/21 (10 days) and there were declines noted in the pressure ulcer. The DON stated Resident #2 was supposed to be started on collagen on 02/01/21 but she could not find a physician order written [MEDICAL RECORD OR PHYSICIAN ORDER] Interview on 04/26/21 at 4:45 P.M. with the Director of Nursing (DON) verified the plan of care for Resident #2 had not been updated since his last admission to the facility and was dated 06/11/20. The DON verified no resident specific interventions, including pressure relieving interventions, were implemented until the alternating air mattress was ordered on 03/18/21, after the pressure ulcer declined. Review the facility policy, Skin Assessment Monitoring or Healing Process Policy and Procedure, dated 01/01/16, revealed a nurse would assess ulcers and wounds at the time of admission, re-admission, a significant change and weekly thereafter until healed. Review of the facility policy, Skin Assessment and Documentation Policy and Procedure, dated 01/01/16, revealed pressure ulcers were to be measured once a week and as needed for any changes in the wound.

Based on observation, record review and interview the facility failed to maintain sufficient levels of nursing staff to ensure the total care needs for all residents were met in a timely manner. The facility identified Resident #1, #2, #3, #7, #9, #10, #11, #12, #13, #14, #15, #16, #17, #19 and #20 who required assistance of one or two staff for activities of daily living (ADL) care and four ventilator dependent residents (Resident #4, #5, #6 and #21) who were totally dependent on at least two staff for ADL care. This had the potential to affect all 20 residents residing in the facility and an additional resident, Resident #21 who was hospitalized at the time of the onsite survey. Findings include: On 01/31/18 at 9:35 A.M., interview with State tested nursing assistant (STNA) #51 revealed she worked day shift and one afternoon shift. She stated on afternoon shift a couple times a week there was only one STNA on duty for the whole building. She stated the night shift STNA had been working 12 hour shifts to help out but she only worked three or four nights a week. She verified there where a lot of two person assist residents including Resident #1, #6, #4, #15, #5, #14, #19, #9, #12, #20 and #21 that she could think of but stated there were more. The STNA stated sometimes staff couldn't get our showers done. She revealed staff had been asking for more assistance in the afternoon for awhile and managements response was they were working on it. On 01/31/18 at 9:40 A.M., interview with Resident #19 revealed she needed two staff persons to assist her and used a mechanical lift to get out of bed and sometimes only one person gets her out of bed with the lift because there was no one else to help especially in the afternoons. On 01/31/18 at 9:55 A.M., interview with STNA #52 revealed she worked day shift and one afternoon shift a week from 2:00 P.M. until 8:00 P.M. She stated on afternoon shift a couple times a week there was only one STNA and sometimes she was by herself when the other STNA was running late. She stated the night shift STNA had been working 12 hour shifts to help out but she only worked three or four nights a week. On 01/31/18 at 10:00 A.M., interview with Resident #5 revealed there was not enough help in the afternoon to timely meet her needs. The resident was ventilator dependent and was totally dependent on at least two staff for most care and frequently there was only one STNA on afternoons and she had to wait awhile to get assistance. On 01/31/18 at 10:40 A.M., Resident #4's call light was observed to be activated. The resident was noted to be ventilator dependent. STNA #51 was on break out of the facility and STNA #52 was in Resident #7's room with the door closed. The nurse was at the nurse's station and the Director of Nursing (DON) and administrator were across the hall in the office, all within hearing range of the need for assistance sound. No one responded to the call light. At 10:55 A.M., STNA #52 came out of Resident #7's room and verified she was providing care for the resident. At 10:57 A.M., STNA #51 re-entered the building and at 10:58 A.M., STNA #52 responded to Resident #4's call light. On 01/31/18 at 11:00 A.M., interview with Resident #4 revealed sometimes there was not enough staff especially in the afternoons and he had to wait awhile for his call light to be answered. On 01/31/18 at 2:05 P.M., interview with LPN #53 revealed she had to help the STNAs daily and it was very rough from 5:00 P.M. until 9:00 P.M. with dinner, medication pass, showers, getting the residents into bed, changing them and turning them. The majority of the residents needed two persons to assist with these activities of daily living (ADL's). The LPN stated, ff the night does not go according to plan it could be disastrous. She indicated she was not able to assist the STNAs at the beginning of the shift because it was a big medication pass time. She verified occasionally there was a second STNA on afternoons from 5:00 P.M. until 10:00 P.M. She stated two STNAs on afternoons would make a world of difference. The residents could get their showers which they don't always get, especially Resident #5 because it was very time consuming. If a second STNA was here residents could get their showers before dinner and the STNAs could work together after dinner getting the residents ready for bed. The LPN stated, we have been asking the administrator and the DON for a while to get us more assistance in the afternoon and they keep saying they are trying. On 01/31/18 at 2:20 P.M., interview with STNA #53 revealed she worked mostly afternoons and it was very difficult to try and meet the residents' care needs. The STNA stated sometimes showers were not given because there was no time. She verified she had been asking for awhile to have another STNA scheduled from 2:00 P.M. until 10:00 P.M. because the nurse was not always available to assist, she does when she can. The administrator and the DON said they had been trying to get more help in the afternoons but it was not budgeted. She also shared, one of the night shift STNAs had been working 12 hour nights recently and coming in at 6:00 P.M. and that had been a great help but it was only three or four times a week. On 01/31/18 at 3:00 P.M., interview with the administrator, the DON and the corporate DON revealed they had been asking chief executive officer (CEO) #54 for awhile to get more staffing, especially in the afternoons but was told they were above minimum staffing levels. On 01/31/18 at 3:15 P.M., phone interview with CEO #54, with the corporate administrator present revealed because of the acuity he liked to keep the per patient day (PPD) staffing levels around 3.1 or 3.2. He stated he was not informed by either the administrator, DON or corporate DON of the need for additional staffing especially in the afternoon and would have looked into the concern if he was aware. He stated he would now look into the concerns about staffing levels. Review of the staffing policy and procedure, dated 01/01/16 revealed to ensure minimum staffing levels were met to ensure proper resident care. The administrator, DON and/or other designee were to be notified in the event the staffing requirements were not able to be met. Review of the spreadsheet, not dated, for determining minimum staffing levels revealed for 21 residents there should be one nurse 24 hours a day and four and a half State tested nursing assistants (STNA) in a 24 hour period. This would meet the facility's determined minimum staffing levels of 2.7 (per patient day) PPD. Review of the staffing schedules revealed the STNA's worked three shifts at 7.5 hours a shift. The past seven days, 01/25/18 to 01/31/18, revealed the following: day shift had two STNA's (at 7.5 hours each), night shift had one STNA (at 7.5 hours) and afternoon shift had one STNA for 7.5 hours and one STNA for 4.0 hours. The facility identified Resident #1, #2, #3, #7, #9, #10, #11, #12, #13, #14, #15, #16, #17, #19 and #20 who required assistance of one or two staff for activities of daily living (ADL) care and four ventilator dependent residents, Resident #4, #5, #6 and #21 who were totally dependent on at least two staff for ADL care. This deficiency substantiates Complaint Number OH 828.

Based on observation, interview and record review the facility failed to ensure Resident #1's weight loss was addressed and he was provided the appropriate therapeutic diet. This affected one of two residents reviewed for weight loss. Harm occurred when Resident #1 sustained an 11 pound weight loss/ 6.6 percent and no interventions were put into place resulting in continued severe weight loss of 11.25 percent in six months from 06/12/17 to 12/10/17. Findings include: Medical record review revealed Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. Review of the current nutrition care plan revealed the resident was at risk due to significant weight loss. The goals were to maintain the usual weight between 150 and 160 pounds and meal intake of at least 75 percent. The interventions included offer a substitute when meal intake was less than 50 percent, provide supplement as ordered, double protein at meals and weigh according to facility protocol. Review of the quarterly nutrition assessment dated [DATE] revealed Resident #1 ate between 75 and 100 percent of meals, was on a regular diet, and was to receive double protein at each meal. Review of the monthly weight dated 04/01/17 indicated a weight of 166 pounds and the weight dated 05/06/17 indicated 155 pounds. The comment section indicated it was a five percent weight loss in one month. Review of the monthly weight from 06/12/17 indicated the resident's weight was 160 pounds and on 07/09/17 his weight was 157 pounds. There was no evidence of a re-weigh for the 06/12/17 or 07/09/17 weights. Review of the June 2017 meal intake records revealed the resident's average intakes were between 50 and 75 percent. Four meals were zero to 25 percent and there was no evidence a substitute was offered when the resident ate less than 50 percent of his meals. Review of the 07/05/17 quarterly nutrition assessment revealed the resident was on a regular diet and was to receive double protein at meals. No supplements were in place, the resident ate between 75 and 100 percent of meals, had a 5.4 percent weight loss in 180 days, protein needs were between 74 and 89 grams per day and the blood urea nitrogen (BUN) was 56 milligrams (mg) per deciliter (dl) (normal 7-25 mg/dl) and the creatinine (Cr) was 3.6 mg/dl (normal 0.6-1.3 mg/dl) on 06/29/17. Both lab values are indicators of kidney function. The assessment did not address the weights dated 04/01/17, 05/06/17, 06/12/17 or 07/09/17. Review of the quarterly minimum data set (MDS) 3.0 assessment dated [DATE] revealed no weights entered on the assessment nor did the assessment indicate a weight loss. Review of the blood work dated 07/13/17 revealed the BUN was 67 and the Cr was 4.3. Review of the 07/13/17 telephone order revealed an order for [REDACTED]. Report of urology consultation note dated 07/15/17 revealed the resident remained with elevated creatinine despite placing bilateral urethral stents. The resident had a [DIAGNOSES REDACTED]. Review of the July 2017 meal intake records revealed the resident's average intakes were between refused and 50 percent. Fifty six meals were refused to 25 percent and there was no evidence a substitute was offered when the resident ate less than 50 percent of his meals. Review of the August 2017 meal intake records revealed the resident's average intakes were between 25 and 75 percent. Twenty three meals were refused to 25 percent and there was no evidence a substitute was offered when the resident ate less than 50 percent of his meals. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed there were no weights entered and the assessment did not indicate a weight loss. Review of the September 2017 meal intake records revealed there was no documentation for intakes from the first to the 15th of the month. The 16th through the 30th revealed the resident's average intakes were between refused and 50 percent. Twenty one meals were refused to 25 percent and there was no evidence a substitute was offered when the resident ate less than 50 percent of his meals. Review of the 09/06/17 quarterly nutrition assessment revealed the resident was on a regular diet and was to received double protein at meals. No supplements were in place, the resident ate between 70 and 100 percent of meals, had a 7.7 percent weight loss in 180 days but was stable since May 2017. Protein needs were between 74-89 grams per day and the 06/29/17 BUN was 56 mg/dl and the Cr was 3.6 mg/dl. Review of the blood work dated 09/07/17 revealed the BUN was 37 and the Cr was 2.9. Review of the 10/09/17 weight indicated 158 pounds and the 11/09/17 weight indicated 150 pounds. The comments section stated a five percent weight loss in one month. Review of the October 2017 meal intake records reveled the resident's average intakes were between refused and 50 percent. Forty seven meals were refused to 25- 50 percent and there was no evidence a substitute was offered when the resident ate less than 50 percent of his meals. Review of the physician order [REDACTED]. Review of the November 2017 meal intake records revealed there was no evidence of records from the first to the 15th of the month. The 16th through the 30th indicated 25 meals were zero to 25 percent. Review of the physicians order dated 11/08/17 revealed diabetic house supplement eight ounces twice a day with breakfast and dinner. Review of the Medication Administration Record [REDACTED]. There was no evidence any other supplements or interventions were offered when the resident was not accepting the house supplement. Review of the nutrition progress note dated 11/10/17 revealed the resident had an eight pound weight loss over the last 30 days. The Registered Dietitian (RD), RD #110 was notified by the nurse earlier in the week of the weight loss. The resident was on [MEDICATION NAME]. Recommendation included starting the house supplement twice a day and inform RD #110 if the resident did not accept the supplement because he could be particular about what he would take. Review of the annual MDS 3.0 assessment dated [DATE] revealed a brief interview for mental status indicated the resident was cognitively intact. There were no weights entered on the assessment nor did the assessment indicate a weight loss. Review of the 11/16/17 BUN revealed it was 62 and Cr was 5.1. Review of the annual nutrition assessment dated [DATE] revealed the resident was on a no added salt, low concentrated sweet diet with double protein at each meal. The meal intake records indicated 50 to 75 percent meal intakes. The resident received a diabetic house supplement which was started 11/08/17 but was not currently taking the supplement. The resident had a five percent weight loss in 30 days or eight pound weight loss. The BUN was 45 and Cr was 4.0 on 10/23/17. The house diabetic supplement was discontinued on 12/04/17. Review of the physician order [REDACTED]. On 12/13/17 the [MEDICATION NAME] was decreased to 7.5 mg daily. Further review of the physicians order dated 12/04/17 revealed Magic cup (nutritional supplement) twice a day. Review of the MAR indicated [REDACTED]. Review of the 12/14/17 BUN revealed it was 97 and Cr was 5.2. Review of the December 2017 meal intake records revealed there was no evidence of records from the first to the 15th of the month. The 16th through the 30th indicated 16 meals were zero to 25 percent and nine meals were 50 percent. There was no evidence a substitute was offered when the resident ate less than 50 percent of his meals. Review of the nutrition progress note dated 12/27/17 revealed the resident's weight was 142 pounds, an eight pounds weight loss in 30 days (a five percent weight loss) and 10 pound weight loss in 60 days. The resident was being treated for [REDACTED]. The progress note indicated Resident #1 was started on [MEDICATION NAME], which could help increase his meal intakes, and Magic cup about three weeks ago for continued weight issues. He took the Magic cup for a while but was now refusing the supplement. The [MEDICATION NAME] was recently decreased and may not be as likely to increase his appetite. Will talk to the resident to see what other type of supplements he would be willing to try. Review of Resident #1's lunch meal ticket revealed a no added salt and concentrated carbohydrate (CC) diet. Under preferences it was indicated a 60 gram protein diet and double portion protein. On 12/27/17 at 12:41 P.M., Cook #111 was observed plating the foods for the residents in the dining room. The meal tickets were laying on the steam table but were not being utilized. On 12/27/17 at 12:43 P.M., Resident #1 was observed in the dining room for lunch. He received a hamburger (with a single two ounce patty), fries, wedding soup, peach crisp, eight ounces hot tea, two four ounces of tomato juice, and eight ounces of milk. At 1:24 P.M., the resident had not touched any of his meal but had drank the hot tea, both four ounce tomato juices and six ounces of the milk. He stated he liked to drink but was just not hungry and did not have an appetite and he was finished eating. On 12/27/17 at 1:03 P.M., interview with Cook #111 verified she did not use the meal tickets. Cook #111 said she had been plating the food for so long she had each resident's meal tickets memorized. Review of Resident #1's meal ticket with Cook #111 revealed he was to have a 60 gram protein diet. Cook #111 said she did not know what that meant and verified he was supposes to get double portion protein at each meal and she did not give him double protein for the lunch meal. On 12/27/17 at 5:45 P.M., Resident #1 was observed in the dining room and received a Magic cup with his entree which included a double portion of chicken, two four ounces of juice and hot tea. The resident drank his hot tea, both four ounces of juice and bites of his chicken. At 5:50 P.M., interview with the resident revealed he was not hungry and did not have an appetite but liked to drink his liquids. On 12/27/17 at 5:55 P.M., interview with Cook #113 verified she gave the resident double protein at his meals. Review of the meal ticket with Cook #113 revealed she did not know what the 60 gram protein meant on the ticket. On 12/28/17 at 1:48 P.M., interview with RD #110 verified the resident's meal ticket indicated 60 gram protein diet and double protein at each meal. She stated the 60 gram protein was probably a minimum amount of protein the previous RD wanted the resident to eat each day. RD #110 said she had been the RD at the facility for one year. She stated Resident #1 had not been eating very well, was losing weight and needed extra protein. She verified her assessments indicated double protein at each meal and did not address the severe weight loss the resident had sustained nor did her assessments document the resident's [MEDICAL CONDITION] or that the resident was being seen by urology and nephrology. She verified there were no interventions put into place to prevent further weight loss from May 2017 until November 2017. She stated the resident was on [MEDICATION NAME] but it was not effective. She was aware the resident was not accepting the Magic cup. She said she was not aware the resident did well with liquids and had not recommended snacks because we try to stay away from the snacks because they sit on there bed side tables and don't get eaten. She indicated the facility did not have a fortified food program. The floor nurses called her at the first of the month with weight changes; she was only at the facility six to eight hours a month and was not usually able to observe meals. She stated she completed a monthly kitchen inspection which included monitoring the orders and the meal tickets. On 12/29/17 at 10:44 A.M., phone interview with Office Attendant #112 revealed the cardiologist ordered the 60 gram protein diet on 07/13/17 in an attempt to preserve the resident's kidneys. On 12/29/17 at 10:45 A.M., interview with Registered Nurse (RN) #105 verified she was not aware Resident #1 was to be on a low protein diet. Review of the physician order [REDACTED]. RN #105 verified there were no interventions or supplements ordered for Resident #1's weight loss prior to 11/08/17. On 12/29/17 at 11:15 A.M., interview with RN #100, with the corporate administrator present, verified the resident's diet order needed to be clarified because the 60 gram protein was for a low protein diet and the double protein was to provide more protein than a regular diet. She verified no one attempted to clarify the diet order to ensure the resident was receiving the optimal nutrition for his health. She was aware Resident #1 was seeing specialists for [MEDICAL CONDITION] and the resident had not been eating. She was responsible for completing the MDS assessments and verified she did not include the resident's weights and document he resident sustained [REDACTED].#100 verified there were was no evidence the physician was notified of the weight loss, prior to November 2017, nor were any interventions put into place until six months after the resident sustained [REDACTED]. She also verified after the house supplement was ordered and the resident did not accept it there was no follow up to ensure an appropriate supplement or different intervention was put in place. Review of the facility's weight protocol policy and procedure dated 01/01/16 revealed all residents would be weighed at least monthly. Residents who were considered at risk for unintentional weight loss would be weighed weekly and referred to risk management when indicated. At risk residents included residents with significant weight change. Re-weights would be done within 24 hours on any weight loss of three or more pounds. The director of nursing (or designee) and dietary would review the weight log to determine if a resident had a significant weight loss. Interventions would be documented on the care plan. Dietary would continue to assess and document other indicators of nutritional status such as clinical condition, appearance, meal and fluid intake and laboratory values. Review of the physician notification policy and procedure dated 01/01/16 revealed the physician must be notified of a resident's change in weight of three pounds within three days of obtaining the weight.