Every finding on record at Brightwood Center

Based on staff interview, record review, and resident observation, the facility failed to develop/implement a comprehensive person-centered care plan related to falls and correct age. This is true for Resident's #5, #12, #61. Facility Census 112. Findings included: a) Resident #61 Review of resident's care plan on pages 24, 25 and 26 revealed the following details: Focus- Resident is at risk for skin breakdown related to Advanced age (greater than 75 years), decreased activity, frail fragile skin, impaired cognition, impaired sensation, incontinence, informed refusal to aspects of care, limited mobility, moisture/excessive perspiration, nutritional concerns, poor safety awareness, shear/friction risks, Chronic Obstructive Pulmonary Disease, Diabetes Mellitus, Hypertension, and Transient Ischemic Attack. Review of Resident 61's electronic medical records revealed her date of birth was in 1961 and and she was [AGE] years of age. During an interview on 08/19/26 at 3:43 PM, the Director of Nursing (DON) acknowledged the care plan was incorrectly stated resident was at an advanced age (75 years or older) and that Resident #61 was [AGE] years old. b) Resident #5A record review, completed on 08/19/26 at 1:00 PM, revealed a fall care plan for Resident #5 that read as follows: -Focus: (Resident #5's name) is at risk for falls related cognitive loss, lack of safety awareness, debility; possible medication side effects, and history of fall at home. 10/10/25-Fall, 11/8/2025-Fall, 12/12/25, Fall 03/16/26, Fall with injury 03/22/26, Fall 5/13/26, Fall 6/13/26, Fall 6/29/26, Fall 7/10/26, Date Initiated: 11/19/2025 Created on: 05/26/2026-Goal: (Resident #5's name) will have risk of serious injury related to falls minimized through next review. Date Initiated: 11/19/2025.-Interventions included Anti-rollback to w/c (wheelchair). Date Initiated: 03/13/2025An observation on 08/19/26 at 3:30 PM, found Resident #5 sitting in the doorway of her room in her wheelchair. No anti-rollbacks were on her wheelchair at this time.During an observation and interview on 08/19/26 at 3:40 PM, the Director of Nursing (DON) observed the wheelchair and stated, No, they are not on here. She might be in the wrong chair. Let me go check with therapy.The DON followed-up with the State Agency Surveyor at 4:00 PM and stated, That was her wheelchair, therapy is going to put them on.c) Resident #12An observation on 08/17/26 at 1:45 PM, revealed Resident #12 lying in bed. A fall mat was on the right side of the bed, and a second fall mat was folded up under the bed. The resident's bed was also in the high position.During an interview and observation on 08/17/26 at 1:47 PM, Nursing Assistant (NA) #25 confirmed that the fall mat was under the bed and stated, This should be on this side of his bed, and I'm lowering his bed. I do not know who put it up like this.A record review on 08/18/26 at 2:00 PM, revealed a fall care plan for Resident #12 that read as follows: -Focus: (Resident #12's name) is at risk for serious injury related to falls related to COPD, ESRD, recent hospitalizations. (Resident #12's name) has history of placing self on the floor/mat in order to pray. 3/9/26-Fall X 2, 3/16/26 Fall, 3/18/26 - Fall, 5/17/26- Fall, 5/23/26- Fall, 6/3/26- Fall, 6/5/26 - Fall, 6/17/26- Fall, 7/1/26 - Fall, 7/5/26 - Fall-GOAL: (Resident #12's name) will have risk of serious injury related to falls minimized through next review. Date Initiated: 03/09/2026 Created on: 03/09/2026-Interventions included: Bed in lowest position when not providing care. Created on 06/05/26 and Bilateral floor mats to bed. Created on 06/18/26.

Based on record review, resident interviews, and staff interviews, the facility failed to ensure all food was temped before leaving the kitchen, to ensure safe food temperatures to prevent foodborne illness and an appetizing temperature of the food. The facility failed to ensure hot foods were served hot and cold foods were served cold. This failed practice had the potential to affect more than a limited number residents. Facility census: 112.Findings include: a) Healthcare Services Group (HCSG) Policies Healthcare Services Group (HCSG) policy #6 titled Food Quality and Palatability states: -Food will be prepared by methods that conserve nutritive value, flavor and appearance. Food will be palatable, attractive and served at a safe and appetizing temperature. -Proper (safe and appetizing) temperature. Food should be at the appropriate temperature as determined by the type of food to ensure resident's satisfaction and minimizes the risk for scalding and burns. -The Dining Services Director and Cooks are responsible for food preparation. Menu items are prepared according to the menu, production guidelines, and standardized recipes. -The Cooks prepare food in a sanitary manner utilizing the principles of Hazard Analysis Critical Control Point (HACCP) and time and temperature guidelines as outlined in the Federal Food Code. HCSG policy #16 titled Food Preparation states: -All foods are prepared in accordance with the FDA Food Code. -The Dining Services Director/Cooks will be responsible, for food preparation techniques which minimize the amount of time that food items are exposed to temperatures greater than 41 degrees Fahrenheit (F) and/or less than 135 degrees F, or per state regulation. -The Cooks will prepare all cooked food items in a fashion that permits rapid heating to appropriate minimum internal temperature. -Time/Temperature Control for Safety (TCS) hot food items will be cooked to a minimum internal temperature, as follows: *All poultry and stuffed foods 165 degrees F (instantaneous) *Ground meat 155 degrees F (for 17 seconds) or 160 degrees F (instantaneous) *Eggs hot held for service 155 degrees F (for 17 seconds) *Fish and shellfish 145 degrees F (for 15 seconds) *Pork, other meats 145 degrees F (and allowed to rest for at least three (3) minutes) *Eggs for immediate service 145 degrees F (for 15 seconds) *All foods will be held at appropriate temperatures, greater than 135 degrees F (or as state regulation requires) for hot holding, and less than 41 degrees F for cold holding. b) Service Line Checklist On 08/19/26 at 12:10 PM, during the follow up visit to the kitchen, the State Agency Surveyor asked the Dining Services Director (DSD) to see the service line checklist for the month of August 2026, to check the food temperatures that had been recorded for all food that was sent to the residents. The following meals did not have food temperatures recorded:-08/04/26 Dinner-08/05/26 Dinner-08/07/26 Breakfast-08/07/26 Lunch-08/13/26 Dinner-08/14/26 Lunch-08/14/26 Dinner-08/15/26 Dinner During an interview with the DSD and the HCSG District Manager (DM) , on 08/19/26 at 12:20 PM. the DSD acknowledged the food temperatures were not taken on the identified dates and stated, The cooks did not do them. c) Anonymous resident interviews identified the following concerns related to food:-The food sucks.-The food is terrible.-The food could be better.-The food is not that good.-The food is really bad.

Based on observation and staff interviews, the facility failed to store, prepare, distribute and serve food in accordance with professional food safety standards. Additionally, the facility failed to follow proper sanitation practices for the kitchen and the food preparation equipment. This practice had the potential to affect more than a limited number of residents. Facility census: 112.Findings include: a) Healthcare Services Group (HCSG) Policies Healthcare Services Group (HCSG) policy #28 titled Environment states: -All food preparation areas, food services areas, and dining areas will be maintained in a clean and sanitary condition.-The Dining Services Director will ensure that all employees are knowledgeable in the proper procedures for cleaning and sanitizing all of the food service equipment and surfaces.-The Dining Services Director will ensure that a routine cleaning schedule is in place for all the cooking equipment, food storage areas, and surfaces.HCSG policy #19 titled Food Storage: Cold Foods states:-All Time/Temperature Control for Safety (TCS) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA Food Code.-All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination.HCSG policy #27 titled Equipment states:-All foodservice equipment will be clean, sanitary, and in proper working order.-All equipment will be routinely cleaned and maintained in accordance with manufacturer's directions and training materials.-All staff members will be properly trained in the cleaning and maintenance of all equipment.-All food contact equipment will be cleaned and sanitized after every use. -All non-food contact equipment will be clean and free of debris. HCSG policy #16 titled Food Preparation states: -All foods are prepared in accordance with he FDA Food Code. -All utensils, food contact equipment, and food contact surfaces will be cleaned and sanitized after every use. b) Initial Kitchen Walkthrough The initial walkthrough of the kitchen on 08/17/26 at 11:49 AM findings are as follows:There were two (2) raw pork loins stored on the same shelf as one (1) case of fresh potatoes in the walk-in refrigerator.The can opener was soiled with food debris.The toaster's crumb tray had debris build-up.There were six (6) damaged meal trays that were cracked and chipped.There was one (1) container of french onion dip located in the B-side nourishment room refrigerator that was outdated with a use by date of 08/12/26.The ice scoop holder located beside the B-side ice machine had a black substance inside of it.The ice scoop holder located beside the A-side ice machine was soiled with debris.The Director of Dining Services (DDS) and the HCSG District Manager (DM) accompanied the State Agency Surveyor during the walkthrough and verified each finding. During an on 08/19/26 at 2:25 PM. the DDS was asked if the the kitchen had a cleaning schedule posted,. The DDS replied, There is no cleaning schedule posted. We just clean without one.

Based on observation, documentation review, staff interview, and resident interview, the facility failed to treat a female resident with dignity and respect in regards to facial hair. This was a random opportunity for discovery. Resident Identifier: #61. Facility Census: 112. Findings included: a) Resident #61 On 08/18/2026 at 12:39 PM, Resident #61 reported she had to ask staff to shave her facial hair. She was observed with long chin hair and stated she would currently like to have it removed. b) Record Review Review of documentation revealed the following: Resident #61 had the capacity to make her own health care decisions. Resident #61's admission MDS, with an assessment reference date of 06/04/26, revealed resident had a Brief Interview for Mental Status (BIMS) score of of 14. A score of 14 is indicative of the fact that resident was cognitively intact. Section GG of the MDS revealed Function Abilities, Question I. Personal Hygiene (including shaving) stated supervision and touch assistance. Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. c) Interview During an interview with the Director of Nursing (DON), on 08/18/26 at 1:24 PM, the State Agency Surveyor discussed Resident #61's facial hair and the fact she had stated she would currently like to have it removed. The DON acknowledged the request and reported they would take care of it. On 08/19/26 at 9:39 AM, Resident #61 reported she was assisted with her chin hair removal on the previous day and the aide who assisted her made the statement, Aren't you capable of doing this yourself? Resident #61 stated she replied she was not allowed to have a razor. The facial hair was removed when observed on this day. Resident #61 reported she was satisfied.

Based on resident interviews, staff interviews, and record review the facility failed to report an alleged abuse allegation within the two-hour time frame. This failed practice was found true for (1) one of (5) five residents reviewed for Activities of Daily Living (ADL) care during the Long-Term Care Survey Process. Resident identifier: #84. Facility Census: 112. Findings include: a) Resident #84 During an interview on 08/18/26 at 3:15 PM, Resident #84 stated, They have only given me a shower a few times. I only want bed baths because I am really afraid of the shower. They force me to go, and it makes me very scared. When the State Agency (SA) asked what happens when she is in the shower, Resident #84 replied, I just freeze up and feel like I can't move, and they wash me anyway. I tell them it scares me, but I am made to do it. During an interview on 08/18/26 at 4:30 PM, the SA informed the Director of Nursing (DON) of the allegation made by Resident #84. The DON stated, I will make sure everyone knows and get her care plan updated. The SA stated, I feel like this is an allegation of abuse. The DON replied, I am not sure that it is. A record review on 08/19/26 at 10:00 AM revealed an ADL care plan for Resident #84 with the following intervention: Resident prefers bed bath, created on 03/05/26. A review of Resident #84's bathing documentation indicated that from 02/01/26 to the present, she was administered 10 showers. During an interview on 08/19/26 at 11:25 AM with the Administrator and the Corporate Speech-Language Pathologist (SLP), the SA requested to review the facility's reportable incident filing for Resident #84 from the previous day. The Administrator stated, We did not have a reportable on her. The SLP stated, We were told that she prefers showers, but were not told that an allegation was made. The SA read Resident #84's interview statement to the Administrator and the SLP, and asked if forcing a resident into a shower despite expressed fear warranted an investigation. The SLP and Administrator confirmed that, based on the resident's statement, the incident should have been reported. They further confirmed that the facility had exceeded the two-hour window for reporting allegations of abuse.

Based on record review and staff interview, the facility failed to ensure the drug regimen of each facility resident was reviewed at least once a month by a licensed pharmacist. This was true for one (1) of five (5) residents reviewed under the unnecessary medications pathway throughout the Long-Term Care Survey Process. Resident identifier # 60. Census 112. Findings include:a) Record reviewOn 08/19/26, a record review was conducted of Resident #60's monthly Medication Regimen Reviews (MRR). A MRR is a required monthly check where a licensed pharmacist systematically evaluates every medication a nursing home resident takes to spot safety issues, stop unnecessary drugs, and prevent harmful side effects. The months reviewed were from 08/1/25 through 08/01/26. Resident #60's record did not reflect an MRR had been completed for the months of December 2025 and February 2026. b) InterviewDuring an interview with the Director of Nursing (DON), on 08/19/26 at approximately 1:00 PM, she stated that she was unable to find any record of a MRR for those months.

Based on observation, record review, and staff interviews, the facility failed to provide liquids in a form that met each resident's individual dietary needs. This failed practice was true for one (1) of eight (8) residents receiving thickened liquids during the Long-Term Care Survey Process. Resident identifier: #114. Facility Census: 112. Findings include: a) Resident #114 A record review, completed on 08/19/26 at 9:00 AM, revealed an order for Resident #114, dated 08/13/26, for a Dysphagia Puree diet texture with Honey-Thick liquids. An observation on 08/19/26 at 9:15 AM revealed a water pitcher at the bedside of Resident #114 containing approximately 1/4 cup of remaining liquid. The liquid was observed to be thin water. The SA asked Resident #114, What happened to your water? Resident #114, who has a Brief Interview for Mental Status (BIMS) score of 15, replied, I drank it. During an interview, on 08/19/26 at 9:15 AM, Nursing Assistant (NA) #12 stated that she works the night shift and believed that the hospitality [NAME] passed out the water pitchers. During the observation, the Director of Nursing (DON) approached the resident's room. The State Agency Surveyor informed the DON that the resident was ordered honey-thick liquids, yet thin liquids were present at the bedside, which the resident reported consuming. The DON confirmed the order for honey-thick liquids and verified that the liquid at the bedside was thin water. The DON stated, We will get him a new drink. During an interview on 08/19/26 at 9:40 AM, the Speech-Language Pathologist/Director of Rehab (SLP/DOR) said that the resident was a recent readmission from the hospital, where a barium swallow study had been conducted. The SLP/DOR noted that the barium swallow study indicated the resident was actively aspirating even on nectar-thick (mildly thick) liquids. A further record review of the hospital's Modified Barium Swallow Study, completed on 08/12/26, revealed the following under History of Present Illness (HPI): (Resident #114's name) is a 78 y.o. (year old) who was referred for a Modified Barium Swallow Study due to dysphagia and feeding difficulties. The patient had a CVA resulting in dysphagia. He has been having occasional coughing/choking episodes. The study was recommended to rule out aspiration. He is currently on a dysphagia 5 minced and moist (Ground) diet with mildly thick (nectar) liquids. The assessment section of the study noted the following: Impression: The patient exhibited oropharyngeal dysphagia. The patient's oral dysphagia was characterized by weak oral structures and impaired tongue coordination resulting in prolonged mastication of the cracker, delayed oral transit time, and poor bolus formation with spillover to the pharyngeal area. The patient's pharyngeal dysphagia was characterized by delayed tongue base retraction with spillover to the vallecula and piriform sinuses, weak tongue base pressure, weak pharyngeal constriction, decreased epiglottic inversion, pharyngeal residue in the vallecula and piriform sinuses, and aspiration of mildly thick (nectar) barium. A chin tuck posture resulted in silent deep penetration to the vocal cords. The plan and recommendations section stated: Recommendations - Diet: Puree. Recommendations - Liquid: Moderately thick (Honey).

Based on resident interview, staff interview and record review, the facility failed to ensure residents were free from sexual and psychosocial abuse perpetrated by another resident . This created an immediate jeopardy situation and put all residents at risk. Resident identifier's: #97 and #102. Facility Census: 111. Findings included: a) Resident #97 At approximately 09:05 AM on 05/20/2025, Resident #97 reported to a surveyor she was abused by Resident #58. Resident #97 stated Resident #58 hit her with her wheelchair and put her hand up my crotch. The resident stated she reported the alleged abuse to Nurse Aide (NA) #63 who, instead of reporting it, made fun of her and laughed while stating, Didn't you like it? The resident stated she told NA #63 she did not like it. NA #63 did not report the allegation of abuse and Resident #97 stated she asked repeatedly to fill out a complaint and the facility would not listen to her. Resident #97 stated a friend, who used to be a Director of Nursing (DON), came to the facility to help her file the complaint. She stated after she filed the complaint, the facility told her to stay away from Resident #58. On 05/21/2025, it was noted the facility logged the allegation of abuse as a grievance related to customer service. The facility educated NA #63 on customer service basics. The education did not mention abuse/neglect, how to identify it or how to report it. The resolution for Resident #97 was to stay away from Resident #58, the alleged perpetrator. The facility did not report the incident as an allegation of abuse and did not place any interventions into place to keep Resident #97 safe from further instances of abuse. At approximately 01:52 PM on 05/21/2025 an interview was conducted with the Administrator and Senior Administrator in which they stated they would report any incident of sexual abuse to law enforcement. At approximately 02:12 PM on 05/21/25 an interview was conducted with Social Worker (SW) #62, in which she stated she took her concerns with this incident to the Administrator and Director of Nursing (DON). At approximately 3:30 PM on 05/21/25, an interview was conducted with the DON in which she stated, We (DON and Administrator) were in meetings in [NAME]. It took a long time to get back to Resident #97 (regarding the incident). The DON stated psych services followed up with Resident #97 after being contacted. The DON stated the facility did not report the allegation because Resident #58 reached between her (Resident #97) legs from behind and did not touch her. At approximately 4:41 PM on 05/21/25, an interview was conducted with NA #63. During the interview, NA #63 stated she did not see the incident, but Resident #97 told her Resident #58 came in and touched her. NA #63 stated this happened around dinner time and she was unaware if anyone else witnessed the incident. NA #63 stated she did not report the allegation of abuse because Resident #97 said she had already told someone else. At approximately 4:46 PM on 05/21/25, an interview was conducted with Resident #97. During the interview, Resident #97 stated, she had her rollator against the door with her hand on her door handle. At this time, Resident #58 reached her hands between my legs and right up into my crotch. I felt the grab with a layer. I was wearing a brief and a pad and pants, and I could feel it through that. Resident #97 was extremely tearful during the interview and stated, while crying, I felt violated. I feel no one should touch me there. Resident #97 stated Resident #58 is constantly in my room. Two days ago, she followed me into my room and said 'psst' and I turned around and told her to get out of my room. She said, 'I'm going to slap you on the ass.' Months ago, she did slap me on the ass, and it stung. The staff think it's cute and funny. I'm sorry, I just don't feel that way. Resident #97 then stated, This is my home, what are they doing to protect me? Resident #97 stated at Bingo on Sunday (05/18/2025), Resident #58 was slapping at her arm and I told her to not touch me, and she stopped. The resident stated She (Resident #58) comes into my room all the time and says she's going to poop in here. I tell her it's my room and to leave. Resident #97 stated the Guest Services Director (GSD) came into her room and asked her what happened. She stated, I told her what happened, and she (GSD) told me that if I touch her (Resident #58) that I would be arrested. I said you mean the mindless have rights and I don't? The resident stated no one else followed up with her that day. Resident #97 stated she told the GSD she wanted to file a complaint about the incident and to get (Resident #102's name) statement because he saw everything. No statement was obtained, and no report was filed. Resident #97 reported SW #62 came into her room, and she told her she wanted to file a complaint about the incident but stated, They ignored me. Resident #97 stated the Administrator and DON came to her room and told her the incident was not reportable. Resident #97 stated she instructed them to get the statement from Resident #102, who witnessed the incident, to which she stated she would. Resident #97 stated she used to come out of her room all the time and stopped coming out after the incident. However, she states she is trying to get out of her room more now. She states she now feels very cautious, avoiding Resident #58's hallway. She stated she was constantly looking behind her when she is out of her room. She stated, I stayed in my room for a while but I'm getting out more now. b) Resident #102 At approximately 06:44 PM on 05/21/2025 an interview was conducted with Resident #102. Resident stated that on 03/20/25, Resident #97 was going into her room when Resident #58 rolled by in her wheelchair, reached out and grabbed Resident #97's butt. Resident #102 stated that Resident #97 was so surprised that she almost fell over. He further stated that she was very upset. Resident #102 further stated that this was not the first time Resident #58 had done this. He said that she had done it to some of the staff. Upon being asked how the staff reacted, he stated that some of them found it to be funny. Resident #97 had a Brief Interview for Mental Status (BIMS) score of 15 cognitively intact) and had capacity to make medical decisions. Resident # 102 had a BIMS of 11(cognitively intact) and had capacity to make medical decisions. On 05/21/25 at 8:45 PM the administrator was informed of the immediate jeopardy situation. All residents in the facility were at risk due to the facility's inability to identify allegations of sexual abuse and protect residents from this type of abuse. On 05/21/25 at 10:15 PM the facility provided the following plan of correction, and the plan was accepted at that time. Social Worker/designee reported allegation of emotional/sexual abuse that occurred on 3/20/25 to APS, OHFLAC and Ombudsman on 5/21/25. The alleged perpetrator was placed on 1:1. CNA suspended 5/21/25. All residents of the facility have the potential to be affected. NHA/ designee interviewed all residents with BIMS score of 8 or above for potential physical, sexual, emotional, and mental distress on 05/21/2025, with any corrective action immediately upon discovery. The Director of Nursing (DON)/designee conducted skin checks on residents with BIMS of 7 or below if resident permits for potential physical, emotional, and mental distress on 5/21/25 with any corrective action immediately upon discovery. NHA/designee reviewed all grievances from 3/01/25 to current to ensure no additional allegations of abuse were listed on a grievance with corrective action immediately upon discovery. The NHA/designee will reeducate all staff on abuse reporting regarding alleged violations involving abuse, neglect, exploitation or mistreatment including injuries of an unknown source and misappropriation of resident property are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury including reporting allegations to the appropriate agencies including abuse and allegation reporting requirements, timely reporting, and reporting to the appropriate agencies with a posttest to validate. Any staff not available during this time frame will be provided reeducation, including posttest by NHA/Designee upon the day of return to work. Director of Nursing/designee will monitor progress notes and grievances daily starting on 5/21/25 to ensure that allegations of emotional, mental distress, and any resident behaviors that may have negative effects on other residents have been correctly identified, reported in a timely manner, and appropriate intervention put in place to prevent recurrence daily for 2 weeks including weekends and holidays, then 3 times a week for 2 weeks then randomly thereafter. Results of monitors will be reported by the Administrator/designee monthly to the Quality Improvement Committee (QIC) for any additional follow-up and or in-servicing until the issue is resolved On 05/22/25 at 2:05 PM the immediate jeopardy was abated.

Based on record review and resident and staff interview, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident by failing to take actions related to allegations of abuse/neglect, when reported by staff. This had the potential to adversely affect all residents residing in the facility. The State Agency (SA) determined these failures caused Resident #97 to suffer sexual abuse and psychosocial harm. Due to the facility's failure to act on the allegation of sexual abuse when they were made aware not only placed Resident #97 at risk for sexual abuse and psychosocial harm but also placed the remaining 110 residents. The SA determined this constituted an Immediate Jeopardy (IJ) situation. Facility census: 111. Resident identifiers: #97, #58, and #102. Findings include: a) Resident #97 The State Agency (SA) identified two (2) Immediate Jeopardy (IJ) situations (F600 and F607) on 05/21/25 dealing with instances of sexual abuse committed by Resident #58 to Resident #97. During the investigations It was determined the facility was made aware of these instances on 03/20/25 and, despite multiple attempts by Resident #97 to report the incident, the facility did not act until 03/26/25. When the facility acted, they logged the allegation of abuse as a customer service grievance instead of an allegation of sexual abuse despite the resident stating she was grabbed in the groin area by Resident #58. The facility was made aware of a witness to the incident, Resident #102, whom she instructed the facility to interview; however, it was confirmed during an interview between Resident #102 and the SA that the facility did not interview this resident regarding the incident. At approximately 9:05 AM on 05/20/25, Resident #97 reported to a surveyor she was abused by Resident #58. Resident #97 stated Resident #58 hit her with her wheelchair and put her hand up my crotch. The resident stated she reported the alleged abuse to Nurse Aide (NA) #63 who, instead of reporting it, made fun of her and laughed while stating Didn't you like it? The resident stated she told NA #63 she did not like it. NA #63 did not report the allegation of abuse and Resident #97 stated she asked repeatedly to fill out a complaint and the facility would not listen to her. She states a friend, who used to be a Director of Nursing (DON), came to the facility to help her file the complaint. She stated after she filed the complaint the facility told her to stay away from Resident #58. On 05/21/25, it was noted the facility logged the allegation of abuse as a grievance related to customer service. The facility educated NA #63 on customer service basics. The education did not mention abuse/neglect, how to identify it or how to report it. In addition, the recommended corrective action on grievance states the facility will re-educate all staff on policy and procedure. The facility is unable to provide any documentation that such education occurred. The resolution for Resident #97 was to stay away from Resident #58, the alleged perpetrator. The facility did not report the incident as an allegation of abuse and did not place any interventions in place to keep Resident #97 safe from further instances of abuse. At approximately 1:52 PM on 05/21/25 an interview was conducted with the Administrator and Senior Administrator in which they stated they would report any incident of sexual abuse to law enforcement. At approximately 2:12 PM on 05/21/25 an interview was conducted with Social Worker (SW) #62, in which she stated she took her concerns with this incident to the Administrator and Director of Nursing (DON). At approximately 3:30 PM on 5/21/2025, an interview was conducted with the DON in which she stated We (DON and Administrator) were in meetings in [NAME]. It took a long time to get back to Resident #97 (regarding the incident). The DON stated psych services followed up with Resident #97 after being contacted. The DON stated the facility did not report the allegation because Resident #58 reached between her (Resident #97) legs from behind and did not touch her. At approximately 4:41 PM on 05/21/25, an interview was conducted with NA #63. During the interview, NA #63 stated she did not see the incident, but Resident #97 told her Resident #58 came in and touched her.NA #63 stated this happened around dinner time and she was unaware if anyone else witnessed the incident. NA #63 stated she did not report the allegation of abuse because She (Resident #97) said she had already told someone else. At approximately 4:46 PM on 05/21/25, an interview was conducted with Resident #97. During the interview, Resident #97 stated she had her rollator against the door with her hand on her door handle. At this time, Resident #58 reached her hands between Resident #97's legs and right up into her crotch. Resident #97 said, I felt the grab with a layer. I was wearing a brief and a pad and pants, and I could feel it through that. Resident #97 was extremely tearful during the interview and stated, while crying, I felt violated. I feel no one should touch me there. Resident #97 stated Resident #58 was constantly in my room. Two days ago, she followed me into my room and said 'psst' and I turned around and told her to get out of my room. She said, I'm going to slap you on the ass. Months ago, she did slap me on the ass, and it stung. The staff think it's cute and funny. I'm sorry, I just don't feel that way. Resident #97 then stated, This is my home, what are they doing to protect me? Resident #97 stated at Bingo on Sunday (5/18/2025), Resident #58 was slapping at her arm and she told her to not touch her, and she stopped. The resident said She (Resident #58) comes into my room all the time and says she's going to poop in here. I tell her it's my room and to leave. Resident #97 states the Guest Services Director (GSD) came into her room and asked her what happened. She stated, I told her what happened and she (GSD) told me that if I touch her (Resident #58) that I would be arrested. I said you mean the mindless have rights and I don't? The resident stated no one else followed up with her that day. Resident #97 stated she told the GSD that she wanted to file a complaint about the incident and to get (Resident #102's name) statement because he saw everything. No statement was obtained and no report was filed. Resident #97 reported Social Worker #62 came into her room and she told her she wanted to file a complaint about the incident, but the resident said the SW ignored her. Resident #97 stated the Administrator and DON came to her room and told her the incident was not reportable. Resident #97 stated she instructed them to get the statement from Resident #102, who witnessed the incident, to which she stated she would. Resident #102 confirmed in an interview on 05/21/25 at 7:20 PM that no one from administration had spoken to him regarding the incident, up to this point. Resident #97 stated she used to come out of her room all the time and stopped coming out after the incident. However, she stated she was trying to get out of her room more now. She states she now feels very cautious, avoiding Resident #58's hallway. She stated she was constantly looking behind her when she is out of her room. She stated, I stayed in my room for a while but I'm getting out more now. At approximately 6:44 PM on 5/21/2025 an interview was conducted with Resident #102. Resident stated that on 03/20/25, Resident #97 was going into her room when Resident #58 rolled by in her wheelchair, reached out and grabbed Resident #97's butt. Resident #102 stated that Resident #97 was so surprised that she almost fell over. He further stated that she was very upset. Resident #102 further stated that this wasn't the first time Resident #58 has done this. He said that she has done it to some of the staff. Upon being asked how the staff reacted, he stated that some of them found it to be funny. Resident #97 has a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact) and capacity to make medical decisions. Resident #58 has a BIMS score of 11 (cognitively intact) and capacity to make medical decisions. The facility's policy and procedure for Abuse Prohibition stated, The Center will implement an abuse prohibition program through the following: Screening of potential hires; Training of employees (both new employees and ongoing training for all employees); Prevention of occurrences; Identification of possible incidents or allegations which need investigation; Investigation of incidents and allegations; Protection of patients during investigations; and Reporting of incidents, investigations, and Center response to the results of their investigations. Due to the inaction of the facility for six (6) days following the report of the incident, coupled with the inaction of the GSD when the incident was reported to her multiple times, the inaction of SW #62 when the incident was reported to her, and upon her reporting her concerns with the incident to the Administrator and DON, which led to them logging the allegation as a customer service allegation, instead of abuse, and informing Resident #97 the incident was not reportable, Resident #97 suffered serious sexual, mental and psychosocial harm. The administration's inaction, once being made aware of the incident, demonstrated their inability to properly identify instances of sexual, physical, and psychosocial abuse, and to take action to protect residents from further harm, despite knowing about the allegations. As part of the initial abatement plan for the IJ issued at F 600, The Administrator and DON were to interview all residents with a BIMS score of 8 or higher regarding abuse. The residents were to be asked if they had ever been abused or witnessed other residents being abused. After the IJ was issued at F 835, the Senior Administrator/Clinical Market Lead/Designee were, as part of that abatement plan, to re-interview each resident that was interviewed by the Administrator and DON. The DON interviewed nine (9) residents. All nine (9) residents, according to those interviews, stated not being abused and not seeing other residents being abused, or did not have any concerns that had not been addressed. When those interviews were redone, seven (7) of those nine (9) reported seeing other residents being touched inappropriately, being touched inappropriately, having money missing, and other concerns that had not been addressed. One resident stated I told them last night when starting her statement. This indicated the DON did not interview the residents initially. At approximately 1:30 PM on 05/22/25, an anonymous employee approached the survey team and wished to give information on the incident. The employee stated they reported the incident on 3/20/2025. At this point, the employee states an investigation was started and statements were obtained, and the employees investigating the incident were then told to not investigate any further, that it was not being reported, it was being logged as a grievance. The facility was first notified of the IJ at 11:55 AM on 5/22/25. The SA received and accepted the Plan of Correction (POC) at 1:45 PM on 5/22/25. The Nursing Home Administrator and Director of Nursing was placed on administrative leave on 5/22/2025 at 10:10am. The Guest Service Director and Social Worker were placed on administrative leave on 5/21/2025. NA #63 was placed on administrative leave on 5/21/2025. All residents have the potential to be affected by this practice. The Senior Nursing Home Administrator/designee conducted an audit of all resident interviews conducted on 5/21/2025 to ensure the resident interviews were not conducted by the Nursing Home Administrator and the Director of Nursing. All resident interviews conducted by the Nursing Home Administrator and the Director of Nursing will be re-interviewed with any corrective action immediately upon discovery. The Director of Nursing (DON)/designee conducted skin checks on residents with BIMS of 7 or below if resident permits for potential physical, emotional, and mental distress on 5/21/2025 and 5/22/25 with any corrective action immediately upon discovery. NHA/designee reviewed all grievances from 3/01/25 to current to ensure no additional allegations of abuse were listed on a grievance with corrective action immediately upon discovery. The Senior Nursing Home Administrator/designee will reeducate all staff on abuse reporting starting on 5/21/2052 regarding alleged violations involving abuse, neglect, exploitation or mistreatment including injuries of an unknown source and misappropriation of resident property are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury including reporting allegations to the appropriate agencies including abuse and allegation reporting requirements, timely reporting, and reporting to the appropriate agencies with a posttest to validate. Any staff not available during this time frame will be provided reeducation, including posttest by NHA/Designee upon the day of return to work. Director of Nursing/designee will monitor progress notes and grievances daily starting on 5/21/25 to ensure that allegations of emotional, mental distress, and any resident behaviors that may have negative effects on other residents have been correctly identified, reported in a timely manner, and appropriate intervention put in place to prevent recurrence daily for 2 weeks including weekends and holidays, then 3 times a week for 2 weeks then randomly thereafter. Results of monitors will be reported by the NHA / designee to the Quality Improvement Committee (QIC) monthly for any additional follow-up and or in-servicing until the issue is resolved, then randomly thereafter as determined by the Quality Improvement Committee. The IJ was abated at 11:45 AM on 05/27/25.

Based on resident interview, staff interview and record review, the facility failed to ensure residents were free from sexual abuse by not implementing written policies for abuse and following policy and procedures to investigate abuse allegations. This was true for one(1) of six (6) residents reviewed for abuse. This failed practice has the potential to affect more than a limited number of residents. The situation was determined to be an Immediate Jeopardy situation due to all residents residing in the facility could experience serious actual or psychological harm if the facility did not immediately intervene. Resident identifier: #97. Facility Census: 111. Findings included: a) Resident#97 Observation during the survey revealed a flyer citing the Elder Justice Act of 2010 posted in the facility's break-room. The flyer stated, If you have reasonable suspicion that a crime has occurred against a resident or patient, the federal Elder Justice Act of 2010 and Genesis Integrity Program require that you report your suspicion to both your state agency and local law enforcement. The law applies to all employees, agents or affiliated contractors of this nursing center. The flyer also stated, If you believe the suspected crime involves serious bodily injury, including sexual abuse, to the patient, you must report it no later than 2 hours after forming a suspicion. The facility's policy and procedure for Abuse Prohibition stated, Centers also strive to comply with the Elder Justice Act (EJA). Under the EJA, employees are designated as mandated reporters and are obliged to immediately report any reasonable suspicion of a crime against a patient. Reporting a reasonable suspicion of a crime only to an immediate supervisor does not meet the obligation to report. On 05/20/25 at 9:05 AM, Resident #97 stated she had reported abuse by Resident #58 multiple times to staff and had asked to file a complaint. The resident stated she had reported resident abuse by Resident #58, but the staff would not take her complaint. The resident filed a Grievance form with the assistance of a friend/resident representative on 03/26/25 for a complaint verbally reported to staff on 03/20/2025. The resident reported Resident #58 had hit her with her wheelchair and put her hand up my crotch. The resident stated she had reported the incident to Nursing Assistant #63 and the Guest Services Director the evening of the incident. The resident reported Nursing Assistant #63, made fun of me and asked me Didn't you like that? and I told her. No I did not like it. On 05/21/25 at 4:41 PM, Nursing Assistant #63 was interviewed about the incident reported by Resident #97 and stated, I did not see a single thing. Nursing Assistant # 63 reported Resident #97 told me Grandma (Resident # 58) came in and touched her. Nursing Assistant # 63 stated it happened around dinnertime, and I don't know if anyone else saw it. Nursing Assistant # 63 stated, I didn't tell anybody because she said she already told someone. Nursing Assistant #63 reported her response to Resident # 97 was oh. On 05/21/25, Resident #97 reported the Guest Services Director came into her room asking about missing items and asked what was wrong. The resident said she told the Guest Services Director what happened, and she said - If I would touch her, I would be arrested and I said you mean the mindless have rights and I don't. The resident reported no one came that day to take my complaint. The resident reported the next day she stopped the Guest Services Director in the hallway and stated she wanted to file a formal complaint, and the Guest Services Director stated, For what? And I told her about the incident yesterday and I wanted to file a formal complaint. The resident reported the Guest Service Director was asked by her to get a statement from Resident #102 that witnessed the incident. The resident stated Social Worker #62 came into her room and I told her I wanted to file a complaint, but they all ignored me. On 05/21/25 at 2:12 PM, Social Worker #62 stated, I remember the incident. I took my concerns to the Administrator and Director of Nursing (DON) about this incident. Social Worker #62 reported she didn't know the exact date but that sounds about the time - 1-2 months ago. The resident reported the Administrator and DON came to my room after the complaint was filed. The DON and Administrator came down and told me it wasn't a reportable incident. On 05/21/25 at 3:30 PM, the DON reported we(looking at the administrator) were in meetings in [NAME], and it took along time to get back to her (Resident # 97). The DON stated it was not reportable because Resident # 58 Reached between her legs from behind and did not touch her. The DON reported, customer service education with Nursing Assistant # 63 was completed for laughing at the resident. On 05/21/25 at 05:36 PM, the DON reported she did not have a written witness statement. She stated, I interviewed him verbally. Resident #102 was interviewed on 05/21/25 at approximately 6:44 PM, Resident #102 stated, Resident #97 was going into her room when Resident # 58 rolled by in her wheelchair, reached out and grabbed Resident # 97's butt. Resident #102 stated that Resident #97 was so surprised that she almost fell over. He further stated that she was very upset. Resident #102 further stated that this was not the first time Resident #58 has done this. He said that she has done it to some of the nurses. Upon being asked how they reacted, he stated that some of them found it to be funny. On 05/21/25 at 7:20 PM, the resident reported no one had talked to him before the state surveyor about the incident. On 05/22/25 at 1:40 PM, an anonymous staff member confirmed the allegation was reported to Social Worker # 62 and had been reported to the Administrator and the Director of Nursing. It was reported everyone in attendance in the facility's stand-down meeting was aware of the allegation. It was stated the reporting process had been changed in February or March at the Genesis Social Worker's meeting for the reportable process to be streamlined for the Director of Nursing and Grievance Officer to complete. The facility's policy and procedure for Abuse Prohibition stated, The Center will implement an abuse prohibition program through the following: Screening of potential hires; Training of employees (both new employees and ongoing training for all employees); Prevention of occurrences; Identification of possible incidents or allegations which need investigation; Investigation of incidents and allegations; Protection of patients during investigations; and Reporting of incidents, investigations, and Center response to the results of their investigations. The situation was determined to be an Immediate Jeopardy situation due to all residents residing in the facility could experience serious actual or psychological harm if the facility did not immediately intervene. On 05/21/2025 at 8:45 PM - the Immediate Jeopardy (IJ) facility notification was given. 05/21/2025 at 10:16 PM - The abatement plan was accepted. 05/22/2025 at 2:05 PM - the immediate jeopardy situation was abated. Abatement plan: Social Worker/designee reported allegation of sexual abuse that occurred on 03/20/25 to APS, OHFLAC and Ombudsman on 5/21/25. The alleged perpetrator was placed on 1:1. CNA suspended 5/21/25. Nursing Home Administrator (NHA)/designee educated Social Service #62 and Guest Service Director on Abuse and Neglect and Grievance Policy and Procedure on 5/21/25. All residents of the facility have the potential to be affected. NHA/designee interviewed all residents with BIMS score of 8 or above for potential physical, sexual, emotional, and mental distress on 05/21/2025, with any corrective action immediately upon discovery. The Director of Nursing (DON)/designee conducted skin checks on residents BIMS of 7 or below if resident permits for potential physical, emotional, and mental distress on 5/21/25 with any corrective action immediately upon discovery. NHA/designee reviewed all grievances from 3/01/25 to current to ensure no additional allegations of abuse were listed on a grievance with corrective action immediately upon discovery. The NHA/designee will reeducate all staff on abuse reporting regarding alleged violations involving abuse, neglect, exploitation or mistreatment including injuries of an unknown source and misappropriation of resident property are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury including reporting allegations to the appropriate agencies including abuse and allegation reporting requirements, timely reporting, and reporting to the appropriate agencies with a posttest to validate. Any staff not available during this time frame will be provided reeducation, including posttest by NHA/Designee upon the day of return to work. Director of Nursing/designee will monitor progress notes and grievances daily starting on 5/21/25 to ensure that allegations of emotional, mental distress, and any resident behaviors that may have negative effects on other residents have been correctly identified, reported in a timely manner, and appropriate intervention put in place to prevent recurrence daily for 2 weeks including weekends and holidays, then 3 times a week for 2 weeks then randomly thereafter. Results of monitors will be reported by the Administrator/designee monthly to the Quality Improvement Committee (QIC) for any additional follow-up and or in-servicing until the issue is resolved.

Based on observation, resident and staff interview the facility failed to provide the right to a safe, comfortable and homelike environment by not providing residents access to over the bed lights. This was a random opportunity of discovery. Facility Census: 111 Findings Include: a) On 5/19/25 at 12:45 PM a resident voiced her concern that she could not see very well while reading in her bed. She believed the light bulb needed to be brighter. Upon further investigation it was found that there was a light fixture over each resident's bed. There was a toggle switch to the right of each fixture. It is placed in a manner that requires the resident to get out of bed, walk to the head of the bed and reach the toggle switch in order to operate the light. On 5/19/25 at 3:30 PM during an interview and walk through of the facility, the Administrator confirmed that there are residents that can not access the switch. She stated she had never even noticed that the lights did not have pull strings or a way residents could access the light other than calling out for staff to assist them. She confirmed that all over the bed lights for all 115 beds in the facility were this way. On 5/21/25 at 10:53 AM the Clinical Reimbursement Coordinator #39 provided a list of independent walkers in the facility. This list consisted of three (3) residents. When asked if this list are the only residents that could get out of bed with no assistance and walk to the head of the bed, she stated, yes, only these three (3). On 05/21/25 at 11:15 AM it was confirmed with the administrator that most residents in the facility at this time could not maximize their independence in operating the light switches without posing a safety risk. She agreed they should have a chain or rope for easy access.

Based on record review and staff interview, the facility failed to ensure posted nurse staffing information was accurate, by failing to update the posting. This was a random opportunity for discovery. This has the potential to affect more than a limited number of residents residing in the facility. Facility census: 111. Findings include: a) During staffing review, daily nurse staff postings were reviewed. During that review, it was determined that the facility failed to accurately update the posted information. The following days were reviewed and compared with the facility's punch in and out reports, with discrepancies: -11/16/2024- No census was indicated on the staffing sheet. Total direct care hours are 309.38 on the staffing sheet. On the facility punch in and out reports, the accurate number was 299.60. 11/23/2024- No census was indicated on the staffing sheet. Total direct care hours are 279 on the staffing sheet. On the facility punch in and out reports, the accurate number was 272.98. 12/28/24- Hours Per Patient Day (HPPD) indicated on the staff posting was 2.8 hours. On the facility Punch In and Out report, HPPD was 2.69 5/3/2025- Hours Per Patient Day (HPPD) indicated on the staff posting was 2.74 hours. On the facility Punch In and Out report, HPPD was 2.60 5/9/2025- No census was indicated on the staffing sheet. Total direct care hours are 299.75 on the staffing sheet. On the facility punch in and out reports, the accurate number was 330.52. At approximately 4:00 PM on 5/27/2025, the inaccuracies were confirmed by Senior Administrator #160.

Based on record review, resident interview, staff interview and observations the facility failed to ensure residents had a right to a dignified existence. This is in relation to their dining experience and failing to invite the residents and/or resident's representative to participate in the care plan meeting. These were random opportunities for discovery. Resident identifiers: #59, #89, #80, #6, #13, #109, #3, #14, #42 #58, #59, #109, and #42. Facility Census: 111 Findings Include: a) Resident #59 On 5/19/25 at 5:15 PM during the dinner meal observation in the Coral Dining Room it was observed that five (5) residents at table #1 were not served their meals at the same time. There were three (3) additional large tables seating five (5) at one table, and three (3) at the other two. There were also two (2) residents sitting at individual tables, alone. Resident #59 received her meal at 5:18 PM and began eating. Staff members continued serving meals to the other tables in the dining room prior to finishing serving all residents at table #1. Resident #59 continued to eat her dinner and finished her meal while the other four (4) residents watched and waited on their dinner. b) Resident #89 On 5/19/25 at 5:15 PM during the dinner meal observation in the Coral Dining Room it was observed that five (5) residents at table #1 were not served their meals at the same time. There were three (3) additional large tables seating five (5) at one table, and three (3) at the other two. There were also two (2) residents sitting at an individual table alone. Resident #59 received her meal at 5:18 PM and began eating. Staff members continued serving meals to the other tables in the dining room prior to finishing serving all residents at table #1. A table mate at table #1, Resident #89, did not receive her meal until 5:25 PM (seven (7) minutes after Resident #59s' meal was served. c) Resident #80 On 5/19/25 at 5:15 PM during the dinner meal observation in the Coral Dining Room it was observed that five (5) residents at table #1 were not served their meals at the same time. There were three (3) additional large tables seating five (5) at one table, and three (3) at the other two. There were also two (2) residents sitting at individual tables, alone. Resident #59 received her meal at 5:18 PM and began eating. Staff members continued serving meals to the other tables in the dining room prior to finishing serving all residents at table #1. A table mate at table #1, Resident #80, did not receive her meal until 5:29 PM (eleven (11) minutes after Resident #59s' meal was served. d) Resident #6 On 5/19/25 at 5:15 PM during the diner meal observation in the Coral Dining Room it was observed that five (5) residents at table #1 were not served their meals at the same time. There were three (3) additional large tables seating five (5) at one table, and three (3) at the other two. There were also two (2) residents sitting at an individual tables, alone. Resident #59 received her meal at 5:18 PM and began eating. Staff members continued serving meals to the other tables in the dining room prior to finishing serving all residents at table #1. A table mate at table #1, Resident #6, did not receive her meal until 5:33 PM (fifteen (15) minutes after Resident #59s' meal was served. e) Resident #13 On 5/19/25 at 5:15 PM during the diner meal observation in the Coral Dining Room it was observed that five (5) residents at table #1 were not served their meals at the same time. There were three (3) additional large tables seating five (5) at one table, and three (3) at the other two. There were also two (2) residents sitting at an individual tables, alone. Resident #59 received her meal at 5:18 PM and began eating. Staff members continued serving meals to the other tables in the dining room prior to finishing serving all residents at table #1. A table mate at table #1, Resident #13, did not receive her meal until 5:37 PM (nineteen (19) minutes after Resident #59s' meal was served. The above findings were confirmed with Nurse Aide #110 on 05/19/25 at 5:40 PM at which time she commented, I know, I was really trying to serve them all together. On 05/19/25 at 05:53 PM, during the Coral Dining Room observation, Resident's #59, #58, #109, #3, and #14 were served their dinner drinks in disposable cups during the dinner meal. Licensed Practical Nurse (LPN) #82 confirmed the resident's drinks were served in disposable cups. LPN #82 stated, Let me check it out. No additional information was given. On 05/20/25 at 12:23 PM, the Regional Dietary Manager #161 stated, a dietary aide reported there were no mugs so disposable cups were sent. The Regional Dietary Manager #161 stated, I informed her not to do that. g) Resident #42 During an interview with Resident #42 on 05/19/25 at approximately 1:04 PM, the resident reported that facility staff had approached him in a threatening manner concerning a comment he posted on Facebook. He explained that his comment was in response to someone asking for information about the services at the facility. The resident noted that he had not said anything particularly offensive, and the comment he made was simply, Do your research! The resident stated that on 05/08/25, the Admissions Director (AD) #72 had approached him and questioned him about a Facebook comment. The resident stated that AD #72 had suggested to him that he could go to another facility if he was not happy there. The resident further stated that he had mentioned to AD #72 that he had the right to post opinions online and that he was not planning to go anywhere else. During an interview with resident's family member on 05/20/25 at approximately 8:35 AM, the resident's family member stated that she had gone into the facility on [DATE] and met with AD #72. Resident #42's family member stated the following: She (AD #72) said she was the one that talked to [Resident #42] about it. She called it a post and I had to point out to her that it was only a comment to someone else's post. She did not see the comment firsthand and admitted hearing about it from someone else. She was not even aware that his comment was complimentary and not derogatory. I told her that if they were so concerned about Facebook, they should have been concerned about all the negative remarks that other people made that weren't residents. During an interview with the Administrator on 05/20/25, at approximately 1:25 PM, she acknowledged awareness of a Facebook comment made by Resident #42. The Administrator confirmed that AD #72 had questioned the resident. However, she stated that she did not know the reason behind AD #72's confrontation with the resident. On 05/21/25 at approximately 11:00 AM, during an interview with AD #72, she stated that she had approached Resident #42 because she had heard from staff members that the resident was unhappy. AD #72 further stated that she had offered to send out referrals to other Long Term Care facilities. AD #72 stated that Resident #42 had said I know why you are trying to push me out. It's because of that Facebook comment!. AD #72 said that she had no knowledge of the Facebook comment and stated that the resident had mentioned it during the conversation. During a follow-up interview with Resident #42 on 05/22/25 at approximately 11:00 AM, he stated that he was a little anxious because he felt that the staff was not happy with him.

Based on staff interview, resident interview, observation and record review, the facility failed to provide suitable snacks for residents consistent with the residents plan of care. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Resident identifier's: # 74, #87, #10, and # 90. Facility Census: 111. Findings included: a) The facility's policy and procedure for Snacks, Nourishments, Supplements and Pantry Stock stated, Snacks, nourishments, supplements and pantry stock are available to complement meal service and are stored in a clean and sanitary environment. The policy and procedure stated the definition of a Snack was Evening snack is planned as part of the menu. and the definition of Pantry Stock was Small amounts of foods stored at the nursing station to accommodate resident requests between meals when the Food and Nutrition Services department is closed, as well as provide products for medication pass. On 05/20/25 at 2:00 PM, a Resident Council Meeting was held. The Resident Council Members reported the following: They haven't seen snacks, They don't bring them out, If you are able to ask for one .you can get one, you have to ask for them, One member reported they had not had snacks for two (2)months. Resident #74, #87, #10, and #90's care plans stated, Offer snacks. On 05/21/25 at 3:05 PM, the Administrator and Director of Nursing (DON) confirmed the care plans stated offer snacks. The DON reported they staff can also make peanut butter and jelly. The State Surveyor reported the pantries were limited in stock with no fruit cups, jello or sandwiches for all residents. Registered Nurse (RN) Supervisor # 111 reported the kitchen brings a snack cart at night and there are no grab and go sandwiches kept in the refrigerator, only what families bring. Regional Dietary Manager #161 reported the kitchen keeps the pantries full. and there is no snack cart.

Based on record review, staff interview and observation, the facility failed to ensure food was stored and served in accordance with professional standards for food service safety. This failed practice had the potential to affect more than a limited number of residents. Facility Census: 111. Findings included: a) The facility's policy and procedure for Food Storage: Dry Goods stated, 5. All packaged and canned food items will be kept clean, dry, and properly sealed. 6. Storage areas will be neat, arranged for easy identification, and date marked as appropriate. The Regional Chef #162 reported, the facility policy is for items to be dated seven (7) days after being opened with an open and close date. The facility's policy and procedure for Food Storage: Cold Foods stated, 5. All foods will be stored wrapped or in covered containers, labeled and date, and arranged in a manner to prevent cross contamination. The Regional Chef # 162 reported, the facility policy is for items to be dated seven (7) days after being opened with an open and close date. On 05/19/25 at 12:17 PM, the Kitchen Task was initiated. The following items were found: Mrs. [NAME] syrup - opened and not dated; [NAME] pasta - opened not sealed and not dated; sandwich bread opened, not sealed and one (1) loaf not dated; Niagara water gallon jug - opened and not dated; maraschino cherries in a plastic container - not labeled or dated; [NAME] Sour Cream - opened and not dated; three (3) bags of ice on the freezer floor- one opened, not sealed and not dated; frozen pancakes - not labeled or dated; frozen pizza dough - not labeled or dated Regional Chef # 162 confirmed the items were not stored and served according to policy and procedure. Regional Chef # 162 stated, Twisted bags are not good enough? Is a knot okay? On 05/20/25 at 9:49 AM, 'B' Pantry was investigated. A loaf of bread was found open, not dated and not sealed. Licensed Practical Nurse (LPN) # 80 confirmed the pantry item. On 05/20/25 at 1:26 PM, 'A' Pantry was investigated. A biscuit wrapped in a napkin dated 03/21/25 was found. Registered Nurse (RN) Supervisor #111 confirmed the pantry item. On 05/20/25 at 2:49 PM, the State Surveyor observed [NAME] # 44 use his foot on the oven door to keep it open while removing food. Regional Dietary Manager #161 confirmed the cook's foot on the open oven door and stated, Unfortunately, he does.

Based on observation, record review, and staff interview, the facility failed to adhere to proper infection control practices by leaving food items being transported from the kitchen to the floor, uncovered and by failing to handle and transport soiled linens in a manner to prevent the spread of infection. This was a random opportunity for discovery. This has the potential to affect more than a limited number of residents residing in the facility. Facility census: 111. Findings include: a) During dinner service on 05/19/25 at approximately 5:35 PM, each tray being pulled from the delivery cart was observed as having an uncovered brownie on it. When asked if the brownies should be uncovered, The Clinical Reimbursement Coordinator (CRC) stated, I ' m not sure, I will let you know. The CRC returned and stated, They can be uncovered because we are taking them from the cart to the rooms. At approximately 11:05 AM, on 5/20/2025, the policy regarding meal distribution was reviewed, and it was confirmed with the Regional Chef, that all items transported from the kitchen should be covered. The policy stated All foods that are transported to dining areas that are not adjacent to the kitchen will be covered. b) On 05/19/25 at 1:17 PM, Staff #73 carried soiled linen from Resident #19 down the hallway and returned with a clean sheet. Staff #73 failed to transport linens in a manner to prevent the spread of infections. Staff #17 confirmed the linen was not bagged and gloves were not used to carry the soiled linen to laundry. The facilities policy and procedure for Linen Handling stated, All linen will be handled, stored, transported, and processed to contain and minimize exposure to waste products. All soiled linen will be handled the same, using Standard Precautions.

Based on investigation, interview and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition. Furthermore, facility staff failed to notify maintenance or management of defective equipment promptly, thereby potentially exposing all residents in the facility to injury. Resident identifier: #24. Facility Census: 111. Findings include: a) Resident #24 Record review on 05/20/25 at approximately 2:30 PM revealed Resident #24 was injured on 04/10/25, when the resident's bed moved while the nursing assistant was providing care. Resident #24 struck his head against the nightstand on the left side of the bed. The resident sustained two lacerations to the top of his head. The facility investigation revealed that the wheel on the resident's bed was broken. The bed moved even when the wheel was locked. Maintenance replaced the wheels and then performed a whole house audit of all the beds in the facility. Further review of the records revealed that the incident was reviewed by the Interdisciplinary Team (IDT) and maintenance was notified. A review of records on 05/20/25 at approximately 2:35 PM revealed that an order had been entered into the TEL's system for a check on the bed's wheels. Maintenance records revealed that the wheel lock was found to be defective, and the wheel was replaced on 04/11/25 at 11:00 AM. Records further indicated that the facility had performed a whole house audit of bed wheels on 04/11/25 to ensure that they were all working properly. Ongoing review of records revealed a statement by Nursing Assistant (NA) #77 which stated: I was changing the resident. I turned him, as I turned him the bed moved. When the bed moved his head hit the corner of the stand at the left side of the bed. Another statement by RN #65 on 04/11/25 stated the following: I have taken care of [Resident] a lot. His bed will move even when it is locked. His bed has been broke like this for a couple of months. All of these beds are hit or miss. You never know if they are going to work right! During an interview with RN #65 on 05/21/25, RN confirmed that she had not reported the malfunctioning bed to the maintenance or management. A document titled One on One Education 04/11/25 stated the following: Any time you are providing care to a resident and notice ANY type of defective equipment (ex: such as wheels being broken on the bed) you must report it immediately so it can be addressed to prevent injuries . The document had been signed by RN #65 on 04/11/25. A review of the preventive maintenance policy on 05/20/25 at 3:05 PM revealed the following: Follow manufacturer's preventive maintenance recommendations Perform maintenance on equipment and physical plant on a schedule which factors in operational activity and complies with applicable code requirements. Refer to equipment specific policies for preventive maintenance schedules. A review of the preventive maintenance logs for resident's beds during the period 05/24 to 05/25 revealed that the bed safety audits consisted of the following: Nursing and maintenance are responsible for conducting bed safety audits Audits will be conducted annually and with a change of a specialty bed or mattress Nursing - check if side rails are clinically indicated Check mattress for tears, rips, odors or stains Evaluate mattress for foam visibility Check mattress for proper inflations settings Check power unit for function Check that the mattress is the correct width and length for the bed frame. However, the preventive maintenance plan did not address, or require the inspection of bed wheels, function and brakes. During an interview with the Administrator on 05/21/25 at approximately 1:15 PM, the Administrator confirmed that the preventive maintenance policy did not include any requirements for checking bed wheels for function. b) On 05/20/25 at 02:49 PM, [NAME] #144 used his foot to hold the oven door open while food was being removed. Regional Dietary Manager # 161 confirmed the broken right oven door and stated a spring was broken and it was hard to get the food out because the door will not stay open.

Based on record review and staff interview, the facility failed to give appropriate notices for discharges for residents who received Medicare Part A services. This was true for one (1) out of three (3) residents reviewed. Resident Identifier: #102. Facility Census: 111. Findings included: a) Resident #102 A discharge for Resident #102 was initiated by the facility from Medicare Part A services when benefit days were not exhausted. A Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) and a Notice of Medicare Non-Coverage (NOMNC) were not acknowledged by the beneficiary or the beneficiary's representative. Findings were confirmed by Senior Nursing Home Administrator #160 on 05/27/25 at 10:04 AM.

Based on interview and record review, the facility failed to notify resident of treatment and healthcare information in accordance with his preferences. The facility further failed to ensure that each resident had the opportunity to exercise their autonomy regarding those things that were important in their life. This was true for one (1) of three (3) residents surveyed for choices. Resident Identifier: #70. Facility Census: 111. Findings Include: a) Resident #70 During an interview on 05/19/25, at 1:08 PM, Resident #70 expressed feeling unsafe because the facility does not keep him informed about his lab test results and other treatment outcomes. The resident, who is [AGE] years old and a veteran, also mentioned that he had not been invited to participate in his care plan meetings. He stated that he receives documentation and lab results from the VA hospital but that his requests for documentation from the Long Term Care facility have been ignored. A review of Resident #70's Care Plan on 05/21/25 at approximately 3:25 PM revealed the following notes: CARE PLAN (Resident #70) will be involved in the care planning process to promote autonomy and respect for his experiences. Date Initiated: 03/10/2025 Created on: 03/10/2025 Promote opportunities for participation in decisions regarding care Date Initiated: 02/26/2025 Created on: 02/26/2025 Inform [Resident] of changes in status/care needs Date Initiated: 02/26/2025 Created on: 02/26/2025 On 05/21/25 at approximately 2:15 PM Director of Social Services (DSS) #66 stated that she did not send out invitations to residents or representatives for care plan meetings. She further stated that the Clinical Reimbursement Coordinator (CRC) #11 sent out the invitations. During an interview on 05/21/25 at approximately 3:10 PM, CRC #11 stated that she sends out invitations to residents and representatives for care plan meetings. However, she was unable to provide any documentation to verify that invitations had been sent out. CRC #11 confirmed that she did not keep copies of the invitations, and did not save them into the resident's record. During an interview with the Director of Nursing (DON) on 05/20/25 at approximately 3:45 PM, she stated that she was not aware that the resident wanted copies of his lab results. She stated that she would make sure to provide resident with copies of his lab reports. Upon notification, Regional Clinical Nurse (RCN) #165 promptly interviewed the resident, addressed his concerns, and provided him with copies of his lab results.

Based on interviews and record reviews, the facility failed to afford the residents and their representatives the opportunity to participate in the care planning process and to be included in decisions and changes in care, treatment, and/or interventions. This was true for two (2) of two (2) residents interviewed. Resident Identifiers: Residents #42 and #70. Facility Census: 111. Findings Include: a) Resident #42 During an interview on 05/19/25, at 1:00 PM, the resident stated that he had not been invited to, nor given the opportunity to participate in, his care plan meeting. He further mentioned that his sister, who was his Medical Power of Attorney (MPOA), was not allowed to attend the meeting. Additionally, the resident's MPOA submitted a written statement that included the following: In our first conversation, Director of Social Services (DSS) #66 told me that a care meeting was being planned for Friday, 3/28/25 at 4:30 p.m. to discuss [Resident's] progress and sending him to LTC. She stated she would be on vacation, returning Monday, March 24. In discussing care at home for [Resident], I mentioned the Medicaid Aged and Disabled Waiver. DSS #66 had no knowledge of it. However, she did reach out to someone and told me she is now aware of it. I mentioned this to her because I had discussed it with [Resident] as a possible part of his home care plan. On 03/27/25 as of 8:05 AM, the care plan meeting was still on, as per an email response from DSS #66 when I asked where it would be and who would be participating. She said that Social Services, Therapy, and the Care Plan Nurse (whom I have come to realize is the Clinical Reimbursement Coordinator (CRC) #11). On 03/27/25, In the afternoon received a call from what I think was Social Services. Was driving so unable to take notes. They were saying that the meeting wasn't necessary now and that we wouldn't be having it. They said the reason was because of something that they didn't want to say in front of everyone in the meeting - they were worried about (resident name) mainly - they said the reason was because [Resident] was incontinent. I hadn't heard this before and asked them to explain what they meant because I know what incontinence means for my dog, but had never heard it about [Resident] because he has never had that problem before. On 03/28/25 (Friday), CRC #11 called me in the morning to tell me that there would be no meeting. She said this is what [Resident] wanted and she said that [Resident] asked her to call me and tell me. Many times, she continued to say throughout the conversation, This is all about [Resident]. This is what [Resident] wants. I've come to find out in conversation with [Resident] that CRC #11 went to him and told him that he did not need the meeting and got him to agree to her reasons why there wouldn't be one. During an interview with Resident #42 on 05/21/25 at approximately 3:00 PM, he stated that while he had capacity, he wanted his MPOA to be involved in any decisions regarding his health care. He also stated that he had not made a request to keep his MPOA away from care plan meetings. Resident #42 further stated that he had not been invited to attend any care plan meetings. On 05/21/25 at approximately 2:15 PM DSS #66 stated that she did not send out invitations to residents or representatives for care plan meetings. She further stated that CRC #11 sent out the invitations. During an interview on 05/21/25, at approximately 3:10 PM, CRC #11 stated that she sends invitations to residents and their representatives for care plan meetings. However, she was unable to provide any documentation to verify that these invitations were sent. CRC #11 confirmed that she does not keep copies of the invitations and does not save them in the residents' records. b) Resident #70 During an interview on 05/19/25, at 1:08 PM, Resident #70 expressed concern about the lack of documentation and information regarding his care. He mentioned that he had neither attended nor been invited to a care plan meeting. The resident has the capacity to understand his situation and was very vocal about his dissatisfaction with not being involved in the care planning process. During an interview on 05/21/25 at approximately 2:15 PM, DSS #66 stated that she did not send invitations to residents or representatives for care plan meetings. She further stated that CRC #11 was responsible for sending out the invitations. During an interview on 05/21/25, at approximately 3:10 PM, CRC #11 stated that she sends out invitations to residents and their representatives for care plan meetings. However, she was unable to provide any documentation to verify that these invitations had been sent. CRC #11 confirmed that she does not keep copies of the invitations and does not save them in the residents' records. CRC #11 stated that she would implement a system for tracking and documenting to ensure that invitations were sent to residents and family members.

Based on observations, medical record review, staff interview, resident interview, and policy review, the facility failed to provide an environment free from accident hazards over which the facility had control. The facility allowed two (2) residents to keep cigarettes and lighters in their room. Resident #9 and #98 both kept their smoking materials in their room. The facility also had a courtyard in which residents could freely access during winter weather and other weather conditions without any type of monitoring by the facility. The doors going into the courtyard did not alarm to alert staff that residents had entered the courtyard area. Residents were observed entering the court yard freely with no alert to the facility. These deficient practices had the potential to affect all residents and had the potential to cause serious harm or death. After consultation with the State office a determination of immediate jeopardy was made based on the facility's failure to ensure each resident received adequate supervision to prevent accidents when out in the courtyard and/or allowing residents to maintain unsecured possession of lighters. The facility administrator was notified of the immediate jeopardies on 01/30/18 at 9:25 p.m. Acceptable plans of correction and their implementation was verified and the immediate jeopardies were abated on 01/31/18 at 12:24 a.m. Resident identifiers: #9 and #98. Facility census: 114. Findings include: a) Resident #9 An interview with Resident #9 on 01/30/18 at 4:20 p.m. revealed the resident was a smoker. She said she kept her cigarettes and lighter in her nightstand. The nightstand was not equipped with a lock to ensure others could not access the lighter. b) Resident #98 An observation of Resident #98 at 7:00 p.m. on 01/30/18 revealed this resident was sitting out in the courtyard with Resident #9. Both were smoking cigarettes. Resident #98 also said she kept her cigarettes and lighter with her and could go out and smoke whenever she wanted. c) On 01/30/18 at 7:29 p.m., an interview with Licensed Practical Nurse (LPN) #43 the LPN verified Resident #9 and Resident #98 both kept their smoking materials with them. LPN #43 said they were both safe smokers and that was why they were allowed to keep the materials with them. On 01/30/18 at 9:15 p.m., an observation made with Registered Nurse (RN) #90 also confirmed Resident #9 and Resident #98 kept their lighters in their room. Neither resident had a secure place to store the lighters to ensure others did not have access to them. RN #90 asked the residents to give her their lighters so they could be kept secured at the nursing station. Both residents gave RN #90 their lighters. The facility's smoking policy revised on 06/01/17 stated, Patients will not be allowed to maintain their own lighter, lighter fluid or matches. c) Doors Based on observations and staff interviews, the facility failed to ensure the facility provided an environment free from accident hazards over which the facility had control and provided adequate supervision. The enclosed courtyard had no locks/alarms to warn staff when any resident went into the enclosed courtyard. Temperatures were below freezing and wind chills were in the negative range. On 01/30/17 at 8:50 PM, it was noted that the door on the D hall leading to the enclosed courtyard was not locked, nor did it have an alarm. This allowed any mobile resident to exit the building without staff awareness. In addition, there were two (2) other doors on either side of the Dining Room which exited to the enclosed courtyard without locks or alarms. In an interview conducted on 01/30/18 at 9:12 PM, Licensed Practical Nurse (LPN #6) confirmed that the door on the D Hall was not locked and was not aware it could be locked. When asked if the door was locked when the outdoor temperatures were below freezing, she stated when it was really cold earlier that month, barrier tape was put across the door(s) so that the residents could not go outside. Observations at that time revealed no barrier tape was on any of the doors exiting into the enclosed courtyard. The outdoor temperature at that time was 16 degrees Fahrenheit (F) with a wind chill of 6 degrees F. Additional information provided by the facility included five (5) residents smoked in the enclosed courtyard at their discretion and nine (9) residents had WanderGuards resided on the A Hall. In an interview with the Nursing Home Administrator (NHA), when asked what security measures were on the doors exiting into the enclosed courtyard. the NHA stated, There are no locks because it is an enclosed area. During an observation at 9:15 PM with the NHA present, the NHA stated, This door should be locked and have caution barrier tape across the door, but it doesn't. The NHA stated, I will take care of this immediately. d) On 01/30/18 at 9:25 PM, the NHA was informed in writing that an immediate jeopardy was being called due to the lack of safety precautions for the enclosed courtyard during inclement weather. The administrator was also informed that an immediate jeopardy existed due to two (2) residents possessing unsecured lighters. e) P[NAME] for the Doors At 11:56 PM on 01/30/18, the facility presented a plan of correction that included placement of alarms on the three (3) exit doors. Rounds were made to ensure all residents were in the building and staff education was provided regarding the alarms. The plan of correction will be monitored by the Director of Nursing (DON)/designee and trends reported to the Quality Assurance Committee on a monthly basis. The IJ was abated on 01/31/18 at 12:24 AM. Rounds were made by two (2) survey team members and confirmed the three (3) courtyard exit doors had alarms and were working. f) P[NAME] for the issue regarding the lighters 1. The Administrator/designee removed smoking supplies, including lighters, from Resident #9 and Resident #98 rooms after reeducation of the residents regarding the smoking policy and procedure including need to secure all smoking materials at 10:00 p.m. on 1/30/2018. 2. All residents of the facility who smoke have the potential to be affected. The Administrator/designee conducted rounds of facility's rooms, including other smokers' rooms on 1/30/2018 at 10:00 p.m. NO additional smoking supplies, including lighters were found at that time. No residents of the facility have experienced any negative outcome. 3. The Administrator/designee will reeducate smoking residents regarding the facility's smoking policy on 1/30/2018 and upon admission and readmission. The Administrator/designee will reeducate all center staff to ensure that resident smoking supplies are secured at all times, including lighters with a posttest to validate understanding. Staff not available during this timeframe will be provided reeducation including posttest by the Nurse Practice Educator/designee upon return to work. New staff during orientation will be provided education including posttest by the NPE/designee. 4. Resident smoking materials will be monitored in the medication room and signed out by the resident and signed back in with the nurse at the completion of smoke breaks across all shifts, 7 days per week. Audits will be conducted by Director of Nurses/designee daily across all shifts x 2 weeks then 3 x per week x 2 weeks then randomly thereafter to ensure that smoking materials are secured. 5. Trends identified will be reported by the Director of Nurses/designee monthly at the Quality Improvement Committee (QIC) for any additional follow up and/or in servicing until the issue is resolved and randomly thereafter as determined by the QIC committee.

Based on observation, record review, staff interview, resident interview, pharmacist interview, laboratory policy review, and review of the facility's nursing drug handbook, the facility failed to monitor Resident #66 for an adverse drug interaction of which the pharmacy had made the facility aware of the potential to develop. The pharmacy had informed the facility of the need to monitor the [MEDICATION NAME] time/partial [MEDICAL CONDITION] time (PT/INR) levels for a resident receiving a macrolide antibiotic while receiving [MEDICATION NAME] (blood thinner). Taking these two (2) medications at the same time can increase the risk of the individual's blood becoming too thin. While taking the combination of these two drugs, Resident #66's PT/INR value reached a critical value requiring implementation of interventions that included sending the resident to the emergency room . The facility's failure to heed the pharmacist's warning was determined to constitute an immediate jeopardy to the health and well-being of residents. On 02/02/18 at 2:34 PM, the facility's administrator was notified that the facility's failure to monitor and identify the adverse drug interaction for which the pharmacist had alerted the facility of the potential to occur, constituted an Immediate Jeopardy (IJ) to the health and well-being of residents. On 02/02/18 at 6:45 PM, the facility provided an acceptable plan of correction (P[NAME]) and the IJ was abated after verifying implementation of the P[NAME]. After removal of the immediate jeopardy, deficient practices remained at a level of E. The facility failed to ensure Resident #39 received ordered medications when readmitted from the hospital. Doses of an antibiotic and a blood thinner were omitted. Two (2) of twenty-three (23) residents reviewed during the facility's annual survey were affected. Resident identifiers: #66 and #39. Facility census: 114. Findings include: a) Resident #66 Observations on 01/29/18 at 4:13 PM, noted Resident #66 had a large bruise covering approximately one-third (1/3) of the skin surface on the top of her left hand. Review of the resident's medical record found she had [DIAGNOSES REDACTED]. Resident #66 was admitted to the facility on [DATE]. Her Brief Interview for Mental Status (BIMS) recorded on the minimum data set (MDS) with an assessment reference date (ARD) of 01/03/18 revealed Resident #66 was cognitively intact. A progress note on 01/15/18 described a change in condition of wheezes and coughing. The physician prescribed a one-time dose of [MEDICATION NAME] (a macrolide antibiotic) 500 milligrams (mg) given on 01/19/18 at 9:00 AM, then [MEDICATION NAME] 250 mg daily for four (4) consecutive days for an upper respiratory infection. Resident #66 received all doses of the [MEDICATION NAME] as ordered. While receiving the [MEDICATION NAME], Resident #66 also received [MEDICATION NAME] 5.0 mg on 01/19/18, [MEDICATION NAME] ([MEDICATION NAME]) 7.5 mg on 01/20/18, [MEDICATION NAME] 5.0 mg on 01/21/18, [MEDICATION NAME] 7.5 mg on 01/22/18 and [MEDICATION NAME] 5.0 mg on 01/23/18. A progress note, written on 01/24/18 by Licensed Practical Nurse (LPN) #77, noted Resident #66 was experiencing a mental status change and had a critical PT of 88.8 and a critical INR of 9.1. (The generally accepted normal range for INR in a resident receiving a blood thinner is 2 to 3.) A progress note on 01/24/18 at 12:53 PM by the APRN (Advance Practice Registered Nurse) revealed Resident #66, was assessed for evaluation and management of subtherapeutic INR of 9.1 with altered mental status. The nurse also noted the resident's altered mental status was not normal for the resident and that there was dried blood noted to several nail beds on her hands. At that time, Resident #66 was administered a dose of Vitamin K 10 mg (milligrams) by mouth and sent the emergency room for evaluation. An additional note by the APRN on 01/26/18 at 2:01 PM included, The patient was seen for follow up s/p (status [REDACTED]. In addition to vitamin K 10mg po (by mouth) given here prior to her transport to the ER, she was given an additional dose of 10mg in the ER as well. During her hospitalization she did have a severe nose bleed which lasted 4-5 hours which was managed by packing and transfusion of 2 units FFP (Fresh Frozen Plasma). Her [MEDICATION NAME] has been on hold; repeat INR this am (morning) was 1.4. At 10:54 AM on 02/02/18, a telephone interview with the general manager of the pharmacy used by the facility explained, [MEDICATION NAME] was filled for Resident #66 on 01/19/18. He went on to state that [MEDICATION NAME] was considered a level two (2) drug. A level two drug interaction refers to the risk of drug interaction with other drugs. The levels range from 1 to 5, with one being the most severe potential for drug to drug interaction. Upon delivery, the pharmacy included with the [MEDICATION NAME], a severity level 2 warning for selected anticoagulants/selected macrolide antibiotics with a patient management notification to closely monitor INR values in patients maintained on anticoagulants in whom macrolide antibiotics were initiated or discontinued. Review of Resident #66's medical records found no evidence the facility monitored or attempted to monitor the resident's PT/INR more closely than every seven (7) days, during the time she received [MEDICATION NAME] and [MEDICATION NAME] at the same time. On 02/02/18 at 2:45 PM, the Director of Nursing (DON) explained during stand-down on the evening of 01/19/18, the APRN voiced there was no concern related to drug interactions when giving [MEDICATION NAME] and [MEDICATION NAME] ([MEDICATION NAME]) together. At 2:52 PM on 02/02/18, the APRN explained Resident #66 had refused to allow a PT/INR value to be monitored more than one time per week. When asked, if there was a consideration to monitor the PT/INR more closely while Resident #66 was receiving [MEDICATION NAME] the APRN she explained she did ask the physician for more frequent PTINR value blood draws, the physician 'saw' Resident #66's PT/INR values, knew of the prescribed [MEDICATION NAME] and still ordered the [MEDICATION NAME]. The APRN went on to state, I think it was appropriately monitored and addressed. On 02/02/18 at 3:15 PM, Resident #66 explained that she did complain about having to have her blood drawn so often and it was decided a PT/INR value would be drawn one (1) time per week. Resident #66 went on to explain she voiced concerns about being allergic to [MEDICATION NAME] and was told this medication was not on her allergy list. She went on to state she did not remember staff explaining to her the potential [MEDICATION NAME]/[MEDICATION NAME] drug interaction or asking her for permission to obtain a blood draw more often to monitor her PT/INR while taking [MEDICATION NAME]. During an interview on 02/02/18 at 3:43 PM, LPN #77 said she had not read the pharmacy warning sent with the [MEDICATION NAME]. When asked to find a warning in the resident's medical record about the potential problem of giving [MEDICATION NAME] due to a critical drug interaction with [MEDICATION NAME], LPN #77 could not. On 02/02/18 at 3:50 PM, a request to the medical director to find a notification placed in the medical records since the incident of [MEDICATION NAME] and [MEDICATION NAME] causing a severe drug interaction with Resident #66. The medical director stated there was no evidence in the medical records that [MEDICATION NAME] should not be given to Resident #66. A review of the facility's Nursing Drug Handbook (YEAR), provided by the DON on 02/02/18 at 3:55 PM, found it included a drug-drug interaction between [MEDICATION NAME] and [MEDICATION NAME] ([MEDICATION NAME]) with a warning the INR might increase and should be monitored carefully. The facility's failure to heed the pharmacist's warning and monitor the resident's PT/INR was determined to constitute and immediate jeopardy to the health and well-being of residents. On 02/02/18 at 2:34 PM, the facility's administrator was notified that the facility's failure to monitor Resident #66, and identify the adverse drug interaction for which the pharmacist had alerted the facility of the potential to occur, constituted an Immediate Jeopardy (IJ) to health and well-being of residents. On 02/02/18 at 6:45 PM the facility provided an acceptable plan of correction (P[NAME]) and the IJ was abated after verifying implementation of the P[NAME]. The P[NAME] included: an assessment of the resident, education of the licensed nurse receiving the macrolide antibiotic, education of the advanced practice registered nurse (APRN) to consider drug interactions and to comply with professional standards. Education to all nurses regarding the potential for [MEDICATION NAME] and antibiotic drug interaction and reporting the potential to the prescribing physician. Adding a warning alert to the medical records of a resident receiving [MEDICATION NAME] and prescribed an antibiotic. A scheduled review of all new physician orders, nursing notes for antibiotics including lab results for residents who receive [MEDICATION NAME] and any drug interaction received from pharmacy to ensure the physician and APRN has been notified prior to administer the medication and to identify trends and report to the Quality Improvement Committee (QIC) for additional follow up until the issue is resolved. After removal of the immediate jeopardy deficient practices remained at a level of E. The facility failed to ensure Resident #39 received medications as ordered when the resident returned from a hospital stay. The omitted medications included [MEDICATION NAME] (a blood thinner) 5000 units every 8 hours. b) Resident #39 A review of the resident's medical record revealed [REDACTED]. Coli bacteremia, and pneumonia. A review of the Physician order [REDACTED]. Further review of the medical record revealed the medication was not given every eight (8) hours as ordered. The administration of the antibiotic was not started until 02/15/18. Through an interview with the Director of Nursing (DON) on 02/06/18 at 10:15 AM, it was revealed the medication was not started as ordered when Resident #39 returned from the hospital because Nurse #69 failed to document the orders on the correct sheet, and failed to transcribe the orders correctly onto the Medication Administration Record [REDACTED]. A review of the Medication Administration Record [REDACTED]. An interview with the DON at 10:15 AM confirmed that due to the transcription errors when the resident returned, medication orders were not transcribed and implemented.

Based on observation, record review, staff interview, resident interview, pharmacist interview, laboratory policy review, and review of the facility's nursing drug handbook, the facility failed to monitor Resident #66 for an adverse drug interaction of which the pharmacy had made the facility aware of the potential to develop. The pharmacy had informed the facility of the need to monitor the [MEDICATION NAME] time/partial [MEDICAL CONDITION] time (PT/INR) levels for a resident receiving a macrolide antibiotic while receiving [MEDICATION NAME] (blood thinner). Taking these two (2) medications at the same time can increase the risk of the individual's blood becoming too thin. While taking the combination of these two drugs, Resident #66's PT/INR value reached a critical value requiring implementation of interventions that included sending the resident to the emergency room . The facility's failure to heed the pharmacist's warning was determined to constitute an immediate jeopardy to the health and well-being of residents. On 02/02/18 at 2:34 PM, the facility's administrator was notified that the facility's failure to monitor and identify the adverse drug interaction for which the pharmacist had alerted the facility of the potential to occur, constituted an Immediate Jeopardy (IJ) to the health and well-being of residents. On 02/02/18 at 6:45 PM, the facility provided an acceptable plan of correction (P[NAME]) and the IJ was abated after verifying implementation of the P[NAME]. After removal of the immediate jeopardy, deficient practices remained at a level of E. The facility failed to ensure laboratory values were obtained in a timely manner for Resident #461, failed to obtain a PT/INR test was completed as ordered by the physician for Resident #110, failed to provide care and services upon admission to the facility for Resident #39, failed to follow-up on results of a PT/INR laboratory value for Resident #16, and failed to complete neurological checks after unwitnessed falls for Residents #462 and #1. Seven (7) of twenty-three (23) residents reviewed during the facility's annual survey were affected. Resident identifiers: #66, #461, #110, #39, #16, #462, and #1. Facility census: 114. Findings include: a) Resident #66 Observations on 01/29/18 at 4:13 PM, noted Resident #66 had a large bruise covering approximately one-third (1/3) of the skin surface on the top of her left hand. Review of the resident's medical record found she had [DIAGNOSES REDACTED]. Resident #66 was admitted to the facility on [DATE]. Her Brief Interview for Mental Status (BIMS) recorded on the minimum data set (MDS) with an assessment reference date (ARD) of 01/03/18 revealed Resident #66 was cognitively intact. A progress note on 01/15/18 described a change in condition of wheezes and coughing. The physician prescribed a one-time dose of [MEDICATION NAME] (a macrolide antibiotic) 500 milligrams (mg) given on 01/19/18 at 9:00 AM, then [MEDICATION NAME] 250 mg daily for four (4) consecutive days for an upper respiratory infection. Resident #66 received all doses of the [MEDICATION NAME] as ordered. While receiving the [MEDICATION NAME], Resident #66 also received [MEDICATION NAME] 5.0 mg on 01/19/18, [MEDICATION NAME] ([MEDICATION NAME]) 7.5 mg on 01/20/18, [MEDICATION NAME] 5.0 mg on 01/21/18, [MEDICATION NAME] 7.5 mg on 01/22/18 and [MEDICATION NAME] 5.0 mg on 01/23/18. A progress note, written on 01/24/18 by Licensed Practical Nurse (LPN) #77, noted Resident #66 was experiencing a mental status change and had a critical PT of 88.8 and a critical INR of 9.1. (The generally accepted normal range for INR in a resident receiving a blood thinner is 2 to 3.) A progress note on 01/24/18 at 12:53 PM by the APRN (Advance Practice Registered Nurse) revealed Resident #66, was assessed for evaluation and management of subtherapeutic INR of 9.1 with altered mental status. The nurse also noted the resident's altered mental status was not normal for the resident and that there was dried blood noted to several nail beds on her hands. At that time, Resident #66 was administered a dose of Vitamin K 10 mg (milligrams) by mouth and sent the emergency room for evaluation. An additional note by the APRN on 01/26/18 at 2:01 PM included, The patient was seen for follow up s/p (status [REDACTED]. In addition to vitamin K 10mg po (by mouth) given here prior to her transport to the ER, she was given an additional dose of 10mg in the ER as well. During her hospitalization she did have a severe nose bleed which lasted 4-5 hours which was managed by packing and transfusion of 2 units FFP (Fresh Frozen Plasma). Her [MEDICATION NAME] has been on hold; repeat INR this am (morning) was 1.4. At 10:54 AM on 02/02/18, a telephone interview with the general manager of the pharmacy used by the facility explained, [MEDICATION NAME] was filled for Resident #66 on 01/19/18. He went on to state that [MEDICATION NAME] was considered a level two (2) drug. A level two drug interaction refers to the risk of drug interaction with other drugs. The levels range from 1 to 5, with one being the most severe potential for drug to drug interaction. Upon delivery, the pharmacy included with the [MEDICATION NAME], a severity level 2 warning for selected anticoagulants/selected macrolide antibiotics with a patient management notification to closely monitor INR values in patients maintained on anticoagulants in whom macrolide antibiotics were initiated or discontinued. Review of Resident #66's medical records found no evidence the facility monitored or attempted to monitor the resident's PT/INR more closely than every seven (7) days, during the time she received [MEDICATION NAME] and [MEDICATION NAME] at the same time. On 02/02/18 at 2:45 PM, the Director of Nursing (DON) explained during stand-down on the evening of 01/19/18, the APRN voiced there was no concern related to drug interactions when giving [MEDICATION NAME] and [MEDICATION NAME] ([MEDICATION NAME]) together. At 2:52 PM on 02/02/18, the APRN explained Resident #66 had refused to allow a PT/INR value to be monitored more than one time per week. When asked, if there was a consideration to monitor the PT/INR more closely while Resident #66 was receiving [MEDICATION NAME] the APRN she explained she did ask the physician for more frequent PTINR value blood draws, the physician 'saw' Resident #66's PT/INR values, knew of the prescribed [MEDICATION NAME] and still ordered the [MEDICATION NAME]. The APRN went on to state, I think it was appropriately monitored and addressed. On 02/02/18 at 3:15 PM, Resident #66 explained that she did complain about having to have her blood drawn so often and it was decided a PT/INR value would be drawn one (1) time per week. Resident #66 went on to explain she voiced concerns about being allergic to [MEDICATION NAME] and was told this medication was not on her allergy list. She went on to state she did not remember staff explaining to her the potential [MEDICATION NAME]/[MEDICATION NAME] drug interaction or asking her for permission to obtain a blood draw more often to monitor her PT/INR while taking [MEDICATION NAME]. During an interview on 02/02/18 at 3:43 PM, LPN #77 said she had not read the pharmacy warning sent with the [MEDICATION NAME]. When asked to find a warning in the resident's medical record about the potential problem of giving [MEDICATION NAME] due to a critical drug interaction with [MEDICATION NAME], LPN #77 could not. On 02/02/18 at 3:50 PM, a request to the medical director to find a notification placed in the medical records since the incident of [MEDICATION NAME] and [MEDICATION NAME] causing a severe drug interaction with Resident #66. The medical director stated there was no evidence in the medical records that [MEDICATION NAME] should not be given to Resident #66. A review of the facility's Nursing Drug Handbook (YEAR), provided by the DON on 02/02/18 at 3:55 PM, found it included a drug-drug interaction between [MEDICATION NAME] and [MEDICATION NAME] ([MEDICATION NAME]) with a warning the INR might increase and should be monitored carefully. The facility's failure to heed the pharmacist's warning and monitor the resident's PT/INR was determined to constitute and immediate jeopardy to the health and well-being of residents. On 02/02/18 at 2:34 PM, the facility's administrator was notified that the facility's failure to monitor Resident #66, and identify the adverse drug interaction for which the pharmacist had alerted the facility of the potential to occur, constituted an Immediate Jeopardy (IJ) to health and well-being of residents. On 02/02/18 at 6:45 PM the facility provided an acceptable plan of correction (P[NAME]) and the IJ was abated after verifying implementation of the P[NAME]. The P[NAME] included: an assessment of the resident, education of the licensed nurse receiving the macrolide antibiotic, education of the advanced practice registered nurse (APRN) to consider drug interactions and to comply with professional standards. Education to all nurses regarding the potential for [MEDICATION NAME] and antibiotic drug interaction and reporting the potential to the prescribing physician. Adding a warning alert to the medical records of a resident receiving [MEDICATION NAME] and prescribed an antibiotic. A scheduled review of all new physician orders, nursing notes for antibiotics including lab results for residents who receive [MEDICATION NAME] and any drug interaction received from pharmacy to ensure the physician and APRN has been notified prior to administer the medication and to identify trends and report to the Quality Improvement Committee (QIC) for additional follow up until the issue is resolved. After removal of the immediate jeopardy deficient practices remained at a level of E. The facility failed to ensure laboratory values were obtained in a timely manner for Resident #461, failed to obtain a PT/INR test was completed as ordered by the physician for Resident #110, failed to provide care and services upon admission to the facility for Resident #39, failed to follow-up on results of a PT/INR laboratory value for Resident #16, and failed to complete neurological checks after unwitnessed falls for Residents #462 and #1. b) Resident #461 On 01/20/18, the resident's PT/INR was 1.0. A recheck of the lab test was ordered to be done on Tuesday 01/23/18. Review of the resident's medical record did not find the results test ordered for 01/23/18. On 02/02/18 at 7:00 PM, the DON provided a laboratory report dated 01/22/18 with an INR result of 1.2. The DON stated the facility did not have the results in the medical records until requested on 02/02/18. While discussing the quality assessment (QA) content on 02/06/18 at 1:45 PM, the DON explained laboratory audits were monitored for several months and discontinued 12/31/17. The DON explained one staff member assured laboratory results were received in a timely manner and reported as needed, but no education occurred in which each staff member was made aware of how to ensure laboratory values were obtained in a timely manner. c) Resident #110 A review of Resident #110's medical record on 02/02/18 revealed the physician ordered a PT/INR be obtained on 01/18/18. There was documentation the lab specimen was collected; however, no test results were found in the resident's medical record for that date. On 02/02/18 at 3:35 PM, the Assistant Director of Nursing (ADON) was interviewed and asked to provide the result for the lab test ordered to be done on 01/18/18. The ADON stated there was no information in the resident's medical record. She said she had called and requested the lab result faxed from the laboratory. At that time, the lab informed the ADON that the specimen had clotted and the lab value was not obtained. During an interview on 02/06/18 at 10:40 AM, the Director of Nursing (DON) revealed that the blood was drawn on 01/18/18, but the specimen had clotted and no notification or results had been received by the facility. A review of the laboratory result sent to the facility on [DATE] at 18:26 (6:26 PM) stated [MEDICATION NAME]- request credited, specimen clotted. There was no notation that the facility had been notified the blood sample had clotted and test ordered for 01/18/18 could not be completed. An interview with the DON on 02/06/18 at 10:40 AM, revealed that the facility failed to follow-up when the lab result was not returned to the facility in a timely manner. d) Resident #39 A review of the resident's medical record revealed [REDACTED]. Coli bacteremia, and pneumonia. A review of the Physician order [REDACTED]. Further review of the medical record revealed the medication was not given every eight (8) hours as ordered. The administration of the antibiotic was not started until 02/15/18. Through an interview with the Director of Nursing (DON) on 02/06/18 at 10:15 AM, it was revealed the medication was not started as ordered when Resident #39 returned from the hospital because Nurse #69 failed to document the orders on the correct sheet, and failed to transcribe the orders correctly onto the Medication Administration Record [REDACTED]. A review of the facility's follow-up on this medication error dated 01/17/18, revealed that Employee #6 failed to review the orders for Resident #39 to ensure the orders were correctly transcribed. It was stated that Employee #6 worked on two other admissions and did not review Resident #39's orders. Further information obtained during the interview with the DON on 02/06/18 at 10:15 AM, revealed the error should have been identified to prevent Resident #39 from missing seven (7) doses of the antibiotic ordered upon return from the hospital. It was further stated that in addition to Employee #69 and Employee #6 failing to complete or review the record, Employees #34 and #61 had also been responsible for ensuring the order was correctly documented and implemented. Review of facility's follow-up dated 01/19/18, found Employee #69 received training on the five rights of medication administration. This included right patient, right medication, right dosage, right route, right time. The education did not address the issues leading to the error and was not signed by the employee as indicated by the facility form and the date on the form provided was 09/05/17. Additionally, not all staff involved in this incident were re-educated. A review of the Medication Administration Record [REDACTED]. An interview with the DON at 10:15 AM confirmed that due to the transcription errors when the resident returned, medication orders were not transcribed and implemented. Resident #39 did not receive ordered doses of: -- [MEDICATION NAME] (used to treat [MEDICAL CONDITION], neuropathic pain, hot flashes, and [DIAGNOSES REDACTED]) 750 mg three times per day, -- [MEDICATION NAME] (a blood thinner) 5000 units injectable every eight (8) hours, -- [MEDICATION NAME] (an antidepressant, has anxiolytic, sedative, antiemetic, and appetite stimulant effects) 15 mg at bedtime, -- [MEDICATION NAME] (used to treat certain stomach and esophagus problems, such as acid reflux) 40 mg every day, -- [MEDICATION NAME] (used to treat nerve pain, depression, generalized anxiety disorder, panic disorder, and social anxiety disorder) 50 mg three times per day, -- [MEDICATION NAME] (a mouthwash) 15 milliliters (ml) twice a day, and -- Colesevelam (to reduce cholesterol) 650 mg, 3 tabs twice a day with meals on 01/13/18. e) Resident #16 Medical record review on 02/02/18 found this resident's [DIAGNOSES REDACTED]. Her physician ordered a blood thinner, [MEDICATION NAME], daily in varying dosages to prevent blood clots. The physician ordered a PT/INR ([MEDICATION NAME] Time/International Normalized Ratio), a test to help the physician determine the dosage of [MEDICATION NAME] to maintain a therapeutic level. An INR range of 2.0 - 3.0 is generally an effective therapeutic range for people who take [MEDICATION NAME] for disorders such as [MEDICAL CONDITION] or a blood clot in the leg or lung. If a [MEDICATION NAME] dose is too high, the patient may bleed too easily, and if too low, the patient's blood may clot too easily. On 01/02/18, the physician ordered [MEDICATION NAME] five (5) milligrams (mg) every Sunday, Tuesday, Thursday, and Saturday. The physician ordered [MEDICATION NAME] 3.5 mg. every Monday, Wednesday, and Friday. This dosage was based on the 01/02/18 INR of 2.2. The physician ordered a repeat of the PT/INR in two (2) weeks. Review of the medical record on 02/02/18 found no evidence of PT/INR results on or near 01/16/18. During an interview with the director of nursing on 02/02/18 at 7:00 p.m., she was unable to provide evidence of a PT/INR test on or near 01/16/18. The DON contacted the lab at that time, and found that a PT/INR was completed on 01/13/18 (rather than on 01/16/18). The INR result on 01/13/18 was 3.6. According to the laboratory's reference range, an INR of 3.0 to 4.0 was considered high intensity [MEDICATION NAME] therapy, whereas in comparison, an INR of 2.0 to 3.0 was considered Moderate intensity [MEDICATION NAME] therapy. When asked whether the physician was notified of this elevated INR result, the DON replied in the negative. She said the 01/13/18 PT/INR result was not recorded on the facility's Flow Sheet for monitoring residents taking [MEDICATION NAME], as directed by the facility's [MEDICATION NAME] monitoring policy. She said she did not know if the lab test (PT/INR) may not have made it to the nursing home, or if it came, but was misfiled. The last recorded information on this resident's Flow Sheet was 12/16/17. The DON said the Flow Sheet for this resident was resumed on the day before, on 02/05/18. Upon inquiry, she confirmed again that she could find no evidence that the physician was notified of the 01/13/18 elevated INR result. She said she could find no evidence that staff used the [MEDICATION NAME] monitoring flow sheets between 12/16/17 and 02/05/18. Further review of the resident's medical record found evidence the resident showed signs of a change in condition from 01/13/18 when the INR was elevated at 3.6, until the date of the next PT/INR which occurred on 01/23/18 with a critical INR value of 8.9, as follows: - 01/19/18 nurse progress note 5:00 p.m. said the resident stated she was not feeling well, like she was going to throw up - 01/19/18 nurse progress note 5:05 p.m. said a nursing assistant came to this nurse and stated the resident was not looking good. When approached by the nurse, the resident seemed very confused and shaky and could hear mucous in throat. The nurse called the hospice to come look at the resident. - 01/19/18 at 8:00 p.m. nurse progress note said hospice came in to see the resident. New orders were received to start [MEDICATION NAME] four (4) drops every four (4) hours as needed (prn) sublingually for secretions; start [MEDICATION NAME] treatments via nebulizer every four (4) hours prn for wheezing; increase Roxinal (for pain) to five (5) mg. sublingually every one (1) hour prn (as needed). - 01/20/18 nurse progress note at 4:39 a.m. said the family was at the bedside, due to declining condition. - 01/20/18 nurse progress note at 3:19 p.m. assessed her skin color as pale, lethargic at times, apical pulse [MEDICAL CONDITION] (rapid) at 119 beats per minutes, no food intake this shift. - 01/21/18 nurse progress note at 12:45 p.m. assessed a heart rate ranging from 88 - 157 beats per minute. The resident had increased alertness today yet remains to have a poor oral intake. - 01/23/18 1:36 p.m. nurse progress note assessed her left and right sides, back and buttocks have purplish, red rashy areas, notified (name of doctor), received new orders--PT/INR now--give [MEDICATION NAME] TID (three times daily) for two (2) days. - 01/23/18 3:36 p.m. nurse progress note addressed they received new orders for Vitamin K five (5) milligrams (MD) once, hold [MEDICATION NAME], and repeat INR Thursday 01/25/18. (Vitamin K is given to counteract the blood thinning effects of [MEDICATION NAME].) - 01/23/2018 2:42 p.m. General Note - Resident has had an overall decline in health recently. Critical lab values were addressed with the physician with new orders. Poor oral intake. - 01/25/2018 9:05 p.m. Care Plan Evaluation Note - new orders for [MEDICATION NAME] 0.5 mg orally prn every four (4) hours as needed for agitation. Review of the medical record found the PT/INR on 01/23/18 was PT 86.4 and INR 8.9. The INR on 01/25/18 was back to the therapeutic level of 2.2. The physician at that time ordered to resume the previous [MEDICATION NAME] dose on Monday 01/29/18. The INR on 01/29/18 was 1.5, and the physician gave orders for daily [MEDICATION NAME] doses until the next PT/INR in one (1) week. Observation of the resident on 02/02/18 at 7:00 p.m. found that she had a small, green- colored bruise to the top of each hand. The one is circular about one inch in diameter. The other is about two inches long and narrow. On 02/06/18 at 11:30 a.m., the DON provided a copy of the facility's policy and procedure on [MEDICATION NAME] monitoring. This was most recently revised on 01/02/14. According to their policy under section 2.2, the facility must use the [MEDICATION NAME] flow sheet and Update with each PT/INR result and with every new [MEDICATION NAME] ([MEDICATION NAME]) order. Steps three (3) and four (4) direct staff to Schedule the lab draws for PT/INR values per physician/mid-level provider order. and Notify physician/mid-level provider for dosage adjustments and for results outside of the patient's therapeutic range. Step 6.1 directs nursing staff to document PT/INR test results on the [MEDICATION NAME] therapy flow sheet. The DON acknowledged that these policy steps were not followed related to the 01/13/18 PT/INR blood test, nor was it followed when the [MEDICATION NAME] monitoring flow sheet was not used between the dates of 12/16/17 and 02/05/18. f) Resident #462 1. Medical record review for Resident #462 revealed the resident had an unwitnessed fall on 01/04/18 at 11:30 a.m. The accident report stated, (typed as written) Resident was assisted in bed. bed alarm sounded and run toward him found him sitting on the floor. Resident had a abrasion to right upper forehead. Bruising to left knee and left shin. Vitals initiated and neuros initiated. A review of the neurological assessment revealed the assessments began at 11:30 a.m. They continued at 12:00 p.m., 12:30 p.m., 1:00 p.m., 2:00 p.m., 3:00 p.m., 4:00 p.m., 8:00 p.m., on 01/05/18 at 1:00 a.m., 4:00 a.m., 8:00 a.m. and 12:00 p.m. The facility's neurological assessment policy, revised on 10/01/12, directed neurological assessments would be performed when a patient sustained an injury to the head and/or had an unwitnessed fall. The purpose of the neurological assessment was to monitor the resident for neurological compromise. The policy indicated the assessments would be completed every (30) minutes for two (2) hours then every hour for four (4) hours then every four (4) hours for 24 hours. According to the facility's policy, these assessments should have been completed at 11:30 a.m., 12:00 p.m., 12:30 p.m., 1:00 p.m., 1:30 p.m., 2:30 p.m., 3:30 p.m., 4:30 p.m., 5:30 p.m. 9:30 p.m. 1:30 a.m., 5:30 a.m., 9:30 a.m., 1:30 p.m., 5:30 p.m., and 9:30 p.m. 2. Medical record review also revealed Resident #462 experienced a fall on 12/13/17 at 5:30 a.m. The accident report stated, Resident had been up most of the night in wheelchair. CNA (nurse aide) had put him to bed this morning and about 15 mins later the alarm was sounding and resident was found sitting on the floor next to bed on the right side of bed with legs facing to door. Neurological checks were completed starting on 12/13/17 at 5:30 a.m., 6:00 a.m., 6:30 a.m., 7:30 a.m., 8:30 a.m., 9:30 a.m., 1:30 p.m., 5:30 p.m., 9:30 p.m., and on 12/14/17 at 1:30 a.m., and 5:30 a.m. According to the facility's policy, neurological checks should have been completed at 5:30 a.m., 6:00 a.m., 6:30 a.m., 7:00 a.m., 7:30 a.m., 8:30 a.m., 9:30 a.m., 10:30 a.m., 11:30 a.m., 3:30 p.m., 7:30 p.m., 11:30 p.m., 3:30 a.m., 7:30 a.m., 11:30 a.m. 3:30 p.m. 7:30 p.m., 11:30 p.m., and 3:30 p.m. On 02/01/18 at 1:06 p.m., the director of nursing agreed the neurological assessments were not completed in accordance with the facility's neurological assessment policy. g) Resident #1 Medical record review revealed Resident #1 experienced a fall on 12/31/17 at 3:00 a.m. The incident/accident report stated, (typed as written) CNA (nurse aide) found sitting on the floor next to the bed on her buttocks, Resident stated she fell , asked how, she said, well I dunno, I slid off the side of the bed, I asked her what she was doing, she said, 'well I told you, I dunno, I just slid off the side of the bed' Vitals obtained, She denies pain, skin assessment completed, Found red area to back of head, started neuro checks, resident had regular socks on. So nonskid socks were added to help prevent slipping. The neurological assessment flow sheet revealed Resident #1's neurological checks were completed on 12/31/17 at 3:00 a.m., 3:30 a.m., 4:00 a.m., 5:00 a.m., 6:00 a.m., 7:00 a.m., 11:00 a.m., 3:00 p.m., 7:00 p.m., 11:00 p.m., and on 01/01/18 at 3:00 a.m., 7:00 a.m., 11:00 a.m., and at 3:00 p.m. According to the facility's policy for neurological assessment the neuro checks should have been completed at 3:00 a.m., 3:30 a.m., 4:00 a.m., 4:30 a.m., 5:00 a.m., 6:00 a.m., 7:00 a.m., 8:00 a.m., 9:00 a.m., 1:00 p.m., 5:00 p.m., 9:00 p.m., 1:00 a.m., 5:00 a.m., 9:00 a.m., 1:00 p.m., 5:00 p.m., and 9:00 p.m., and 1:00 a.m., 5:00 a.m., 9:00 a.m., and 1:00 p.m. On 02/02/18 at 12:19 p.m., the director of nursing was interviewed regarding the lack of neurological assessments following a fall for Resident #1. No further information was provided. .

Based on review of the medical records, concern logs, incident and accident reports, resident interview, and staff interviews, the facility failed to provide the necessary care and services to attain or maintain the highest possible level of well-being in accordance with the individuals comprehensive assessment and plan of care. Resident #98 experienced actual harm when she sustained skin tears while being placed on a Hoyer lift pad. This was found for one (1) of one-hundred forty-nine (149) incident/accident reports reviewed. Additionally, seven (7) of thirteen (13) residents reviewed had not received all of their medications as ordered. Residents #6, #52, and #33 did not receive all of their scheduled medications as prescribed. Resident #27 received the wrong antibiotic; Resident #90 received the wrong nutritional supplement, and Residents #16 and #31 missed prescribed medications because the orders were not transcribed correctly. Resident identifiers: #98, #6, #52, #31, #27, #90, #16, and #33. Facility census: 107. Findings include: a) Resident #98 On 03/01/16 at 11:00 a.m., a review of the incident/accident forms revealed an incident/accident for Resident #98 dated 02/14/16 at 7:20 a.m., identifying actual harm to the resident. The form stated (typed as written), CNA (Certified Nursing Assistant) was putting resident on hoyer pad while she was laying in bed, when assisting resident to turn to position on hoyer pad, the hoyer strap caught residents leg causing two skin tears. Both on lower right leg. Proximal skin tear v-shaped with skin flap intact 2 cm (centimeter) x 2 cm x < (less than) 0.1 cm. Distal skin tear 1 1/2 cm x 1.3 cm x < 0.1 cm flap intact. Cleansed areas with wound cleanser, patted dry, applied three steri strips to proximal skin tear and two steri strips to distal skin tear. Educated staff members on safety positioning resident, and to monitor positioning of hoyer straps to prevent further injuries. The physician was notified and ordered treatment for [REDACTED]. On 03/02/16 at 9:30 a.m., a review of the medical record revealed the quarterly Minimum Data Set Assessment with an assessment reference date of 12/07/16, identified the resident required the extensive assistance of two (2) staff for bed mobility and transfers. During an interview with Resident #98 on 03/02/16 at 10:45 a.m., she stated, The girl cut my leg with a strap, sometimes they try to rush doing things, but she apologized for doing it. She got the nurse and she (nurse) put stuff on my leg. Then the girl (CNA) finished putting the lift under me and got me up. My leg was sore for a while but is better now. b) Review of the incident/accident forms on 03/01/16 at 3:00 p.m. revealed the following medication errors: 1. Resident #6 Resident #6 did not receive his prescribed pain medication ([MEDICATION NAME] 75 milligrams) on 02/22/16 at 8:00 p.m. and 02/23/16 at 8:00 p.m. The physician's orders [REDACTED]. The order was transcribed on to the Medication Administration Record [REDACTED] Review of the control substance log on 03/02/16 at 9:00 a.m., confirmed this medication was not given at 8:00 p.m. on 02/22/16 and 02/23/16. During an interview on 03/02/16 at 10:00 a.m., Resident #6 reported the staff had not given him his evening pain medication on two (2) occasions. He stated he had a history of [REDACTED]. 2. Resident #52 According to an incident report, Resident #52 reported she had not received her scheduled 1:00 p.m. dose of [MEDICATION NAME] on 12/22/15. No reason for the omission was noted. The December 2015 MAR indicated [REDACTED]. Give 1 tablet by mouth three times a day related to idiopathic peripheral autonomic [MEDICAL CONDITION], unspecified. The medication was scheduled to be administered daily at 9:00 a.m., 1:00 p.m., and 8:00 p.m. The Director of Nursing (DON) reviewed the MAR indicated [REDACTED]. 3. Resident #31 This resident's readmission order for Glucerna 240 milliliters daily was not transcribed to the MAR. This error was found by staff on 02/01/16 after she had missed twenty-one (21) daily doses. The physician's orders [REDACTED]. Glucerna 240 ml QD (daily). The MAR indicated [REDACTED]. 4. Resident #27 Resident #27 received the wrong intravenous antibiotic at 8:00 a.m. on 12/17/15. The MAR indicated [REDACTED] Resident #27 received [MEDICATION NAME] 1 gram intravenously for his 8:00 a.m. dose on 12/17/15, instead of his prescribed [MEDICATION NAME]. (The physician was notified and issued no new orders.) 5. Resident #90 Licensed Practical Nurse (LPN) #142 identified a transcription order on Resident #90 s MAR indicated [REDACTED]. The physician's orders [REDACTED]. The order was transcribed onto the MAR indicated [REDACTED]. Resident #90 received seven (7) doses of the incorrect medication. 6. Resident #16 This resident's lab work was reviewed by his physician and a fax was returned to the facility on [DATE] with an order to start [MEDICATION NAME] (a medication used to treat high cholesterol and high triglycerides) 48 mg daily. The order was not written in the medical record or transcribed to the MAR until the error was found on 02/14/16. c) Resident #33 Review of the concern logs on 02/29/16 at 2:00 p.m., revealed a report from Resident #33's daughter dated 10/29/16, which stated her father had reported he had not received his night time medications on Monday night (10/26/16). The MAR indicated [REDACTED]. d) The Director of Nursing (DON) and the facility Administrator acknowledged they were aware of these medication errors during an interview on 03/01/16 at 11:10 a.m. The DON reported the medication omissions and errors have decreased since the facility started doing an audit of medication transcriptions, errors and omissions. e) At the time of the investigation, the only inservice education provided regarding these errors was the nurse finding the error/omission educated the nurse who made the error.

Based on record review, observation, and interview, the facility failed to prevent unintended weight loss in three of four residents reviewed for nutritional concerns. The facility's multiple system failures identified during the investigation yielded significant weight loss resulting in harm for one ( #110) of the three (#159, #126) residents. Findings include: 1. Review of the medical record for Resident #110 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS), a comprehensive assessment, dated 08/07/12, revealed the resident scored 4 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated the resident had severely impaired cognition. Resident #110 had been assessed to require total care from 1-2 staff members for most Activities of Daily Living (ADL) including dependency on staff for eating. At the time of the assessment Resident #110 had been assessed to be 67 inches tall and to weigh 112 pounds. Resident #110 was also assessed to have recently experienced weight loss. The MDS also indicated Resident #110 received a mechanically altered diet. The Care Area Assessment (CAA) revealed Resident #110 received a texture modified diet, had a history of [REDACTED]. The Care Plan for Resident #110 had been created on 09/20/11 and revised on 09/10/12. The plan of care identified the resident to be at nutritional risk due to: a texture modified diet, a [DIAGNOSES REDACTED]. The interventions for the plan of care included: provide rehab eating devices - specifically 2 handled sippy cups during meals; dine in the Coral Room; evaluate for proper consistency of diet; honor the resident's food preferences within the meal plan; encourage consumption of the fluids provided; weigh the resident as ordered and alert the dietitian and physician to any significant weight loss or gain; monitor for changes in nutritional status - such as changes in intake, ability to feed self, unplanned weight loss/gain, abnormal labs and report to physician as indicated; monitor intake at all meals; offer alternate choices as needed; provide regular pureed diet as ordered; offer snacks; supervise; cue; and assist Resident #110 as needed with meals. A second plan of care for Resident #110 revealed that the resident was at risk for impaired swallowing related to dysphagia. The interventions for the plan of care included: provide extensive to total assistance during meals; obtain a speech and language pathologist (SLP) evaluation, as ordered; provide pureed consistency diet as ordered; provide sippy cup for all meals; and, observe for signs and symptoms of aspiration - if coughing occurs no food liquids until coughing resolves. The Kardex was identified by the facility as the source of directives for the Certified Nurse Aides providing care to the residents. The Kardex revealed the following interventions related to Resident #110's eating: provide extensive-to-total assistance during meals; provide pureed consistency diet, as ordered; provide a sippy cup for all meals; and, dine in the Coral Room for all meals. Review of the computerized/electronic dietary assessment for Resident #110 revealed an assessment dated [DATE] which had been completed by dietary staff #34, identified as the Assistant Food Service Director and a Certified Dietary Manager. The assessment identified Resident #110 had a Body Mass Index (BMI) of 17.6, and was on a regular pureed diet and no nutritional supplements had been ordered. The weight used in the calculation of the BMI was 112.4 pounds and came from a weight recorded on 07/03/12. The assessment also identified that Resident #110 had experienced a 5% weight loss (6.6 pounds) in the preceding month and a significant or severe weight loss (13.8 pounds) in the last 6 months. Additionally, the assessment identified that Resident #110 was not on a prescribed weight loss regimen. The assessment also indicated that the resident consumes greater than 50% of her meals. Review of the summary and plan for this assessment revealed the resident's physician and medical power of attorney (MPOA) had been notified on 07/13/12 of the weight loss. The plan related to the assessment findings were documented to: provide the diet as ordered by the physician; monitor intake of meals; review weight per protocol; and, the Registered Dietitian should assess as needed. Review of the progress notes for Resident #110 revealed a note written by dietary staff #34 on 08/07/12 which stated a nutrition assessment had been completed on that date and there were no nutritional concerns. Review of an 08/10/12 computerized/electronic assessment completed by the Registered Dietitian (RD) # 156 revealed Resident #110's weight at 111.8 pounds on 08/07/12. RD #156 identified that Resident #110 had experienced a 7% weight loss over the previous 3 months and that the resident was not on a prescribed weight loss regimen. The assessment stated Resident #110 consumes 50% of the meals provided to her. Review of the summary and plan related to this assessment revealed the resident's diet is regular puree, appetite is fair to poor and the resident's average intake is 50% of meals. Resident #110 dines in the Coral Dining Room for lunch and dinner. The resident's weight loss over the previous 6 months was 15.6 pounds or 12% of body weight. The documentation stated that the physician and POA had been notified on 07/13/12 of the weight loss. The RD's plan was to provide the physician ordered diet, monitor the resident's intake of meals, review weight per protocol, and re-assess as needed. Review of the progress notes for Resident #110 revealed a nutritional progress note completed by the RD #156 on 08/10/12. The progress note stated a nutrition assessment had been completed on 08/07/12 and there was a nutrition concern of involuntary weight loss. Further review of earlier computerized/electronic progress notes for Resident #110 revealed that on 07/12/12 a nutritional assessment had been completed and a nutritional concern of involuntary weight loss had been identified. A progress note on 07/13/12 revealed a computer generated "weight warning" which stated Resident #110 had a documented weight of 112.4 pounds which was a 5.5% change over the previous 30 days and a 11.2% change over the previous 180 days. The progress note added that the physician and MPOA were aware of the weight loss. Another "weight warning" appeared in the progress notes on 09/05/12 which stated Resident #110 had a documented weight of 110.8 pounds and a 10.1 % change/loss in weight over the previous 180 days. The progress note goes on to say Resident #110 had lost weight over the last few months and the physician and MPOA were aware. The documented weights (in pounds) for Resident #110 were as follows: 127.4 on 02/06/12 124.0 on 02/13/12 124.8 on 02/20/12 125.8 on 03/06/12 123.2 on 04/02/12 121.2 on 05/01/12 119.0 on 06/06/12 112.4 on 07/03/12 111.8 on 08/07/12 110.8 on 09/05/12 The physician's progress notes for Resident #110 revealed a 05/11/12 order to discontinue the medication [MEDICATION NAME] (an appetite stimulant) after 2 doses were given the following day. The physician also wrote on the order that it was a trial, to watch the resident's weight and weigh Resident #110 weekly. On 05/23/12 a physician's orders [REDACTED]. On 06/15/12 a physician's orders [REDACTED]. On 06/22/12 a physician's orders [REDACTED]. Physician notes since June 2012 did not address the resident's declining weight. An undated document, identified by the facility as a faxed communication to the physician from the facility, revealed that the resident had experienced a weight loss. Weights provided were 119.0 pounds on 06/06/12 and 110.8 pounds on 09/05/12. The area on the form for the physician's response and comments was blank. There was no evidence that the form had actually been faxed to the physician. Nor was there documentation in the medical record by the physician in response to Resident #110's continuing weight loss. Review of the CNA documentation of percentage of meals eaten by Resident #110 revealed the following: April 2012: out of 90 meals offered, Resident #110 refused 22 of them, ate 25% of 22 meals, and ate 50% of 20 meals. The remaining meals were recorded at 75-100%. May 2012: out of 93 meals offered, Resident #110 refused 14 of them, ate 25% of 25 meals and ate 50% of 17 meals. The remaining meals were recorded at 75-100%. June 2012: out of 90 meals offered, Resident #110 refused 20 of them, ate 25% of 26 meals, and ate 50% of 12 meals. The remaining meals were recorded at 75-100%. July 2012: out of 93 meals offered, Resident #110 refused 10 of them, ate 25% of 28 meals and ate 50% of 20 meals. The remaining meals were recorded at 75-100%. August 2012: out of 93 meals offered, Resident #110 refused 9 of them, ate 25% of 19 meals and ate 50% of 20 meals. The remaining meals were recorded at 75-100%. September 2012: out of the meals offered thus far in the month of September, Resident #110 refused 2 of them, ate 25% of 14 meals and ate 50% of 18 meals. The remaining meals were recorded at 75-100%. The CNA documentation also indicated Resident #110 had consistently taken 0% of a snack in the evening since 05/01/12. Certified Nurse Aide (CNA) #51 stated during interview at 3:27 P.M. on 09/25/12 that Resident #110 eats about 25% of her meals when she assists her with eating. Review of a policy provided by the facility titled, "Assessment and Management of Patient Weights" dated 06/01/01 and last revised on 11/15/08 revealed the staff member entering the verified weights into the computerized charting system would print the Weights Exception Report for review and follow up would be provided by a licensed nurse. Significant weight changes were to be reviewed by the licensed nurse for evaluation. The licensed nurse would then: document verified significant weight changes in the medical record and on the 24 hour change of status report; notify the physician and dietitian of significant weight changes and document the notification of the physician and dietitian. The dietitian should then document the nutritional assessment and weight management recommendations in the medical record. The unit manager or licensed nurse should notify the physician of the dietitian's recommendations. Residents who have significant weight change were to be weighed weekly and discussed at the Customer At Risk or other clinical meeting to determine possible causes of the weight loss (or gain) including goals for care. The interdisciplinary care plan will then be updated to reflect individualized goals and approaches for managing the weight change. Resident #110 was observed on 09/25/12 at 12:58 P.M. eating lunch in the Coral Dining room while being fed by Certified Nurse Aide (CNA) #126. Resident #110 was observed to have pureed lasagna, a green vegetable, vanilla ice cream, a pureed desert, a yellow liquid and a small disposable 6 ounce glass of chocolate milk. At 1:40 P.M. on 09/25/12 CNA #98 approached Resident #110 and mixed the chocolate milk with the ice cream then offered it to the resident. There was no sippy cup observed on the table for Resident #110. During interview with CNAs #98 and #126 on 09/25/12 at 1:17 P.M., the CNAs stated they were not aware of any item on the resident's tray that had been provided for additional calories to promote weight gain. During interview with RD #156 on 09/25/12 at 3:44 P.M. the RD stated that she reviews resident weights every month and the dietary manger gets weekly weight reports. According to RD #156 the dietary manger communicates with the RD and the nursing unit managers. The computerized/electronic charting system includes weight warnings which go to the nurses. RD #156 stated residents would be weighed weekly if the resident was experiencing a decline or if a resident had a significant weight loss. RD #156 also stated that a regular diet is 2500 calories a day and 85 grams of protein. The pureed diet provides 3000 calories and 100 grams of protein each day. According to RD #156 Resident #110 should have her nutritional needs met with the diet she is on and if less than 75% of the meal is being eaten she would investigate the foods eaten. RD #156 stated that on 07/12/12 she had recommended that dietary send whole milk with meals, ice cream on each lunch tray and fortified cereal with breakfast daily. On 08/10/12 RD #156 recommended that in addition to the 7/12/12 recommendations, the resident also receive cottage cheese on each lunch tray and pudding with the dinner tray. RD #156 verified that these specific interventions to avert weight loss had not been added to the plan of care and felt the interventions currently in place on Resident #110's care plan encompassed the aforementioned recommendations. RD #156 also verified the task of updating the plan of care is a shared task. RD #156 stated if she goes into the care plans she will add the intervention. RD#156 also stated that since Resident #110's September nutritional assessment, the facility would weigh the resident weekly. On 09/26/12 at 7:58 A.M., Resident #110 was observed being fed in bed by CNA #81. Resident #110 had pureed eggs, pureed sausage, cream of wheat, orange juice and whole milk on her tray. During interview with CNA #81 at the time of the observation it was verified she was not aware if any of the foods on the resident's tray was fortified or provided additional calories which would promote weight gain. On 9/26/12 at 2:21 P.M., Resident #110 was observed seated in the Coral Dining Room with a cup of chocolate milk in front of her. CNA #126 stated during interview on 9/26/12 at 12:23 P.M. that Resident #110 is able to drink from the disposable cup. There was no 2 handled sippy cup observed near Resident #110. At 1:13 P.M. on 9/26/12 Resident #110 was observed being fed by CNA #98. The CNA stated the meal ticket, which identified the resident's diet, supplements, and likes/dislikes, identified that the resident disliked oatmeal. The meal ticket listed beverage preferences as juice, coffee, and whole milk. Also under the area of meal preferences the letters FFC were written. During interviews with CNAs #98, #126 and #31 none were able to identify what FFC stood for. CNA #31 stated the facility previously placed fortified foods in different colored bowls so the staff could easily identify the fortified foods. CNA #31 also stated during the interview that the restorative nurse aides are in charge of obtaining the weights in the facility. CNA #31 also stated that if a resident had a 5 pound weight loss or gain they would re-weigh the resident and notify the nurse. On 9/27/12 at 8:16 A.M., SLP #148 was observed at Resident #110's bedside. SLP #148 stated she was there to conduct a speech evaluation. The speech evaluation that had been ordered on [DATE] had never been done and she suspected the eval had been ordered due to weight loss. SLP #148 also stated that when she entered the resident's room the nurse aide had already assisted the resident with her meal, however, she was trying again. SLP #148 verified that resident #110 had eaten less than 25%. It was also verified that the carton of whole milk had been opened and poured on the cream of wheat but had not been stirred in and did not appear to have been offered to Resident #110. At 8:21 A.M. CNA # 108 entered the resident's room and stated she had attempted to feed Resident #110 earlier and felt the resident had eaten 25%. CNA #108 verified the resident had not been offered the whole milk or the cream of wheat (fortified cereal). CNA #108 also stated during the interview that she was not aware of any food on the resident's meal tray that had been provided for extra calories to avert the weight loss. During interview with RD #156 on 09/27/12 at 2:10 P.M., she stated that she is not notified immediately of weight loss. According to RD #156 the Assistant Director of Nursing (ADON) would notify her of weight losses after the weight loss meeting on Thursdays. RD #156 verified she is not present at all of the weight loss meetings. RD #156 also stated the nurse aides are trained to record meal points of foods and liquids consumed by the residents however, the only way to be certain how much the resident consumes is to do a calorie count. It was verified during the interview the letters FFC on the meal tickets were indicators for fortified cereal. During interview with the Director of Nursing on 09/27/12 at 3:41 P.M., it was stated the nursing assistants had never had training regarding dietary interventions for weight loss, such as adding whole milk, cottage cheese, pudding or fortified cereal. The DON verified during the interview the nursing assistants would not be aware of what the term FCC means on the meal ticket delivered with resident trays. During interview with Rehab Manager #154 on 09/27/12 at 9:35 A.M. she stated that she had been asked to review Resident #110's chart and had discovered that the resident had a physician's orders [REDACTED]. The Rehab Manager stated the Rehab department receives a written referral from nursing when such an order is received. The Rehab Manager stated she keeps the written referrals but could not locate one for the speech evaluation ordered on [DATE]. Rehab Manager #154 also stated during the interview that dietary staff #34, identified as the Assistant Food Director and a Certified Dietary Manager, would bring up weights at the Care Area Assessment (CAA) meetings. She added that a weight sheet is filled out and distributed on Tuesdays and she thought nursing and dietary staff were handling all weight loss issues. She was not aware that Resident #110 had a significant weight loss. During interview on 09/28/12 at 10:26 A.M., Licensed Practical Nurse (LPN) #5 stated that the Assistant Food Director brings the list of residents with weight loss to the weekly meetings. LPN #5 added that the weight warnings automatically show in the computerized charting system. LPN #5 stated she's been in this position for a short period of time and had not received training regarding how the computerized charting system works for potential weight loss alerts and was not clear as to who was responsible for follow up with the physician or dietitian. During interview on 09/28/12 at 10:32 A.M. Dietary staff #34 stated the facility discusses weight loss each every Thursday. If a resident has had weight loss, nursing will fax the doctor. When asked who alerts the dietitian, Dietary staff #34 stated RD #156 runs her own weight report when she comes to the facility and nobody is in charge of notifying her. It was confirmed that RD #156 does not have set days to work. Dietary staff #34 stated there is nothing in place to monitor resident weight losses when RD #156 is not there. (According to Dietary staff #156 it is nursing's job to notify RD #156.) Dietary staff #34 stated she had previously been involved and would contact the physician when weight losses occurred, but now nursing staff is involved and she no longer has input regarding weight loss interventions. When asked if the facility utilizes nutritional supplements Dietary staff #34 stated nursing provides them and those types of supplements are not on dietary's formulary. During interview with ADON #27 on 09/28/12 at 2:06 P.M. it was confirmed that no weekly weights had been obtained for Resident #110 as ordered by the physician and there was no documentation that the physician had been notified of Resident #110's significant weight loss. 2. Resident #159 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's admission Minimum Data Set (MDS), dated [DATE], indicated the resident required limited assistance of one person for physical assist with eating. A Nutritional assessment dated [DATE] indicated the resident was on a regular pureed diet and had experienced a 5% weight loss in one month and her Body Mass Index was 36. The documentation indicated the resident had received Speech Therapy, but it had been discontinued on 8/10/12 because the resident required extensive assistance with meals and continued to pocket food in her mouth. The weights and vital summary document listed weekly weights for the resident that began on 8/7/12. Recorded weights were: 08/07/12 weight of 235 pounds, 08/14/12 weight of 230.4 pounds, 08/20/12 weight of 225.8 pounds, 08/28/12 weight of 228 pounds. On 8/22/12 the registered dietitian had ordered pudding with lunch and dinner, whole milk with meals and fortified cereal at breakfast due to a significant weight loss in one month and the oral intake was not meeting the resident's needs. The most recent care plan, dated 6/1/12, indicated the resident required extensive assistance for Activities of Daily Living (ADL's) due to failure to thrive and [MEDICAL CONDITION] and required limited to extensive assist of one for eating. The care plan also indicated the resident was at nutritional risk due to dementia and depression which may affect oral intake and result in significant weight loss. Interventions included: encourage resident participation while providing appropriate ADL care; use simple concrete statements; dine in the Coral dining room for lunch and dinner; serve whole milk three times a day; serve fortified cereal and pudding for lunch and dinner; weigh as ordered; alert dietitian and physician to any significant weight loss; monitor for changes in nutritional status including unplanned weight loss and report to physician as indicated On 9/26/12 at 2:40 P.M. Speech Therapist (ST) #148 was interviewed and stated the resident had received speech therapy for pocketing food, but she had not progressed with her goals. She stated there were no reasons medically why she didn't progress and her continued weight loss was discussed in the weekly meeting. She had talked to the dietitian for an assessment due to the resident ' s food pocketing. When her weight loss was discussed in the meeting, behavior, as a possible link to the weight loss was considered. ST #148 stated the resident was discharged from speech therapy and staff cue her to eat and swallow at times. She stated the pureed diet was the safest diet for the resident and there are no choking issues because the food usually dissolves in her mouth. She stated the resident received a regular textured diet upon admission, but had declined to a pureed texture. At 2:50 P.M. an interview with Restorative Certified Nurse Aide (RCNA) #31 was conducted and she stated that the resident pockets food at times and has to be reminded to swallow. She sits at a table with staff so she can be monitored and cued when she eats. Some days she does well and other days she requires assistance. At 3:00 P.M. the Licensed Social Worker (LSW) #41 was interviewed. LSW #41 stated that on 7/23/12 the physician had ordered a psychiatric evaluation, however, the resident had not yet been seen. LSW #41 stated the psychiatrist was in the facility and would see the resident today. Observations were made on 9/27/12 at 8:17 A.M. of Certified Nurse Aide (CNA) #111 assisting the resident with breakfast in her room. The CNA was interviewed and stated she did not know how to identify if the resident received a fortified cereal. (The meal ticket had FCC printed on the bottom of the card.) During interview on 9/27/12 at 2:40 P.M. the dietitian stated the resident had a weight loss in August 2012 and new interventions had been put in place on 8/22/12. There had been no new recommendation on 9/7/12 when the dietitian was in the facility. The dietitian stated the resident had issues with pocketing food and had been seen by speech therapy and was now being assisted by the staff for meals. The nutritional note indicated the resident had a significant weight loss, but the Body Mass Index indicated obesity. The dietitian stated the 9/7/12 assessment was her last assessment of the resident, however she would see the resident again today, 9/27/12, for the continuing weight loss. The Minimum Data Set (MDS) Registered Nurse (RN) #59 was interviewed at 4:40 P.M. and confirmed the accuracy of the MDS for the period of decline. The ADL flow records were reviewed for the past three months and showed the resident had an up and down trend for eating. During interview on 9/28/12 at 1:55 P.M. Registered Nurse (RN) #105 stated the resident's weight on 9/10/12 had been 221.8 pounds, on 9/17/12 the weight was 221.8 pounds and on 9/26/12 the weight was 218.6 pounds. RN #105 stated the physician had been notified and there had been no further documentation from the dietitian regarding the weight loss. The policy and procedure for Assessment and Management of Patient Weights was reviewed. The significant weight change management indicated the weights would be reviewed by the LPN. The LPN would document the weight in the medical record, notify the physician and the dietitian and document the notification. The dietitian would then evaluate the resident who has a significant weight change and complete a nutritional assessment, if appropriate, and document the assessment and weight management recommendations in the medical record. The unit manager or licensed nurse will notify the physician of the dietitian ' s recommendations and family notification documented in the medical record. If the physician chooses not to implement the dietitian's recommendations, they must document in the medical record the rationale. Residents who have a significant weight change will be weighed weekly and discussed at the Customer at Risk meeting or other clinical meeting to determine possible causes of the weight change including goals for care. On 9/28/12 at 3:00 P.M. the Director of Nursing (DON) verified the resident's weight had decreased in September and the Registered Dietitian had not been informed. The DON verified the interventions on the care plan had not been followed by the staff to notify the dietitian of the weight loss. The DON verified the staff had not been in-serviced on how to identify foods on the meal tray that were fortified or to have a higher nutritive value. The DON verified the meal percentages of all foods were calculated together and liquids on the trays were all calculated together. The DON verified supplements with additional calories to promote weight gain were not considered separately to determine if the interventions to provide extra nutrition had been successful. 3. Resident #126 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Difficile, hepatic [MEDICAL CONDITION], hypertension, [MEDICAL CONDITION] and [MEDICAL CONDITION]. The Most Recent (MDS) Assessment, dated 7/15/12, indicated the resident had a weight loss of 5% or more in the last month or a loss of 10% or more in the past 6 months and received a mechanically altered diet. The most recent plan of care, dated 7/14/12 and to be in place through 10/14/12, indicated the resident was at risk for nutritional weight loss due to a texture modified diet, dementia, anxiety, [MEDICAL CONDITION] and significant weight loss. Interventions included: encourage resident to consume all fluids during meals; honor food preference on meal ticket; weigh per orders; alert physician of significant changes; monitor all intake of meals; provide regular pureed diet; offer snacks; dine in Coral Dining Room; supervise/cue/assist with meals; monitor for changes in nutritional status including unplanned weight loss, abnormal labs and report to food/nutrition and physician as needed. Physician notes dated 8/7/12 indicated the resident continued to lose weight and her condition was progressively worsening due to progressive dementia. Physician notes dated 7/10/12 indicated that progressive dementia was the reason for the resident's continued weight loss. Nurses notes were reviewed and on 4/5/12 documentation by the nurse indicated the resident had lab results that were negative for [MEDICAL CONDITION]. On 4/21/12 the nurse documented the resident was incontinent of bowel and bladder. On 4/23/12 the nurse documented that a urinalysis had been obtained for a possible urinary tract infection. On 4/24/12 and 4/25/12 laboratory results were received and indicated the resident's urine was positive for infection and the resident had [MEDICAL CONDITION]. The physician ordered [MEDICATION NAME] for 10 days and [MEDICATION NAME] for 7 days to treat the urinary tract infection and the [MEDICAL CONDITION]. On 5/4/12 the nurse documented the resident continued on [MEDICATION NAME] for [MEDICAL CONDITION]. On 5/16/12 nursing documentation indicated the resident had loose, foul smelling stools and the physician gave orders to repeat a stool sample for [MEDICAL CONDITION]. On 5/17/12 the physician ordered [MEDICATION NAME] for 2 weeks. Nutrition notes were reviewed and on 5/22/12 the dietitian documented that the resident was on a house supplement due to weight loss, would benefit from fortified cereal and whole milk with meals, had [MEDICAL CONDITION] and the course of [MEDICATION NAME] had been completed on 5/31/12. On 6/29/12 a nutrition note indicated the resident had no significant weight changes, the Body Mass Index (BMI) was within normal limits and continue to monitor. On 7/18/12 the dietitian added pudding or ice cream with lunch and dinner and whole milk with meals due to the recent weight loss. On 8/7/12 the resident's weight increased by two pounds. On 9/5/12 the resident's weight was 105.4 pounds with a 5% weight loss in 30 days. The physician was notified with no new orders. There was no documentation of the dietitian being notified. The resident's previous weight on 8/7/12 had been 111.6 pounds. There were no new interventions documented for the resident's weight loss from 111.6 pounds on 8/7/12 to 105.4 pounds on 9/5/12. Observations were made on 9/25/12 at 12:50 P.M. of the resident in the Coral Dining Room being fed by Certified Nurse Aide (CNA) #16. The resident was eating a pureed diet for lunch. On 9/26/12 at 1:05 P.M. the resident was observed in the Coral Dining Room being fed by CNA #23. The resident was eating a pureed diet. Interview with CNA #23 stated she did not know if the resident had any foods on her tray that were fortified or had additional calories. Interview with CNA #31 at 1:07 P.M. stated they previously served the fortified foods in a different colored bowl so the staff would recognize the foods with extra calories, but they don't do that anymore. Observations were made on 9/27/12 at 8:15 A.M. of CNA #53 feeding the resident in bed. The meal ticket was observed to have FCC written on the bottom. CNA #53 stated he didn't know if the resident had fortified cereal or not on her tray. He verified that all foods that came on the resident's tray were calculated together as a percentage to give the total of the resident's meal intake. On 9/27/12 at 11:45 A.M. an interview was conducted with Licensed Practical Nurse (LPN) #5. LPN #5 stated that after she receives the weights from the restorative aides she enters the weights into the computer. If she identifies weight loss she faxes details related to the weight loss to the physician. On 9/27/12 at 2:10 P.M. an interview was conducted with the Registered Dietitian (RD) #156. RD #156 stated the resident receives whole milk at all meals and pudding with lunch and dinner and the interventions were meeting her needs. She stated the resident had a history of [REDACTED]. The resident had been treated with different antibiotics. The resident had a weight gain in June, a weight decli