Every finding on record at Brown Memorial Home Inc

Based on record review, staff interviews, review of hospital records, review of orthopedic notes and review of facility policy, the facility failed to ensure the hallways were maintained free from accident hazards to prevent falls and failed to ensure the cause of falls were investigated. Actual harm occurred on 01/12/26 when a housekeeping employee placed a bag of garbage on the hallway floor. Resident #44 stumbled over the edge of the bag and fell to the floor, resulting in pain and a comminuted intra-articular right distal radius fracture which required surgical intervention. This affected one (Resident #44) out of the three residents reviewed for falls. The facility census was 37. Findings include:Record review for Resident #44 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included schizoaffective disorder, dementia, psychosis, and hallucinations. Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/23/26, revealed the resident had impaired cognition. Review of the care plan, revised 02/06/26, revealed the resident had potential for falls. Interventions included but not limited to keeping pathways free of clutter/obstacles that could obstruct pathways used to mobilize self. Review of the nurses progress note, dated 01/12/26, revealed Resident #44 was found on the floor at 11:03 A.M., fall was witnessed, resident tried to catch herself with her wrist. Resident complained of pain, rating it a ten on a one to ten scale. She complained of right wrist pain, right knee pain, and both hips. 911 was called at 11:05 A.M. and the physician was notified at 11:06 A.M. Vitals signs were obtained and a head to toe assessment was completed. The fall was witnessed by houskeeping staff, who said Resident #44 did not hit her head. Resident #44 was sent to the emergency department (ED) for evaluation. Review of the hospital visit summary, dated 01/12/26, revealed Resident #44 presented from a nursing facility via EMS (Emergency Medical Services) by herself with complaints of wrist injury, fall, and syncope. She had a witnessed fall where she tripped and fell. Deformity to right wrist. Hit her head against her walker and landed on her knees. Given 100 micrograms (mcg) of Fentanyl (an opioid pain medication) en route via EMS. X-ray of right knee showed comminuted fracture of the distal radius with intra-articular extension. Fracture demonstrates significant dorsal displacement and angulation. Mildly displaced and comminuted fracture of the distal ulna including involvement of the ulnar styloid. Patient medicated for pain, sling placed, order to call orthopedic surgeon to schedule follow up appointment and to leave sling in place until evaluated by orthopedics. Review of the orthopedic After Visit Summary note, dated 01/13/26, revealed Resident #44 was injured at the facility when she fell and landed awkwardly on her right wrist. She had an immediate onset of deformity and was there for definitive care. She was seen in the emergency room [DATE]. Clinical and radiographic examination supported diagnosis of a comminuted intra-articular right distal radius fracture. Due to the displacement and intra-articular nature of the fracture, we discussed the limited role of nonoperative care and the consequence of allowing it to unite with intra-articular displacement. Placed her into a sling and discussed care with her power of attorney and intent to do an open reduction with internal fixation. Will proceed with surgery on 01/19/26. Review of the nurses progress note, dated 01/19/26, revealed Resident #44 returned from surgery. Dinner provided per resident request. New orders obtained. Review of the medical record revealed there was no fall investigation, root cause analysis, witness statements, or staff education provided related to Resident #44's fall on 01/12/26. During an interview on 07/24/26 at 10:55 A.M., the Director of Nursing (DON) stated Resident #44 fell on [DATE] and was sent to the hospital where she was found to have fractures which resulted from the fall. The DON stated she was unaware of the details of the fall as the previous DON had not completed an investigation of the fall, including determining the cause of the fall and had not obtained witness statements from staff who witnessed the fall. The DON stated education for staff had not been completed or documented following the fall. During an interview on 07/24/26 at 11:28 A.M., Environmental Manager #229 stated she witnessed Resident #44 come out of her room [ROOM NUMBER]/12/26 and stopped to talk with a housekeeper who was emptying trash out of her cart. Environmental Manager #229 stated the housekeeper had placed a bag of garbage on the floor while she was putting a new bag in the cart and stopped to talk to Resident #44. Resident #44 was attempting to step around the bag of garbage and stumbled over it and fell to the floor. Environmental Manager #229 confirmed bags of garbage should not be placed on the floor and should immediately be placed in trash receptacles. Environmental Manager #229 stated she was unaware of any staff receiving education following the fall regarding keeping all equipment on the right side of the hallway, ensuring proper fitting shoes are in place before ambulation, or staff not placing bags of garbage on the floor. During an interview on 07/24/26 at 12:10 P.M., the Administrator stated the former DON had not completed a thorough fall investigation following Resident #44's fall on 01/12/26 which contributed to the former DON being terminated from employment at the facility for poor job performance. Review of facility policy titled Assessing Falls and Their Causes, revised 03/18/18, revealed the purpose of the procedure was to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall. Within 24 hours of a fall, begin to try to identify possible or likely causes of the incident. Refer to resident-specific evidence including medical history, known functional impairments, etc. Continue to collect and evaluate information until the cause of falling is identified or it is determined that the cause cannot be found. This deficiency represents non-compliance identified under Complaint Number 3070865.

Based on resident record review, staff interviews, and review of facility policy, the facility failed to ensure a resident received the correct dose of medication as ordered by the physician. This affected one resident (#44) out of the three residents reviewed for medication administration. The facility census was 37. Findings include:Record review for Resident #44 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included schizoaffective disorder, dementia, psychosis, and hallucinations. Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/23/26, revealed the resident was assessed to have impaired cognition. Review of the nurses progress note, dated 12/28/26, revealed Resident #44 was experiencing increased fatigue, was sleeping more, and was staying in her room. Physician made aware. Review of the nurses progress note, dated 12/28/26, revealed return call from physician. New orders to decrease Seroquel (an anti-psychotic medication) to 50 milligrams (mg) in the morning and 100 mg in the evening. Review of the nurses progress note, dated 05/14/26, revealed order clarifications received and noted to Seroquel. Review of the physician order, dated 03/24/24, revealed administer 200 mg of Seroquel every hour of sleep. The order was not discontinued until 05/14/26. Review of the physician order, dated 03/24/24, revealed administer 100 mg of Seroquel every day. The order was not discontinued until 05/14/26. Review of the physician order, dated 12/28/25, revealed administer 50 mg of Seroquel every day. The order was discontinued on 12/31/26. Review of the active physician order, dated 12/28/25, revealed administer 100 mg of Seroquel every day. Review of the active physician order, dated 05/15/26, revealed administer 50 mg of Seroquel every day. Review of the Medication Administration Records (MARs) for Resident #44 from 12/25/25 through 07/23/26 revealed the resident was documented to receive 300 mg of Seroquel from 12/25/25 through 12/27/25, 200 mg of Seroquel on 12/28/25, 350 mg of Seroquel on 12/29/25, 450 mg of Seroquel on 12/30/25, and 400 mg of Seroquel from 12/31/25 through 05/14/26. The resident received 150 mg of Seroquel from 05/15/26 through 07/23/26. Interview on 07/24/26 at 10:55 A.M. with the Director of Nursing (DON) confirmed Resident #44 had been receiving 300 mg of Seroquel every day prior to experiencing fatigue and sleeping more on 12/28/25. The DON confirmed the physician was notified and new orders to decrease Seroquel to 150 mg a day were given. The DON confirmed the orders were not implemented appropriately resulting in Resident #44 receiving a higher dose of Seroquel until she caught the error while auditing psychotropic medications on 05/14/26. The DON confirmed the physician and responsible party of the resident were notified of the error and the physician provided clarification to decrease the Seroquel to 150 mg a day as he had originally ordered on 12/28/25. Review of the facility policy titled Adverse Consequences and Medication Errors, revised 06/2025, revealed a medication error is defined as the preparation or administration of drugs or biologicals which is not in accordance with providers orders.

Based on medical record review, staff interview, and facility policy review, the facility failed to adequately monitor skin issues/bruising for residents know to have skin alterations. This affected one (Resident #17) of three residents reviewed for skin alterations. The census was 33. Findings Include:Resident #17 was initially admitted to the facility for respite care on 07/07/25. Her diagnoses were Alzheimer's disease, dementia, amnesia, visual hallucinations, chronic fatigue, nonrheumatic mitral valve insufficiency, and encounter for palliative care. Review of her minimum data set (MDS) assessment, dated 11/18/25, revealed she had a severe cognitive impairment.Review of Resident #17 progress notes, dated 12/04/25, revealed hospice shower aid came to the facility nurse and stated she noted some bruising and swelling on Resident #17's lower left extremity (LLE). It was noted there were two dark colored bruises, but there was no measurement, description or exact location of the skin alteration. Review of Resident #17's progress notes, dated 12/05/25 to 12/19/25, revealed no specific information as to where the bruising was located, or any other description of the bruise including size or color. Review of Resident #17's skin assessments, dated 11/25/25, 12/02/25, 12/09/25, and 12/16/25, revealed there were no skin issues documented including bruising or skin injuries, noted on any of the skin assessments. There was no documentation, including measurements, shape, or other descriptors, of the bruising on Resident #17's lower left extremity.Review of Resident #17's shower logs/documentation, dated 12/04/25 to 12/19/25, revealed no skin assessments/documentation to support monitoring of the bruising that was reported to Resident #17's lower left extremity.Review of Resident #17's hospice notes, dated 12/04/25 to 12/19/25, revealed mention of bruising that was found to her lower left extremity. However, there was no documentation or descriptors of the bruising at any point she was in the facility.Interview with current Director of Nursing (DON), new DON, Administrator, and Assistant Director of Nursing (ADON) #35 on 12/23/25 at 3:10 P.M. confirmed they have no documentation in the facility to support the bruising was monitored, measured, or described if it grew in shape/size throughout the time that Resident #17 was in the facility and the bruise had been identified. The DON, Administrator, and ADON confirmed the bruise should have been monitored after it was identified. They confirmed they will get the hospice records to determine if they monitored the bruise.Interview with current DON on 12/24/25 at 8:16 A.M. confirmed the hospice records did not have any descriptive language about the bruise on Resident #17's lower left extremity.Review of facility Skin Assessment policy, dated 2022, revealed it is the policy to perform a full body assessment as a part of the systematic approach to pressure injury and management. A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/readmission, daily for three days, and weekly thereafter. The assessment may also be performed after a change in condition or after any newly identified pressure injury. This deficiency represents non-compliance investigated with complaint number 2691551.

Based on medical record review and staff interview, the facility failed to ensure gradual dose reduction (GDR) pharmacy recommendations were completed as required. This affected one (Resident #20) of five residents reviewed for unnecessary medications. The census was 33.Resident #20 was admitted to the facility on [DATE]. Her diagnoses were gastro-esophageal reflux disease, emphysema, hyperlipidemia, morbid obesity, major depressive disorder, congestive heart failure, osteoarthritis, Type II Diabetes, chronic obstructive pulmonary disease, fibromyalgia, obstructive sleep apnea, hypertension, vitamin D deficiency, and history of falling. Review of her minimum data set (MDS) assessment, dated 09/14/25, revealed she was cognitively intact. Review of Resident #20's physician orders found the following medications ordered/administered and the dates in which they were initiated: Wellbutrin (antidepressant) 150 milligrams (mg) for depression, which was initiated on 03/11/24, and Citalopram (antidepressant) 10 mg, one half tab for depression, which was initiated on 12/06/23.Review of Resident #20's monthly pharmacy reviews, dated December 2024 to December 2025, revealed no pharmacy recommendations related to a GDR for either Citalopram or Wellbutrin for the 13 months reviewed.Interview with Current Director of Nursing (DON) and new DON on 12/24/25 at 8:13 A.M. and 10:15 A.M. confirmed there were no recommendations for a GDR for Wellbutrin or Citalopram. She confirmed there should have been, but the information she received from the pharmacist was that there was no indication for a dose reduction at this time due to psychiatric notes/review. Current DON confirmed they do not have any psychiatric notes to support a recommendation or a review for a GDR in the last 12 months.

Based on medical record review and staff interview, the facility failed to monitor the use of blood pressure medication appropriately. This affected two (Residents #11 and #5) of five residents reviewed for unnecessary medications. The census was 33.Findings Include: 1. Resident #11 was admitted to the facility on [DATE]. Her diagnoses were other long term drug therapy, anxiety disorder, Alzheimer's disease, dementia, repeated falls, hyperlipidemia, orthostatic hypotension, personal history of other diseases, visual hallucinations, cardiac murmur, restless leg syndrome, osteoporosis, neurocognitive disorder with Lewy bodies, and Parkinson's disease. Review of her minimum data set (MDS) assessment, dated 09/06/25, revealed she was cognitively intact. Review of Resident #11's current physician orders revealed an order for Midodrine HCl (used to treat low blood pressure) oral tablet 2.5 milligrams (mg), one tablet daily for hypotension. There were parameters documented to hold the medication if the systolic blood pressure (SBP) was greater that 90 mm hg (millimeters of mercury), and the diastolic blood pressure (DBP) was greater than 50 mm hg. This order was initiated on 03/12/25. Review of Resident #11's medication administration records (MAR), dated July 2025, revealed the following dates Midodrine was held and did not have a blood pressure taken or proper justification at the time the medication was to be given (8:00 A.M.): 07/07/25, 07/17/25, 07/20/25, 07/21/25, 07/22/25, 07/26/25, 07/27/25, and 07/31/25. The following dates the Midodrine was documented as administered when the blood pressure was above the ordered parameter and should have been held: 07/12/25, 07/13/25, 07/16/25, and 07/18/25. Review of Resident #11's medication administration records (MAR), dated September 2025, revealed the following dates Midodrine was held and did not have a blood pressure taken or proper justification at the time the medication was to be given (8:00 A.M.): 09/02/25, 09/06/25, 09/07/25, 09/08/25, 09/09/25, 09/10/25, 09/11/25, 09/14/25, 09/18/25, 09/19/25, 09/20/25, 09/21/25, 09/25/25, 09/27/25, 09/28/25, 09/29/25, and 09/30/25. The following dates the Midodrine was documented as administered when the blood pressure was above the ordered parameter and should have been held: 09/01/25, 09/03/25, 09/04/25, 09/12/25, 09/15/25, 09/16/25, 09/23/25, and 09/26/25. Review of Resident #11's medication administration records (MAR), dated October 2025, revealed the following dates midodrine was held and did not have a blood pressure taken or proper justification at the time the medication was to be given (8:00 A.M.): 10/01/25, 10/02/25, 10/03/25, 10/04/25, 10/05/25, 10/06/25, 10/07/25, 10/08/25, 10/09/25, 10/12/25, 10/13/25, 10/14/25, 10/17/25, 10/18/25, 10/19/25, 10/20/25, 10/21/25, 10/22/25, 10/23/25, 10/26/25, 10/27/25, 10/28/25, and 10/31/25. The following dates the Midodrine was documented as administered when the blood pressure was above the ordered parameter and should have been held: 10/10/25, 10/11/25, 10/15/25, 10/16/25, 10/24/25, 10/25/25, 10/29/25, and 10/30/25. Review of Resident #11's medication administration records (MAR), dated November 2025, revealed the following dates Midodrine was held and did not have a blood pressure taken or proper justification at the time the medication was to be given (8:00 A.M.): 11/06/25, 11/11/25, 11/14/25, 11/15/25, 11/16/25, 11/18/25, 11/20/25, 11/25/25, 11/26/25, 11/27/25, and 11/29/25. The following dates the Midodrine was documented as administered when the blood pressure was above the ordered parameter and should have been held: 11/01/25, 11/02/25, 11/03/25, 11/04/25, 11/07/25, 11/08/25, 11/09/25, 11/12/25, 11/13/25, 11/17/25, 11/19/25, 11/22/25, 11/23/25, and 11/28/25. Review of Resident #11's medication administration records (MAR), dated December 2025, revealed the following dates Midodrine was held and did not have a blood pressure taken or proper justification at the time the medication was to be given (8:00 A.M.): 12/08/25, 12/09/25, 12/12/25, 12/17/25, and 12/21/25. The following dates the Midodrine was documented as administered when the blood pressure was above the ordered parameter and should have been held: 12/02/25, 12/06/25, 12/07/25, 12/14/25, and 12/18/25. Interview with Current Director of Nursing (DON) and New DON on 12/24/25 at 8:16 A.M. and 9:57 A.M. confirmed Midodrine was held and not administered to Resident #11 without blood pressure or vital signs were being taken or documented at the time the medication was to be administered. They confirmed the vital signs should have been taken to determine if the medication should or should not have been given. Also, they confirmed that Midodrine was administered outside the parameters written by the physician. They have contacted the physician to clarify the parameters for that medication. 2. Review of the medical record for Resident #5, revealed an admission date of 11/26/25. Diagnoses included but were not limited to myocardial infarction, chronic respiratory failure, Alzheimer's disease, major depressive disorder, emphysema, insomnia, bipolar disorder, vascular dementia, extrapyramidal and movement disorder, schizoaffective disorder, bipolar disorder, congestive heart failure, Type II Diabetes Mellitus, Chronic Obstructive Pulmonary Disease (COPD), and schizophrenia. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15 indicating intact cognition. The resident was assessed to have received seven days of insulin during the look back period, antipsychotics, antidepressants, anticoagulant, diuretic, antiplatelet, hypoglycemic, and anticonvulsant medications with indications documented. On 11/26/25 the provider ordered Midodrine HCL oral tablet 10 milligrams (mg) every eight hours as needed for hypotension. Administer if the systolic blood pressure is less than 100 millimeters of mercury (mm hg). Review of documented blood pressures revealed Resident #5 had documented systolic blood pressures less than 100 mm hg. 11/29/25 at 8:30 P.M. Resident #5's blood pressure was 95/57, on 11/30/25 at 8:32 P.M. Resident #5's blood pressure was 98/56, on 12/04/25 at 8:00 P.M. Resident #5's blood pressure was 98/74, on 12/15/25 at 8:30 A.M. Resident #5's blood pressure was 98/48, and on 12/23/25 at 8:55 A.M. Resident #5's blood pressure was 95/53. Review of the MAR for Resident #5 from 11/26/25 until 12/24/25 reveled Midodrine HCL oral tablet 10mg had not been administered to Resident #5 when the systolic blood pressure was less than 100mm hg as ordered. Interview on 12/24/25 at 10:21 A.M. with the DON confirmed the medication Midodrine ordered for Resident #5 had never been administered and the physician order was not followed.

Based on observation and staff interview, the facility failed to ensure shower room exhaust fans were maintained in good and working order. This had the potential to affect all 33 residents identified by the facility as using the shower rooms. The facility census was 33. Findings include: Observation and interview with the Director of Nursing (DON) on 05/28/25 at 11:00 A.M. confirmed the exhaust fans in the front and back shower rooms were not working. A small amount of a mildew-like substance was present on the ceiling around the exhaust fan in the back shower room. The DON stated she was not sure if parts had been ordered to repair or replace the exhaust fans but she would check. Interview with the DON on 05/28/25 at 12:33 P.M. confirmed there were no receipts or records of parts for the shower room exhaust fans being ordered. Interview with Maintenance Supervisor #299 on 05/28/25 at 1:20 P.M. confirmed the exhaust fans in the front and back shower rooms were not working and no parts had been ordered prior to 05/28/25 to repair or replace them. This deficiency represents non-compliance investigated under Complaint Number OH00164469.

Based on observations, staff interview, and facility policy review, the facility failed to appropriately date opened food items in the refrigerator and freezer. The deficient practice had the potential to affect all 39 residents who resided in the facility. The facility did not identify any residents with a physician ordered nothing by mouth (NPO) diet. Findings Include: Observations completed during the initial tour of the kitchen on 09/03/24 at 10:20 A.M. with Dietary Manager (DM) #106 revealed the following items in the refrigerator had been opened and not dated: One large glass container of dill pickle spears One large plastic container of mayonnaise, 75% empty One plastic container of pimento cheese spread One large plastic container with a handle of Pace Picante salsa One bottle of Frank's Red Hot sauce One bottle of Siracha hot sauce Two small plastic containers of chicken base One small container of beef base One small jar of minced garlic One small jar of sliced jalapenos One large plastic container of sour cream One large plastic container of ham salad One large plastic container of vanilla yogurt One large jar of Concord grape jelly One package of sliced deli ham One package of sliced deli salami One package of sliced deli turkey breast Interviews on 09/03/24 at 10:24 A.M. and 10:28 A.M. with DM #106 confirmed the above findings. Observation on 09/03/24 at 10:35 A.M. of the facility kitchen freezer with DM #106 revealed the following items were opened and not dated: One bag of frozen chicken tenders One bag of frozen blueberries One bag of frozen chicken breasts One bag of frozen tator tots One bag of frozen fish patties The above findings were confirmed by DM #106 at the time of the observations. Review of the facility policy, Refrigerated Storage, undated, revealed the policy stated, refrigerated food shall be stored in a manner that optimizes food safety and quality. Refrigerated items shall bear a label indicating product name and date (month, day, and year) product was received, used or first opened.

Based on record review, review of the facility's beneficiary notice list and notices, staff interview, and facility policy review, the facility failed to provide an Advanced Beneficiary Notice (ABN) to one resident (Resident #141) when he was discharged from Medicare part A services and remained in the facility. The deficient practice affected one resident (Resident #141) of one reviewed for beneficiary notices. The facility census was 39. Findings Include: Review of the closed record for former Resident #141 revealed an original admitted on 01/08/24, readmitted s on 04/05/24 and 06/30/24, and a discharge date on 07/13/24. Medical diagnoses included complete traumatic amputation of right midfoot, protein-calorie malnutrition, dementia with behavioral disturbance, Type II Diabetes Mellitus with diabetic polyneuropathy, non-pressure chronic ulcers of right and left feet, peripheral vascular disease, and osteoarthritis. Review of the facility's Beneficiary Notice-Residents discharged Within the Last Six Months revealed Resident #141 was discharged from Medicare Part A therapy services with benefit days still remaining and remained in the facility on 03/01/24 and 07/10/24. Review of the beneficiary notices provided to Resident #141 revealed the resident was not provided with an ABN when he was discharged from Medicare Part A therapy services on either occasion. Interview on 09/04/24 at 4:42 P.M. with Business Office Manager (BOM) #121 confirmed Resident #141 was not provided with an ABN when he was cut from Medicare Part A therapy services and remained in the facility. BOM #121 stated she was not aware the resident should have been provided with an ABN. BOM #121 stated she did not review the options listed on the ABN with Resident #141 to determine if the resident may want to continue receiving therapy services. Review of the document, Form Instructions Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) Form CMS-10055, dated 2024, revealed the document stated, the skilled nursing facility must give the applicable Medicare coverage guideline(s) and a brief explanation of why the patient's medical needs or condition do not meet Medicare coverage guidelines. Example 1: Patient no longer requires daily skilled care but wants to continue residing in the skilled nursing facility. Care: Inpatient Skilled Nursing Facility stay requiring daily skilled care which includes custodial room and board charges. Reason Medicare May Not Pay: You need only assistive or supportive care. You don't require daily skilled care by a professional nurse or therapist. Medicare won't pay for your stay, including custodial care room and board charges, at this facility unless you require daily skilled care. Review of the facility policy, Advance Beneficiary Notices, undated, revealed the policy stated, it is the policy of this facility to provide timely notices regarding Medicare eligibility and coverage. Additional notices shall be issued to Medicare beneficiaries when appropriate. 1. If services are being terminated and the beneficiary wants to continue to receive the care that is no longer considered medically reasonable and necessary, the facility shall issue an ABN prior to furnishing non-covered care.

Based on staff interview and record review the facility failed to document a resident transfer in the medical record when Resident #23 was transferred to the hospital for a change in condition. This affected one (Resident #23) of three Residents reviewed for hospitalization . The facility census was 39. Findings include: Record review of Resident #23 revealed an admitted [DATE] with pertinent diagnoses of, fracture of unspecified part of neck of left femur, benign neoplasm of cerebral meninges, pick's disease, dementia with severe mood disturbance, anxiety disorder, seizures, atrial fibrillation, major depressive disorder, mood disorder with depressive features, anxiety disorder, and insomnia. Review of the 06/07/24 quarterly Minimum Data Set (MDS) assessment revealed the resident is rarely or never understood. The resident did not use mobility devices and wandered one to three days during the look back period. The resident was dependent for eating, oral hygiene, toileting, shower, upper body and lower body dressing, personal hygiene, rolling left and right, sit to lying, and lying to sitting. She was independent in walking up to 150 feet. The Resident was always incontinent of bladder and frequently incontinent of bowel. Review of the electronic medical record Minimum Data Set (MDS) tab revealed the Resident was discharged on [DATE] and returned on 08/22/24. Review of the medical record on 09/04/24 revealed there was no progress note about why Resident #23 discharged on [DATE] or an assessment for her condition. Interview with the Director of Nursing (DON) on 09/05/24 at 9:18 A.M. revealed Resident #23 went out the hospital on 08/21/24 and she verified there was no information in the medical record explaining the hospitalization . The DON stated she would expect staff to document why a resident went out to hospital and complete an assessment.

Based on record review, staff interview, and facility policy review, the facility failed to notify the local Ombudsman when two residents (Residents #35 and #23) were transferred out of the facility and/or discharged from the facility. The deficient practice affected two residents (Residents #35 and #23) of four reviewed for hospitalization s and discharge. The facility census was 39. Findings Include: Review of the medical record for Resident #35 revealed and initial admitted on 08/08/23 and a readmitted on 04/23/24. Medical diagnoses included congestive heart failure, chronic obstructive pulmonary disease, and progressive systemic sclerosis. Review of the clinical census for Resident #35 revealed the resident was hospitalized on [DATE] and 06/24/24. Review of the discharge Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #35 had an unplanned discharge from the facility with return anticipated. Review of the discharge Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #35 had an unplanned discharge from the facility with return anticipated. Interview on 09/05/24 at 10:27 A.M. with the Director of Nursing (DON) confirmed Resident #35 had been hospitalized on [DATE] and 06/24/24 and returned to the facility following treatment in the hospital. The DON confirmed the local Ombudsman office should be notified of all facility-initiated transfers and discharges from the facility. The DON confirmed the facility did not have any evidence the local Ombudsman had been notified of hospitalization s or discharges. 31404 2. Record review of Resident #23 revealed an admitted [DATE] with pertinent diagnoses of, fracture of unspecified part of neck of left femur, benign neoplasm of cerebral meninges, pick's disease, dementia with severe mood disturbance, anxiety disorder, seizures, atrial fibrillation, major depressive disorder, mood disorder with depressive features, anxiety disorder, and insomnia. Review of the 06/07/24 quarterly Minimum Data Set (MDS) assessment revealed the Resident was rarely or never understood. The Resident did not use mobility devices and wandered one to three days during the look back period. The Resident was dependent for eating, oral hygiene, toileting, shower, upper body and lower body dressing, personal hygiene, rolling left and right, sit to lying, and lying to sitting. She was independent in walking up to 150 feet. The Resident was always incontinent of bladder and frequently incontinent of bowel. Review of the electronic medical record Minimum Data Set (MDS) tab revealed the Resident was discharged on [DATE] and returned on 08/22/24. The Resident was also discharged on [DATE] and returned 08/30/24. Interview with the Director of Nursing (DON) on 09/05/24 at 2:00 P.M. revealed Resident #23 went out to the hospital on 08/21/24 and 08/29/24. The DON stated she was unable to provide evidence the Ombudsman was notified of Resident #23 transfer on those dates. Review of the facility policy, Transfer or Discharge Notice, undated, revealed the policy stated, a copy of the (transfer) notice is sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative.

Based on record review, staff interview, review of bed hold notices, and facility policy review, the facility failed to notify two residents (Residents #35 and #23) of the number of bed hold days each resident had remaining upon being transferred to the hospital from the facility. The deficient practice affected two residents (Residents #35 and #23) of three reviewed for hospitalization s. The facility census was 39. Findings Include: Review of the medical record for Resident #35 revealed and initial admitted on 08/08/23 and a readmitted on 04/23/24. Medical diagnoses included congestive heart failure, chronic obstructive pulmonary disease, and progressive systemic sclerosis. Review of the clinical census for Resident #35 revealed the resident was hospitalized on [DATE] and 06/24/24. Review of the discharge Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #35 had an unplanned discharge from the facility with return anticipated. Review of the discharge Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #35 had an unplanned discharge from the facility with return anticipated. Review of the bed hold notices dated 04/14/24 and 06/24/24 revealed the number of bed hold days Resident #35 had remaining at the time of each transfer to the hospital was not included on either of the bed hold notices. Interview on 09/05/24 at 10:27 A.M. with the Director of Nursing (DON) confirmed bed hold notices should indicate how many bed hold days a resident had remaining. The DON confirmed the bed hold notices for Resident #35's hospitalization s did not include the number of bed hold days the resident had remaining at the time of each transfer to the hospital. 31404 2. Record review of Resident #23 revealed an admitted [DATE] with pertinent diagnoses of, fracture of unspecified part of neck of left femur, benign neoplasm of cerebral meninges, pick's disease, dementia with severe mood disturbance, anxiety disorder, seizures, atrial fibrillation, major depressive disorder, mood disorder with depressive features, anxiety disorder, and insomnia. Review of the 06/07/24 quarterly Minimum Data Set (MDS) assessment revealed the Resident was rarely or never understood. The Resident did not use mobility devices and wandered one to three days during the look back period. The Resident was dependent for eating, oral hygiene, toileting, shower, upper body and lower body dressing, personal hygiene, rolling left and right, sit to lying, and lying to sitting. She was independent in walking up to 150 feet. The Resident was always incontinent of bladder and frequently incontinent of bowel. Review of the electronic medical record Minimum Data Set (MDS) tab revealed the Resident was discharged on [DATE] and returned on 08/22/24. The Resident was also discharged on [DATE] and returned 08/30/24. Review of the bed hold notices dated 08/21/24 and 08/29/24 revealed there was no indication of the duration of the bed hold. The notices did not show how many bed hold days were remaining for Resident #23. Interview with the Director of Nursing (DON) on 09/05/24 at 2:00 P.M. revealed Resident #23 went out to the hospital on 08/21/24 and 08/29/24. The DON verified the bed hold notices for Resident #23 did not show how many bed hold days the resident had remaining. Review of the facility policy, Bed-Holds and Returns, undated, revealed the facility policy stated, Residents and/or representatives are informed (in writing) of the facility and state (if applicable) bed-hold policies. All residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave).

Based on staff interview and record review the facility failed to update the Preadmission Screening Resident Review (PASRR) documents when a resident received a new mental health diagnosis. This affected two (Resident #10, and #34) of four residents reviewed for PASRR. The facility census was 39. Findings include: 1. Record review of Resident #10 revealed an admitted [DATE] with pertinent diagnoses of, vascular dementia with mild agitation, obesity, gastroenteritis and colitis, low back pain, schizoaffective disorder, bipolar disorder, abdominal distension, hyponatremia, localized edema, major depressive disorder, seasonal allergic rhinitis, age related osteoporosis, paranoid schizophrenia, pneumocystosis, extrapyramidal and movement disorder, psychosis, hallucinations, anxiety disorder, delusional disorders, type two diabetes mellitus, cerebral amyloid angiopathy, gastro-esophageal reflux disease, hypertension, insomnia, and chronic obstructive pulmonary disease. Review of the 08/06/24 annual Minimum Data Set (MDS) assessment revealed the resident was moderately cognitively impaired and does not use any devices for mobility. The resident was independent with dressing and personal hygiene and was always continent of bladder and bowel. Review of the most recent PASRR for Resident #10 revealed the document was completed on 8/02/21. Review of the medical record on 09/03/24 at 1:43 P.M. revealed Resident #10 had a new diagnosis of paranoid schizophrenia dated 09/13/22. Interview with Social Services Designee #102 (SSD) on 09/04/24 at 11:00 A.M. verified this was Resident #10 most recent PASRR and she did not have diagnosis of paranoid schizophrenia updated. 37100 3. Resident #34 was admitted to the facility on [DATE]. Her diagnoses were cervicalgia, anxiety disorder, schizoaffective disorder, chronic obstructive pulmonary disorder, bipolar disorder, hyperlipidemia, drug induced subacute dyskinesia, hypertension, osteoarthritis, and personal history of irradiation. Review of her Minimum Data Set (MDS) assessment, dated 06/01/24, revealed she was cognitively intact. Review of Resident #34's PASRR document, dated 06/29/23, revealed under Section D, the document only had personality disorder listed as a mental health diagnosis. Review of Resident #34's diagnoses list, the following diagnoses should have been indicated/updated on her PASRR document: bipolar disorder, which was added to her diagnoses list on 06/23/23, schizoaffective disorder, which were added to her diagnoses list on 10/03/23, and anxiety disorder, which was added on 03/10/24. Interview with Director of Nursing (DON) on 09/04/24 at 2:52 P.M. confirmed the PASRR documents provided were the most up to date and confirmed all the diagnoses in Resident #34 medical records were not listed on her PASRR document. She confirmed she spoke about this with the social services director prior to giving the document to the surveyor, and they confirmed all the diagnoses were not listed.

Based on medical record review and staff interview, the facility failed to revise care plans when significant changes in the resident's condition occurred. This affected one (Resident #34) of 15 resident care plans reviewed. The census was 39. Findings Include: Resident #34 was admitted to the facility on [DATE]. Her diagnoses were cervicalgia, anxiety disorder, schizoaffective disorder, chronic obstructive pulmonary disorder, bipolar disorder, hyperlipidemia, drug induced subacute dyskinesia, hypertension, osteoarthritis, and personal history of irradiation. Review of her Minimum Data Set (MDS) assessment, dated 06/01/24, revealed she was cognitively intact. Review of Resident #34's current physician orders revealed she was not on hospice care at that time. Review of her previous/discontinued physician orders found she was discharged from hospice care on 02/23/24. Review of Resident #34's nutritional notes, dated 08/15/24, revealed a recommendation from the dietitian to decrease her chocolate/strawberry milk intake recommendation from eight ounces to four ounces due to her significant weight increase. Review of Resident #34's current physician orders revealed she was ordered to have four ounces of chocolate/strawberry milk. Review of Resident #34's current care plans revealed she had a care area related to Nutrition/Dehydration. The care area for this care plan stated, the resident has nutritional problem related to diagnoses, mechanically altered diet, varied intakes, significant weight loss, inadequate meal intakes, poor supplement acceptance, medications with potential side effects, and swallowing difficulty; requests texture upgrades; admit to Hospice (11/09/23). The current interventions included: honor comfort care desires per hospice protocol and add eight ounces chocolate or strawberry milk with all meals as ordered. Interview with Director of Nursing (DON) on 09/04/24 at 2:55 P.M. confirmed Resident #34 was no longer on hospice services since February 2024. Interview with Dietitian #400 on 09/05/24 at 10:30 A.M. confirmed Resident #34 graduated from hospice in February 2024 due to improved health conditions, which included gaining weight. She confirmed her nutritional care plan should have reflected that. She also confirmed she made the recommendation on 08/15/24 to reduce her chocolate/strawberry milk intake from eight ounces to four ounces due to her significant weight gain. She also confirmed the care plan interventions should have been updated to reflect the current order.

Based on observation, staff interview, and resident record review, the facility failed to ensure the care planned assistance devices were properly placed to prevent falls for one (Resident #89) of three reviewed for accident hazards. The census was 39. Findings Include: Review of the medical record for Resident #89 on 09/03/24 at 9:58 A.M. revealed an admitted [DATE] with a diagnosis of atherosclerotic heart disease of native coronary artery. Review of a skilled nurse's note dated 09/01/24 at 10:09 P.M. revealed Resident #89 had a history of falls with multiple falls within the last six months. Review of the baseline careplan dated 09/01/24 at 10:14 P.M. revealed documented fall interventions including: Non-skid footwear, parameter mattress, bed in low position, and mattress to floor. Review of a nurse's note dated 09/02/24 at 5:35 A.M. revealed that the nurse was alerted by an aide that Resident #89 was found laying on the floor by his bed on his back. Observations on 09/03/24 at 9:58 A.M. and 1:42 P.M., and again on 09/04/24 at 9:51 A.M. accompanied by the Director of Nursing (DON) revealed Resident #89 in bed wearing black sports socks without non-skid tread, without a parameter mattress in place, without the bed in low position, and no mattress on the floor. Interview with the Director of Nursing (DON) on 09/04/24 at 9:51 A.M. confirmed that the care planned interventions to prevent falls for Resident #89 were not in place.

Based on record review, staff interview, and facility policy review, the facility failed to ensure Bilevel Positive Airway Pressure (BiPAP) (a machine that helps to push air into your lungs) settings were included in the physician order for one resident (Resident #35). The deficient practice affected one resident (Resident #35) of one reviewed for respiratory care. The facility census was 39. Findings Include: Review of the medical record for Resident #35 revealed and initial admitted on 08/08/23 and a readmitted on 04/23/24. Medical diagnoses included congestive heart failure, chronic obstructive pulmonary disease, secondary pulmonary arterial hypertension, and progressive systemic sclerosis. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #35 had intact cognition and scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #35 required partial to moderate assistance with tub transfers and showering but was independent with other Activities of Daily Living (ADLs). Resident #35 received oxygen therapy and used a non-invasive mechanical ventilator. Review of the physician orders dated August 2024 revealed Resident #35 had an order for a Continuous Positive Airway Pressure (CPAP) machine with home settings to be on at night (HS) and off in the morning (AM) every night shift. The order was dated 11/06/23. Review of the care plan, revised 08/22/24, revealed Resident #35 had an altered respiratory status. Interventions included CPAP with home settings on at HS and off in AM. Interview on 09/04/24 at 2:55 P.M. with Resident #35 revealed the resident used a Bilevel Positive Airway Pressure (BiPAP) machine at night as well as when needed for shortness of breath and difficulty breathing. The resident did not have or use a CPAP machine. Resident #35 stated the machine was set up for her and she did not know what settings were supposed to be used for the machine. Interview on 09/05/24 at 10:27 A.M. with the Director of Nursing (DON) confirmed Resident #35 used a BiPAP machine, not a CPAP machine at night. The DON stated the settings for the BiPAP machine should be included in the physician's order. The DON confirmed the physician's order only indicated home settings and did not provide what the specific setting for the machine should be. Interview on 09/05/24 at 10:37 A.M. with Licensed Practical Nurse (LPN) #100 revealed Resident #35's BiPAP machine was set up for her at home prior to being admitted to the facility. LPN #100 confirmed she did not know what the specific settings for the machine were supposed to be. Review of the facility policy, Verbal Orders, undated, revealed the policy stated, Verbal orders are those given to the nurse by the physician in person or by telephone, however, are not written by the physician in the medical record. Repeat any prescribed orders back to the physician or health care provider. Use clarification questions to avoid misunderstandings. Enter the order into the medical record manually or electronically. Write T.O. (telephone order) or V. O. (verbal order), including date, time, name of the resident, the complete order; and sign the name of the physician or health care provider and nurse or sign off the electronic order as per the software system guidelines.

Based on medical record review, staff interview, and facility policy review, the facility failed to obtain proper parameters for as needed pain medications. This affected two (Residents #34 and #29) of five residents reviewed for unnecessary medications. The census was 39. Findings Include: 1. Resident #34 was admitted to the facility on [DATE]. Her diagnoses were cervicalgia, anxiety disorder, schizoaffective disorder, chronic obstructive pulmonary disorder, bipolar disorder, hyperlipidemia, drug induced subacute dyskinesia, hypertension, osteoarthritis, and personal history of irradiation. Review of her Minimum Data Set (MDS) assessment, dated 06/01/24, revealed she was cognitively intact. Review of Resident #34's medical records revealed her physician orders included Oxycodone (opioid medication for pain) five milligrams (mg) every eight hours as needed for pain and Acetaminophen (analgesic medication to relieve pain) 650 mg every four hours as needed for pain. Review of his physician orders, Medication Administration Record (MAR), and care plan revealed there were no parameters as to what pain level should be present to administer each medication. Review of Resident #34's MARs, dated May 2024 to August 2024, revealed she was administered as needed Acetaminophen 16 different times when her pain level was six and above. Also, from May 2024 to July 2024, she was administered Oxycodone 15 times when her pain level was five or below. Review of Resident #34's current care plan revealed the facility was to administer the scheduled and as needed pain medication per physician orders. Interview with Director of Nursing (DON) on 09/04/24 at 2:55 P.M. confirmed parameters should be listed on the as needed pain medications. She confirmed they will ask the resident what level of pain they have, and they will offer the lower strength (Acetaminophen) if the resident's pain level was five or below. If the resident stated they do not want the lower strength pain medication, but want the higher strength medication (Oxycodone), they will administer the higher strength medication anyway. The DON confirmed the typical parameters for as needed pain medications was pain level one to five, offer to lower strength medication and if it's pain level six to ten, they will offer the higher strength medication. 41266 2. Review of the medical record for Resident #29 revealed and original admitted on 10/18/21 and a readmitted on 08/14/22. Medical diagnoses included other chronic pain, type II diabetes mellitus, gastric ulcer, paroxysmal atrial fibrillation, rheumatoid arthritis, and osteoarthritis. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #29 had intact cognition and scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #29 required varied amounts of assistance from staff to complete Activities of Daily Living (ADLs) which ranged from independence with eating to dependence on staff for showering, dressing, and shower transfers. Resident #29 received scheduled and as needed (PRN) pain medications. The resident almost constantly had pain. The resident reported a pain level of eight out of ten, where ten was the worst pain level possible. Review of the Medication Administration Records (MAR) dated July 2024 and August 2024 revealed Resident #29 had the following orders: Acetaminophen Tablet 500 mg with instructions to give one tablet by mouth every six hours as needed (PRN) for pain. Please add corresponding number for non-pharmacological interventions dated 12/14/22 and Oxycodone Hydrochloride (HCl) oral tablet 5 mg with instructions to give 0.5 tablet by mouth every six hours PRN for pain dated 05/10/24. There were no parameters added to the physician orders for Resident #29's PRN pain medications. Review of the MAR dated July 2024 revealed the PRN Acetaminophen medication had not been administered to Resident #29 at all in the month of July. The PRN Oxycodone HCl medication was administered 32 times in the month of July for pain levels which ranged from four to nine on a scale from one to ten, where ten is the worst possible pain. There was no evidence of any non-pharmacological interventions being attempted prior to administering the PRN pain medication to Resident #29. The medication was noted to be effective, except 07/01/24 at 3:51 A.M. and 07/07/24 at 2:44 P.M. where it was marked ineffective. Review of the MAR dated August 2024 revealed PRN Acetaminophen medication had not been administered to Resident #29 at all in the month of August. The PRN Oxycodone HCl medication was administered 15 times in the month of August for pain levels which ranged from five to ten, where ten is the worst possible pain. There was no evidence of any non-pharmacological interventions being attempted prior to administering the PRN pain medication to Resident #29. The medication was noted to be effective, except on 08/01/24 at 2:17 P.M. and 08/02/24 at 2:55 A.M. where it was marked as ineffective. There was no evidence the physician was notified on 07/01/24, 07/07/24, 08/01/24, or 08/02/24 when Resident #29's PRN Oxycodone HCl medication was marked ineffective. Interview on 09/05/24 at 10:46 A.M. with Licensed Practical Nurse (LPN) #100 revealed there were no parameters included in the physician's orders for any PRN pain medications. LPN #100 stated based on her nursing judgement as well as any non-verbal indicators of pain, she would administer PRN Acetaminophen for pain levels of one to five and would administer Oxycodone HCl for pain levels of six or higher (on a scale from zero to ten, where ten was the worst possible pain). LPN #100 stated non-pharmacological interventions should also be documented on the MAR. LPN #100 stated if a pain medication was ineffective for a resident, the physician should be notified in order to gain further instructions on how to proceed with addressing a resident's pain. Interview on 09/05/24 at 11:26 A.M. with the Director of Nursing (DON) confirmed the above findings indicated including Resident #29's physician was not notified on days the resident's PRN pain medications were marked as ineffective, there was no evidence of any non-pharmacological interventions attempted prior to administering the medication, and there were no parameters included in the physician orders for the PRN pain medications. The DON stated the nursing staff should administer Acetaminophen for lower levels of pain and Oxycodone HCl for higher levels of pain. Review of the facility policy, Administering Pain Medications, undated, revealed the policy stated, when opioids are used for pain management, the resident is monitored for medication effectiveness and adverse effects. Conduct a pain assessment with the resident. Evaluate and document the effectiveness of non-pharmacologic interventions. Administer pain medications as ordered.

Based on record review, staff interview, and facility policy review, the facility failed to administer blood pressure medication as ordered to one resident (Resident #29). The deficient practice affected one resident (Resident #29) of five reviewed for unnecessary medications. The facility census was 39. Findings Include: Review of the medical record for Resident #29 revealed an original admitted on 10/18/21 and a readmitted on 08/14/22. Medical diagnoses included essential primary hypertension, paroxysmal atrial fibrillation, morbid obesity, type II diabetes mellitus without complications, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #29 had intact cognition and scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #29 required varied amounts of assistance from staff to complete Activities of Daily Living (ADLs) which ranged from independence with eating to dependence on staff for showering, dressing, and shower transfers. Review of the Medication Administration Records (MAR) dated August 2024 revealed Resident #29 had an order for Losartan Potassium Tablet 50 milligrams (mg) with instructions to give one tablet by mouth one time a day for hypertension (HTN) and hold if systolic blood pressure (SBP) was less than 100. Review of the Medication Administration Record (MAR) dated August 2024 revealed Losartan Potassium medication was held on 08/24/24, 08/25/24, 08/26/24, and 08/27/24. Resident #29's blood pressures were 110/62, 121/74, 108/68, and 110/62. Interview on 09/05/24 at 11:26 A.M. with the Director of Nursing (DON) confirmed Resident #29's Losartan Potassium medication was held on the above dates. The DON confirmed Resident #29's blood pressure readings were within the physician ordered parameters and therefore, the medication should have been administered to the resident. A policy related to following physician orders was requested at the time of the survey. A policy titled, Verbal Orders, undated, was provided by the facility. However, the policy does not address administering medications according to the physician order.

Based on observations, staff interview, and facility policy review, the facility failed to ensure pureed food items were prepared at an appropriate texture prior to surveyor intervention for one resident (Resident #17). The deficient practice affected one resident (Resident #17) of one who had a physician ordered pureed diet. The facility census was 39. Findings Include: Observation on 09/04/24 at 10:50 A.M. of pureed food items with [NAME] #120 revealed the cook added one breaded pork chop and 1/4 cup of hot water to a blender and started blending. Another 1/4 cup of hot water was added to the blender. At 10:57 A.M., [NAME] #120 chopped another breaded pork chop on a cutting board and added it to the blender. Another 1/2 cup of hot water was added to the blender and continued blending. At 11:00 A.M., [NAME] #120 stopped the blender. [NAME] #120 scraped the sides of the blender and poured the pureed pork chops into a small Styrofoam container. This surveyor observed the pureed pork chops to be visibly stringy and watery. Interview on 09/04/24 at 11:02 A.M. with [NAME] #120 confirmed she felt the pureed pork chops were an appropriate texture for serving to one resident (Resident #17) who had an ordered pureed diet. This surveyor requested to taste the pureed pork chops if she was ready to serve them to the resident. [NAME] #120 again confirmed she was ready to serve them and handed this surveyor a clean spoon. This surveyor tasted the pureed pork chops and found them to still be stringy with small gristly chunks left on tongue. The pureed pork chops were also bland and watery. [NAME] #120 confirmed the recipe for breaded pork chops stated to add 1/4 cup of hot water per pork chop but she doubled it and had added 1/2 cup of hot water per pork chop. [NAME] #120 confirmed she added approximately one cup total of hot water to the pureed pork chops. [NAME] #120 confirmed the pureed pork chops were watery and bland with not much flavor. Interview on 09/04/24 at 11:04 A.M. with [NAME] #120 revealed pureed food items should not have any shreds of meat and should be mushy or as smooth as possible. [NAME] #120 tasted the pureed pork chops and confirmed they were not an appropriate texture to serve to any residents and she would need to continue to blend the food item before safely serving it to the residents. Interview on 09/04/24 at 11:45 A.M. with Dietary Manager (DM) #106 revealed after attempting to puree the breaded pork chops with [NAME] #120 again, the pork chops would not reach an appropriate texture and DM #106 substituted the breaded pork chops for pureed chicken breasts. Review of the recipe for breaded pork chop revealed to measure one cooked chop and 1/4 cup water for each pureed serving needed. Review of the facility policy, Puree Food Preparation, undated, revealed the policy stated, the policy of this facility to provide puree food that has been prepared in a manner to conserve nutritive value, palatable flavor, and attractive appearance. Puree means that all food has been ground, pressed and/or strained to a consistency of a soft, smooth thick paste similar to a thick pudding. If the food item requires chewing, it will be excluded from the puree diet and prepared in a way that preserves vitamins and a minimum loss of nutrients.

Based on observations, staff interviews, review of the facility's policy, review of the Centers for Disease Control and Prevention (CDC) guidance, and record reviews, the facility failed to appropriately wear Personal Protective Equipment (PPE) during the COVID-19 pandemic, and failed to perform appropriate hand hygiene during wound care for Resident #12 and medication administration for Resident #11. This had the potential to affect all 37 residents who resided in the facility. Findings include: 1. Review of Resident #12's medical record revealed an original admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . coli infection of gastrointestinal tract, chronic kidney disease, and diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/13/21, revealed Resident #12 had clear speech, always understood others, always made himself understood and had no cognitive deficits. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Apply Hydrogel to wound bed, and cover with ABD pad. Secure with tape to borders. Observation of Licensed Practical Nurse (LPN) #331 and #352 providing wound care to Resident #12's abdominal wound on 11/10/21 at 10:30 A.M. revealed supplies were gathered and Resident #12 was pre-medicated for pain and assessed for pain prior to beginning the treatment. LPN #331 removed the old, dirty bandage which had a scant/trace amount of purulent drainage observed on it. The old bandage was not dated or initialed. Resident #12 stated the bandage was changed yesterday. There were two circular wounds located on the residents abdomen. Both wound beds were covered 95% in slough and 5% granulation tissue. The slough was observed to be thick and yellow/gray in color. After the old bandage was removed, LPN #331 proceeded to change gloves and perform hand hygiene, she then cleansed the wound with gauze and normal saline. She did not change gloves or perform hand hygiene, and proceeded to apply hydrogel using a cotton tipped applicator, then covered the wound with an abdominal pad and secured it with tape. LPN #331 then proceeded to remove gloves, and perform hand hygiene. The old bandage and supplies were disposed of in the trash receptacle. Interview with LPN #331 and LPN #352 on 11/10/21 at 10:40 AM verified gloves were not changed and hand hygiene was not performed between cleansing the wound with normal saline and gauze and applying the new, clean dressing. 2. Observation upon entry to the facility on [DATE] at 8:05 A.M., State tested Nursing Assistant #341 was observed exiting room [ROOM NUMBER], which was on isolation precautions, without a mask or face shield in place. The mask was below the staff members chin during this observation. State tested Nursing Assistant #341 verified she did not have the appropriate PPE in place during this observation. Licensed Practical Nurse #330 also was observed in the main nursing hall and was not wearing her mask appropriately as it was also under her chin and not on her face. Licensed Practical Nurse #330 verified she was not wearing her mask appropriately. Review of the Centers for Disease Control and Prevention (CDC) guidance titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel during the COVID-19 Pandemic, dated 09/10/21, revealed source control and physical distancing are recommended for everyone in a healthcare setting. Source control refers to use of respirators and well-fitting facemasks or cloth masks to cover a person's mouth and nose to prevent the spread of respiratory secretions when they are breathing, talking, sneezing, or coughing. 3. Observation of medication administration on 11/08/21 at 7:20 A.M. revealed Licensed Practical Nurse (LPN) #303 preparing to administer oral medications to Resident #11. LPN #303 was observed to spill the medications from the medication cup on the floor of Resident #11's room, by mistake. LPN #303 picked up the medications with her bare hands, threw them away, and went to the medication cart and pulled new medications for Resident #11, without washing her hands. LPN #303 then returned to Resident #11 and administered the medications without washing her hands. Interview on 11/08/21 at 7:25 A.M. with LPN #303 confirmed she did not wash her hands following picking the medication cup from the floor and administering new medications to Resident #11. Review of the facility's policy titled Medication Administration, revised 2019, revealed nurses should wash hands prior to administering medications.

Based on observation, resident and staff interview, review of the facility's policy, and record review, the facility failed to provide appropriate monitoring and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . This affected two (#26 and #234) of three residents reviewed for medications. The facility identified 10 residents on anticoagulation therapy. The facility identified census was 37. Findings include: 1. Review of the medical record for Resident #26 revealed an admitted [DATE]. Resident #26's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment, dated 10/07/21, revealed Resident #26 was receiving an anticoagulant medication. The MDS assessment was silent for any skin conditions. Review of the physician orders for Resident #26, dated 10/01/21, revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record for Resident #26 revealed skin assessments to be completed on 09/30/21, 10/07/21, 10/14/21, 10/21/21, 10/28/21, and 11/04/21, and all of the skin assessments to be silent for bruising or any other skin concerns. Review of the plan of care, dated 10/26/21, revealed Resident #26 to be on anticoagulant therapy related to [CONDITION(S)]. Interventions listed were to inspect skin daily and report abnormalities to nurse and physician. Resident #26 was also care planned for actual/potential impairment to skin integrity, dated 10/01/21. Interventions included skins weeps weekly per facility protocol. The plan of care for Resident #26 was updated on 11/08/21 (after surveyor intervention) to include scattered bruising/petechiae, and no new interviews were implemented. Observation and interview on 11/07/21 at 9:19 A.M. with Resident #26 revealed large, very dark red bruises on the inside of his right and left arms. The largest bruises on the insides of Resident #26's arms measured approximately five centimeters (cm) by six cm each. Additional smaller bruises were noted to be scattered throughout the inside of both of Resident #26's arms. Resident #26 revealed that he bruises very easily and always has bruises and he was not sure how long they have been there. Resident #26 shared that he couldn't remember if any of the nurses or aides asked about the bruises. Interview on 11/08/21 at 5:55 A.M. with Licensed Practical Nurse (LPN) #353 revealed the facility policy was to monitor and document bruising on weekly skin assessments. Interview on 11/08/21 at 12:00 P.M. with the Director of Nursing (DON) confirmed the presence of the bruising and petechiae on the arms of Resident #26 and that the medical record was silent for any mention of bruising or petechiae for Resident #26. Review of the facility's undated policy titled Skin Assessment revealed skin assessments should be completed on admission and weekly thereafter, noting any skin conditions such as redness, bruising, and skin tears. 2. Review of the medical record for Resident #234 revealed an admitted [DATE]. Resident #234's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS assessment, dated 10/20/21, revealed Resident #234 was receiving an anticoagulant medication. Review of the physician orders, dated 10/18/21, revealed orders for [MEDICATION(S)] 2.5 mg twice daily. No physician order was present to monitor for side effect of anticoagulant therapy. Review of the plan of care for Resident #234 did not reveal any care plan related to anticoagulant therapy or monitoring for adverse effects of anticoagulant therapy. Review of the nurse progress notes from 09/30/21 to 11/07/21 for Resident #234 revealed the progress notes to be silent for nose bleeds, Interview on 11/07/21 at 9:34 A.M. with Resident #234 revealed her nose bleeds a lot since starting the anticoagulation therapy. Resident #234 shared that the nurses were aware. Resident #234 shared she last had a nose bleed the night before last but that she got it to go away without staff help. Interview on 11/09/21 at 2:02 P.M. with State tested Nurse Aide (STNA) #342 revealed Resident #234 has had a couple of minor nose bleeds since she has been the facility. STNA shared that she did report the nose bleeds to a nurse, but could remember which nurse or when. Interview on 11/09/21 at 11:50 A.M. with the DON confirmed the medical record for Resident #234 was silent for a care plan or any interventions to monitor for side effects of anticoagulation therapy, and contained no mention of nose bleeds. The DON confirmed that facility policy was to monitor for adverse effects for those residents being treated with anticoagulation medications. Review of the facility's policy titled Medication Administration, revised 2019, revealed the nurse should report and document any adverse side effects of medications.

Based on observation, medical record review, staff, family and physician interviews, review of the Ohio Board of Dietetics (OBD) Standards of Practice in Nutrition Care, review of the National Pressure Ulcer Advisory Panel (NPUAP) treatment of [REDACTED]. (#52). Additionally, the facility failed to provide sufficient nutritional support for a second resident (#60) which resulted in a severe unplanned weight loss of 7.4 percent (%) in less than a one month period of time. This resulted in Immediate Jeopardy for two (#52 and #60) of six residents reviewed for nutrition. The facility identified a total of eight residents as being at nutritional risk. On 02/25/15 at 3:20 P.M., the Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON) #2 were notified Immediate Jeopardy began on 02/03/15 when Resident #52 experienced a severe weight loss of 5.8% in a one month period of time and Registered Dietitian (RD) #1 failed to reassess the nutritional needs of the resident, failed to review and revise the plan of care, and failed to identify the resident was not receiving a previously ordered physician prescribed nutritional supplement. In addition, Resident #52's pressure ulcer declined to a Stage IV pressure ulcer (Full thickness skin loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed and often includes undermining and tunneling) and a subsequent [DIAGNOSES REDACTED]. Furthermore, Resident #60 was placed in Immediate Jeopardy on 02/05/15 when the RD #1 failed to assess the resident's caloric, protein, and fluid needs, and the resident experienced a severe weight loss of 12.4 pounds in one month. The Immediate Jeopardy was removed on 02/27/15 when the facility's two newly contracted registered dietitians (#3 and #5) began conducting on-site nutrition screenings and assessments, including recommendations for all current residents, and the facility implemented the following corrective actions: · On 02/25/15, the facility administrator directed their contract registered dietitian (#1) to assess all resident's nutritional needs with weight loss and/or wounds weekly and review and revise any current plans of care in place for all residents reviewed. · On 02/25/15, RD #1 reassessed Resident #52 at 3:25 P.M. and new interventions included to discontinue previous supplement orders and start [MEDICATION NAME] and a protein drink at breakfast and dinner, a Health Shake with lunch and 8:00 P.M. medication pass, and to offer double servings of protein at meals. Calorie counts were initiated for three days, and would be calculated with subsequent follow-up on 03/04/14. · On 02/25/15, Resident #60 had a pre-[MEDICATION NAME] laboratory test drawn and results were 26.8 which were within normal limits (the normal range is 17.6-36.0). · On 02/26/15, the Administrator and DON met with the two current contract dietitians (RD #1 and RD #7) to discuss their responsibilities for assessment, care planning, and interventions for residents at risk for weight loss. They reviewed the Federal Regulation at Data Tag F325 (CFR 483.25 (i) Nutrition) and the interpretive guidelines, including the need to calculate calorie and protein requirements. Copies of F325 and the interpretive guidelines were provided to the dietitians. · On 02/26/15, all residents were reassessed using a standardized mini-nutritional screening tool. Registered Dietitians #1 and #7 calculated individualized protein and calorie requirements for Residents #15, #22, #50, #52, and #60 who were reviewed for nutritional risk. Nutritional care plans and interventions were evaluated against protein and calorie requirements and recommendations were made accordingly. Physicians were notified of current nutritional goals and interventions. Nutritional orders were obtained to begin a three day calorie-count monitoring. The consultant dietitian would review the results of all mini-nutritional screening tools with the DON on 02/27/15. · On 02/26/15, an engagement agreement was signed to secure the services of a new consulting dietitian firm effective 02/26/15. The consulting dietitian was scheduled to begin the on-site assignment on 02/27/15. The consulting dietitian would perform duties including, but not limited to, review of existing nutritional assessments and care plans, participate in interdisciplinary review of residents at nutritional risk, make recommendations for on-going nutritional services, and participate in quality assurance and performance improvement monitoring. · On 02/26/15, a nutritional-at-risk meeting was scheduled to occur on 02/27/15 and then weekly for four weeks. The meeting would be conducted by an interdisciplinary team consisting of a nursing representative, the DON, administrator and consultant dietitian. All residents identified at high nutritional risk, including those with significant weight loss, would be audited by the interdisciplinary team. The team, at a minimum, would review as applicable: dietary orders/plan, weight changes, laboratory values, food/fluid intake, wound/skin condition, and functional change/decline. All findings would be shared with the medical director and quality assurance committee. · On 02/27/15, two newly contracted registered dietitians (#3 and #5) began conducting on-site nutrition screenings and assessments, including recommendations for all residents residing in the facility. · On 02/27/15, mandatory nursing staff meetings began and would be completed by 03/02/15 with education provided by the DON. In-service topics included: o Immediate notice to the registered dietitian of any changes in condition or new orders pertaining to a resident's nutrition. o Importance of being aware of diet orders and restrictions o Responsibility of nurses to pass dietary supplements o Need to assure timely response from physician when faxing nutritional orders/requests o Need to follow-up on registered dietitians orders (e.g. Health Shakes) promptly · On 02/27/15, the DON, consultant dietitian, or designee will conduct weekly audits of five residents to evaluate effectiveness of mandatory education. Audits will be performed weekly for four weeks, monthly for three months, and as directed by the quality assurance committee thereafter. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as all staff had not been in-serviced on communication, notification, and provision of nutritional care and services to all residents, and the facility was in the process of implementing weekly audits to monitor for on-going compliance. Findings include: 1. Medical record review revealed Resident #52 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The comprehensive Minimum Data Set (MDS) assessment 3.0 dated 11/09/14 indicated the resident's cognition was moderately impaired. The resident was also assessed as requiring extensive physical assistance of two persons for bed mobility and transferring, was independent with tray set up assist for meals, had a Stage III pressure ulcer, no weight loss and the resident was on a mechanically altered, therapeutic diet. The nutritional plan of care was revised on 11/13/14 and documented the resident was compliant with drinking a high protein, high calorie nutritional supplement (Resource) three times daily. The nutritional goal was for the resident to maintain adequate nutritional status as evidenced by maintaining weight within baseline (undefined), no signs and symptoms of malnutrition and consuming at least 75% of meals daily through the next review date. The interventions included to continue with the nutritional supplement three times daily, revised on 01/29/15, to continue the protein liquid supplement twice daily and start a nutritional supplement [MEDICATION NAME] once daily (a product that is an [MEDICATION NAME]-intensive powder formulated for patients to promote chronic wound healing). Review of Resident #52's Medication Administration Record [REDACTED]. Review of Resident #52's nutritional progress note, dated 11/20/14, revealed RD #1 received a consult for the resident due to a Stage III pressure ulcer wound not healing. The resident was receiving Resource, four ounces three times daily (TID), and refused the [MEDICATION NAME]. The recommendation was to continue Resource TID and to add 30 milliliters (ml) of a liquid protein in the drink of choice daily, and a multivitamin (MVI) with zinc to promote wound healing. There was no documented evidence that RD #1 assessed the resident's estimated caloric and protein needs. Review of Resident #52's physician telephone orders dated 11/20/14 documented to actually discontinue the Resource supplement and to add liquid protein 30 ml in a drink of choice twice daily. Further record review revealed there was no documented evidence RD #1 was notified of the supplement changes and a progress note on 11/20/14 documented a phone message was left for a family member regarding the supplement being changed. There was no documented evidence in the nursing notes that the family requested the supplement be discontinued due to cost or resident refusal. Review of a facsimile form to the physician on 11/20/14 revealed, RD #1 recommended starting a MVI with zinc. The physician responded twenty days later on 12/11/14 and ordered the MVI with zinc to start. Review of Resident #52's MAR indicated [REDACTED]. Review of Resident #52's nutritional progress note dated 12/11/14 revealed the resident's wound had worsened from a Stage III to a Stage IV. RD #1 noted the resident's intake of the liquid protein twice daily was 100% acceptance and recommended to add a MVI. RD #1 did not reassess the nutritional caloric and protein needs of the resident nor revise the plan of care at that time. Review of Resident #52's medical record revealed physician orders dated 12/31/14 for a pre-[MEDICATION NAME] laboratory test to be completed but there was no documented evidence this was completed. Review of the resident's weight status on 01/06/15 was documented at 130.8 pounds and revealed the resident had lost 6.4 pounds in twenty two days which was a 4.7% weight loss. A physician's order dated 01/18/15 revealed another pre-[MEDICATION NAME] laboratory draw was ordered and the results were at a low level of 12.5 (the normal range is 17.6-36.0). The physician again ordered a dietary consult on 01/21/15. Review of Resident #52's dietary consult was completed eight days later on 01/29/15 which revealed the pre-[MEDICATION NAME] was low and the resident had a non-healing Stage IV wound. The resident was eating well (75-100% of most meals), drank 30 ml of a protein supplement twice daily, and was on a MVI with zinc. The note documented the resident had been non-compliant with a turning and repositioning schedule, refused the [MEDICATION NAME] in the past and other recommendations included [MEDICATION NAME] once daily in addition to current supplements and if the resident continued to refuse [MEDICATION NAME] then would recommend trying 30 ml liquid protein in a drink three times daily. The dietary consult did not include addressing the resident's nutritional caloric and protein needs nor did it address the weight loss. On 02/03/15, Resident #52 had further weight loss and triggered for an 11% significant weight loss in six months. Nine days later RD #1 noted a greater than 5% significant weight loss in one month and 11% in six months. RD #1 recommended a sugar free nutritional supplement Health Shake with the morning and night medication pass. Further review of the resident's medical record revealed [REDACTED]. Review of the physician's assessment on 02/14/15 revealed a new [DIAGNOSES REDACTED]. The results of the pre-[MEDICATION NAME] laboratory test on 02/16/15 revealed a further decline with a result of 8.8. On 02/18/15, the wound to the coccyx increased in size. On 02/11/15 the wound measured 1.7 centimeters (cm) in length x 0.6 cm width x 0.6 cm depth and on 02/18/15, it measured 1.8 cm in length x 0.6 cm width x 0.7 cm depth. As of 02/25/15 at 3:10 P.M., RD #1 had not reassessed the resident despite the new [DIAGNOSES REDACTED]. During an interview on 02/20/15 at 3:01 P.M. with RD #1 she verified she does not calculate estimated nutritional caloric and protein needs of any residents including Resident #52. RD #1 stated she waits until weight loss occurs or a pressure ulcer wound does not heal or worsens and then provides nutritional intervention. RD #1 stated that is how she knows if her interventions are not working. Interview with ADON #2 on 02/24/15 at 3:23 P.M. confirmed Resident #52's physician ordered pre-[MEDICATION NAME] laboratory work from 12/31/15 was not completed. Interview with RD #1 on 02/25/15 at 9:32 A.M. confirmed the recommendation from 11/20/14 for Resident #52 included to continue the Resource supplement three times daily. RD #1 stated she was not aware the supplement was discontinued including when she completed her progress note on 12/11/14. RD #1 verified that on 12/11/14, she did not review and revise Resident #52's nutritional care plan which identified the Resource supplement was supposed to still be in place. Further interview with RD #1 and the DON verified Resident #52 did not receive the recommended sugar free Mighty Shakes from 02/12/15 until 02/25/15 after surveyor intervention. RD #1 verified she identified Resident #52 had a significant weight loss and also an additional 0.3 pound weight loss since her last assessment on 02/12/15. RD #1 confirmed the resident's coccyx wound had increased in size and she had not reassessed the resident's nutritional caloric or protein needs and provided appropriate interventions. Interview with ADON #2 on 02/25/15 at 9:50 A.M. revealed the Resource supplement was discontinued from family request due to the cost of the supplement and the resident ' s refusal to consume it. Further interview with ADON #2 on 02/25/15 at 11:10 A.M. confirmed the MVI recommended by RD #1 on 11/20/14 was not ordered until 12/11/14 and could not explain why it took so long to get the physician order. Interview with Physician #3 on 02/25/15 at 12:30 P.M. revealed he added the new [DIAGNOSES REDACTED]. During the interview, Physician #3 stated Resident #52 had a recent weight gain and then verified he was not aware Resident #52 had actually been losing weight since January resulting in a significant weight loss in February. Interview with a family member of Resident #52 on 02/25/15 at 6:30 P.M. revealed the family did not refuse supplements for the resident and stated the facility informed them the resident was refusing the supplement by only taking a sip or two so they agreed to the Resource supplement being discontinued. The family member further indicated the facility did not talk to them about food alternatives and/or other nutritional supplements to try. Interview with ADON #2 on 02/26/15 at 11:50 A.M. confirmed the physician's standing order protocol included a MVI with zinc and could be initiated by the nurse if the dietitian recommended it. ADON #2 verified the facility did not start the MVI on 11/20/14 when the dietitian recommended it. Review of the facility's physician standing order protocol (undated) revealed that nursing may initiate nutritional supplements and vitamins for at risk residents per the RD, Speech Therapist (ST) and/or nutritional committee and the program included fortified meals, liquid supplements, two Cal three ounces four times daily, multivitamin one by mouth daily or stress tab with zinc one by mouth daily, Promod one scoop with food three times daily, and [MEDICATION NAME] one packet by mouth two times daily. Review of the Ohio Administrative Code 4759, Ohio Board of Dietetics Chapter 4759-2-01 definitions, revealed a nutritional assessment is the integrative evaluation of nutritionally relevant data to develop an individualized care plan. This data may include: nutrient intake; anthropometric measures; biochemical values; physical and metabolic parameters; socio-economic factors; current medical [DIAGNOSES REDACTED]. Review of the facility policy addressing the nutrition program (revised December 2008) revealed the facility would have an organized nutrition-related program. Direct care staff, assisted by the facility's clinical dietitian, would evaluate each individual's physical function, and psychosocial factors that affect eating and nutritional intake and utilization. A facility dietitian would help assess the nutritional needs and risk of all residents and patients in the facility, and help the facility assure that it provided appropriate meals and other nutritional interventions. Review of the facility's contract with clinical dietitians (dated July 2011) included that hospital clinical dietitians would formulate nutritional assessments and care plans on all new admissions, make resident visitations, and observe eating in rooms and dining areas, and monitor weight, skin, and hydration management programs. Review of the facility's Nutrition Impaired/Unplanned Weight Loss-Clinical Protocol policy (revised 2011) revealed the physician would review possible causes of anorexia or weight loss with the nursing staff and/or dietitian before considering interventions. The dietitian would estimate calorie, nutrient, and fluid needs, and with the physician, would identify whether the resident's current intake was adequate to meet his or her nutritional needs. Strategies to increase a resident's intake of nutrients and calories may include fortification of foods, increasing portion sizes at mealtimes, and providing between-meal snacks and/or nutritional supplementation. The physician and staff would closely monitor residents who had been identified as having impaired nutrition or risk factors for developing impaired nutrition. Monitoring may include evaluating the care plan to determine if the interventions are being implemented and whether they are effective in attaining the established nutritional and weight goals. Monitoring may also include recognizing the emergence of complications associated with certain interventions and recognizing the emergence of new risk factors; for example pressure ulcers, fever, or acute illness. Review of the National Pressure Ulcer Advisory Panel (NPUAP) 2014 prevention and treatment of [REDACTED]. Additionally, assessment should include a determination of the individual's caloric, protein and fluid requirements. 2. Resident #60 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. This resident had a physician's order for a heart healthy, no added salt diet. The resident was readmitted to the facility on [DATE] following a hospitalization for pneumonia with orders for health shakes to be added at meals. Review of the Nutritional Risk Assessment, dated 10/22/14, revealed Resident #60 was 5 foot 10 inches and weighed 168 pounds with a goal weight range of 160 to 188 pounds. The nutritional goal for this resident was to maintain his weight within his goal range. The assessment did not identify Resident #60's caloric, protein, and fluid needs. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a brief interview of mental status (BIMS) of 15, indicating the resident was cognitively intact. Resident #60 required extensive assistance of one staff for eating, he had no swallowing disorders, and no significant weight loss in the past 30 or 180 days. The MDS documented the resident had no dental problems. Review of the Care Area Assessment (CAA) for nutrition, dated 11/03/14, revealed the care area triggered due to Resident #60 being a new admission with cardiac dysfunction and [MEDICAL CONDITION]. The CAA revealed the goal was for the resident to maintain a weight within the goal weight range. The CAA revealed the intervention was to continue the cardiac diet and monitor the need for diet liberalization or supplement based on intakes and weight support. The assessment revealed the resident required staff assistance with meals due to difficulty feeding him-self related to tremors to both hands. Review of Resident #60's weights revealed on 12/02/14 his weight was 169.2 pounds, on 01/03/15 he weighed 171 pounds and on 01/22/15 he weighed 169 pounds. Review of the nurses' notes revealed on 01/28/15, the resident was admitted to the hospital with [REDACTED]. Review of Resident #60's Nutritional Risk assessment dated [DATE] revealed Resident #60 had a recent hospital stay with decreased food intakes while in the hospital. Resident #60 had a 4.1% weight loss in the last month and was just started on health shakes with meals since returning from the hospital. The assessment did not identify the resident's caloric, protein and fluid needs. The assessment made no reference to a need for increased frequency of obtaining this resident's weight. The assessment did not reveal if the food and nutritional supplement provided by the facility met the resident's nutritional needs. Review of Resident #60's plan of care (revised 02/05/15) revealed a nutritional problem related to the therapeutic diet secondary to cardiac dysfunction and [MEDICAL CONDITION] with interventions which required hands on assistance with meals due to tremors of both hands and arms. The plan of care revision included the resident had an unintentional 4.1% weight loss in the last month with a recent hospitalization and decreased meal intakes. The goals were for Resident #60 to maintain adequate nutritional status as evidenced by maintaining weight within goal weight range, no signs and symptoms of malnutrition, and consuming at least 75% of meals daily. The resident would be provided and served his diet as ordered. The registered dietitian would evaluate and make diet change recommendations as needed. There was no nutritional assessment or evaluation after 02/05/15 to assess the resident's continued weight loss. Further review of Resident #60's medical record revealed on 02/06/15, Resident #60 weighed 158.6 pounds. The resident lost 12.4 pounds in one month representing a severe weight loss of 7%. Observation of Resident #60 on 02/19/15 at 8:27 A.M. revealed the resident was in bed, looked thin wearing blue jeans that were very loose on him at his hips. The resident was observed at 12:25 P.M. and State tested Nursing Assistant (STNA) #61 was feeding him. The resident received a hot dog on a bun, green beans, lemonade, iced tea and canned peaches. The resident ate 80% of the food he was provided as the resident refused the green beans. Review of the menu revealed the resident did not receive mashed potatoes, gravy, and margarine per the planned menu. The resident did not receive other food items of similar nutritive value to replace the omitted foods. Taking the omitted foods into consideration the resident ' s intake would have been 50% of the calories for that meal (estimated utilizing a point per food item). STNA #61 confirmed the resident's intake was documented as 80%. Observation of the resident being weighed on 02/20/15 at 11:07 A.M. revealed Resident #60's current weight was 149.2 pounds. This represents a further severe weight loss of 9.4 pounds or a 5% weight loss in 14 days. Review of Resident #60's Medication Administration Record [REDACTED]. Resident #60's Health Shake intake ranged from 25% to 100% with an average intake of 50% of the Health Shake during this time period. On 02/03/15, 02/05/15, and 02/12/15 there was no documentation of how much of the Health Shake Resident #60 consumed. Based on the Harris Benedict formula (a method used to estimate an individual's daily caloric requirements), Resident #60's calculated estimated caloric and protein needs using the 01/30/15 weight of 161.2 (the weight RD #1 had available at the time of the assessment) revealed the resident required 2,506 calories per day and the resident's estimated protein needs were 73 to 88 grams per day (using 1.0 to 1.5 grams protein per kilogram of body weight). Review of the facility's estimated caloric and protein values of the daily menu (dated 02/23/15) revealed the facility's averages included 1,748 calories and 65 grams of protein. Each serving of the nutritional supplement (ordered three times per day) provided 200 calories and six grams of protein adding 600 calories and 18 grams of protein above what the menu provided for a total of 2,348 calories and 83 grams of protein. However, there was no way to determine how many calories and grams of protein the resident received from the food provided as the resident did not always receive all the items on the menu and no replacement was provided for the omitted food items. Resident #60's average intakes were documented as 50-100%. Interview with RD #1 on 02/20/15 at 3:10 P.M. revealed she was at the facility weekly and had not assessed Resident #60 since 02/05/15. RD #1 stated she did not recommend him for weekly weights and had no rationale for not doing so. RD #1 stated her protocol for weight loss was 2.5% or greater in one week or a significant weight loss, at which time RD #1 would look into it more. RD #1 stated she was only notified of residents requiring nutritional interventions when she came to the facility on Thursdays but she was not notified in between visits of residents who required nutritional interventions. RD #1 stated she had not re-evaluated Resident #60 since 02/05/15 and verified the facility did not notify her of Resident #60's weight loss. Interview with Resident #60 and his wife on 02/24/15 at 9:36 A.M. revealed he drinks some of the supplements but he does not finish them because he does not like them. After the first few sips of the supplement they taste bad to him. Resident #60's wife stated the facility told her Resident #60 had lost weight. The wife stated he had been in bed more since he had pneumonia, and he was not eating as well as he did before. The resident and his wife gave no reason for his decreased intake. Interview with Licensed Practical Nurse (LPN) #65 on 02/24/15 at 10:57 A.M. revealed either dietary staff or the nurse gives Resident #60 his health shake. LPN #65 stated "I check to see how much he drinks and document it. Resident #60 usually takes only a few drinks of the supplement. I do not think he wants the extra fluids, he drinks a ton of water for me." LPN #65 stated Resident #60 eats food better than he takes the supplement. Further interview with RD #1 on 02/25/15 at 9:32 A.M. confirmed there was no way to know what the resident ate with the facility's select menus so the percentage of the resident's intake could be of the full menu or just a few selected items. RD #1 verified she does not calculate calorie, protein, or fluid needs for the residents, including Resident #60. 3. Medical record review revealed Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #15's quarterly MDS assessment completed on 01/18/15 revealed the resident's cognition was severely impaired, the resident required extensive physical assistance with two people for bed mobility and transfers, limited physical assistance with one person for eating, and had one pressure ulcer. Review of Resident #15's nutritional plan of care dated 04/30/14 revealed the resident had a nutritional problem due to cardiac and endocrine dysfunction with [DIAGNOSES REDACTED]. The nutrition goal was for the resident to maintain adequate nutritional status as evidenced by maintaining weight within baseline, no signs or symptoms of malnutrition, and consuming at least 75% of meals. The nutrition interventions included a 2,000 milliliters (ml) fluid restriction, divided adaptive plate, obtain and monitor laboratory/diagnostic work as ordered, RD to evaluate and make diet change recommendations as needed, administer sugar free health shake twice daily with medication pass, continue MVI due to multiple wounds, and administer a nutritional supplement [MEDICATION NAME] in the resident's drink of choice daily. Review of the laboratory results for Resident #15 revealed on 11/20/14 the resident's serum [MEDICATION NAME] level (a test that measures the amount of this protein in the clear liquid portion of the blood was 3.0 g/dL (Normal 3.5-5.0 g/dL). Review of Resident #15's nutritional assessment dated [DATE] revealed the resident was on a carbohydrate consistent diet, 2,000 ml fluid restriction, had increased nutritional needs with a Stage III and Stage II pressure ulcer wound and the nutritional goals were for meal intakes to be greater than 75% for at least two meals and wound healing. The nutritional intervention was to continue with the current diet and supplements and to monitor wound status for the need for further supplementation. There was no documented evidence of any estimated calorie and/or protein needs calculated on this assessment. Review of Resident #15's nutrition progress note dated 01/29/15 revealed RD #1 recommended to add a nutritional supplement [MEDICATION NAME] in addition to health shakes twice daily due to a Stage III wound not improving for two weeks. This progress note did not evidence any documentation of the resident's estimated calorie or protein needs. On 02/20/15 at 3:01 P.M., interview with RD #1 verified she does not calculate estimated nutritional energy (calorie) and protein needs of any residents including Resident #15. RD #1 stated she waits until weight loss occurs or a pressure ulcer wound does not heal or worsens and then provides interventions. RD #1 stated that is how she knows if her interventions are not working. RD #1 provided the facility's average calories and protein the planned menus provided daily and it was an average of 1,748 calories and 65 grams of protein. RD #1 provided nutritional information on the sugar free mighty shakes which provided 200 calories and 7 grams of protein per carton (4 ounces) and the [MEDICATION NAME] which provided 25 calories and 4.5 grams of protein. Review of the NPUAP estimated energy needs for a resident with an existing pressure ulcer (30 to 35 calories pe

Based on observation, medical record review, review of the facility policy on pressure ulcers, review of the National Pressure Ulcer Advisory Panel (NPUAP) treatment of [REDACTED]. This resulted in actual harm when Resident #52's pressure ulcer worsened from a Stage III to a Stage IV, when the facility failed to implement preventative measures. This affected one (#52) of three residents reviewed for pressure ulcers. The facility identified two residents currently residing in the facility with pressure ulcers. The facility census was 39. Findings include: Review of Resident #52's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The comprehensive Minimum Data Set (MDS) assessment dated [DATE] indicated the resident's cognition was moderately impaired. The resident was also assessed as requiring extensive physical assistance of two persons for bed mobility and transferring, and had a Stage III pressure ulcer. Review of Resident #52's nutritional status note dated 11/20/14 revealed Registered Dietitian (RD) #1 received a consult for the resident due to a Stage III pressure ulcer wound not healing. The resident was receiving a nutritional supplement, Resource, four ounces three times daily (TID), and refused [MEDICATION NAME], also a nutritional supplement used to promote wound healing. The recommendation was to continue the Resource TID and add 30 milliliters (ml) of a liquid protein in the drink of choice daily, and a multivitamin (MVI) with zinc to promote wound healing. There was no documented evidence that RD #1 assessed the residents estimated energy and protein needs. Review of Resident #52's physician telephone orders dated 11/20/14 documented to actually discontinue the resource supplement and add liquid protein 30 ml in a drink of choice twice daily. Review of a fax form to the physician on 11/20/14 revealed RD #1 recommended starting a MVI with zinc. The physician responded 21days later on 12/11/14 and ordered the MVI with zinc to start. Review of Resident #52's Medication Administration Record [REDACTED]. Review of Resident #52's plan of care for skin, revised 12/10/14, revealed the resident was admitted to the facility with a pressure ulcer to the coccyx and was at risk for further altered skin integrity and potential for further pressure ulcer development related to impaired mobility, extensive assist with bed mobility task, episodes of incontinence, presence of lower extremity [MEDICAL CONDITION] and [DIAGNOSES REDACTED]. Slough or eschar maybe present on some parts of the wound bed and often includes undermining and tunneling) with undermining. The interventions included: to assist to turn and reposition at least every two hours, more often as needed or requested, monitor nutritional status, serve diet as ordered, monitor meal intake and record, obtain and monitor laboratory and diagnostic work as ordered and report results to the physician and follow-up as indicated, pressure reduction cushion to the wheelchair, and an air mattress to the bed. The interventions also included a liquid protein nutritional supplement in drink of choice, a MVI with zinc daily, and follow-up with the wound clinic. Review of Resident #52's wound/skin progress note dated 12/10/14 revealed the coccyx wound had worsened. The note documented this was probably due to recent illness and increased mobility concerns, since the resident had been in bed more often. The wound treatment was changed to cleanse with normal saline or water, apply Santyl, gauze pack and border foam, and change daily and as needed. Review of Resident #52's nutritional status note dated 12/11/14 revealed the resident's wound changed from a Stage III to a Stage IV. RD #1 noted the resident's intake of the liquid protein twice daily was 100 percent acceptance and recommended to add a MVI. RD #1 did not reassess the nutritional caloric and protein needs of the resident nor revise the plan of care at that time. Review of the physician assessment dated [DATE] noted Resident #52's coccyx wound was now a Stage IV pressure ulcer and the plan was to check the pre-[MEDICATION NAME] (can be used for monitoring nutritional status) and hemoglobin A1c (to examine glucose levels over a two to three month period and can be useful tool in judging the effectiveness of a treatment) tests. Review of Resident #52's medical record revealed physician orders dated 12/31/14 for the pre-[MEDICATION NAME] laboratory draw but it was never completed. Review of Resident #52's physician order dated 01/18/15 revealed another pre-[MEDICATION NAME] laboratory draw was ordered and the results were at a low level of 12.5 (normal range is 17.6-36.0). The physician ordered a dietary consult on 01/21/15. Review of Resident #52's dietary consult completed eight days later on 01/29/15 revealed the pre-[MEDICATION NAME] was low and the resident had a non-healing Stage IV wound. The resident was eating well (75-100% of most meals), drank 30 ml protein supplement in drink of choice twice daily, and was on a MVI with zinc. The note documented the resident had been non-compliant with turns and refused [MEDICATION NAME] in the past and would recommend [MEDICATION NAME] once daily in addition to current supplements, and if the resident continued to refuse [MEDICATION NAME] would then recommend trying 30 ml liquid protein in a drink three times daily. The dietary consult did not include addressing the resident's nutritional caloric and protein needs to promote wound healing. On 02/12/15, RD #1 documented the resident had greater than 5 percent (%) weight loss in the past month, greater than 10 % weight loss in six months, a Stage IV wound and recommended a sugar free nutritional supplement Health Shake with the morning and night medication pass. Review of the resident ' s medical record revealed RD #1's recommendation for the sugar free supplement had not been sent to the physician and had not been acted upon. Physician assessment on 02/14/15 revealed a new [DIAGNOSES REDACTED]. Review of Resident #52's wound assessment flow sheet dated 02/11/15 revealed the wound measured 1.7 centimeters (cm) length by (x) 0.6 cm width x 0.6 cm depth and on 02/18/15, it measured 1.8 cm length x 0.6 cm width x 0.7 cm depth. Observation of Resident #52 on 02/19/15 at 2:54 P.M. revealed Licensed Practical Nurse (LPN) #63 measured the coccyx wound to be 3 cm length x 2 cm wide x 1.0 cm deep, and tunneling at 12 o'clock, 0.2 cm, 3 o'clock was 0.1 cm, 6 o'clock was 1.3 cm, and then Resident #52 requested the measurements and treatment to stop. The wound was described as having a foul odor, the pad to the dressing was saturated with serous drainage, the wound was pink and red around the wound, and edges were adhered. Interview with RD #1 on 02/20/15 at 3:01 P.M. verified she does not calculate estimated nutritional caloric and protein needs of any residents including Resident #52. RD #1 stated she waits until weight loss occurs or a pressure ulcer wound does not heal or worsens and then provides interventions. RD #1 stated that is how she knows if her interventions are not working. Observation on 02/20/15 at 9:09 A.M. revealed Resident #52 was observed sitting in a regular dining room chair without a pressure reduction cushion. The resident was observed to be sitting in the dining room chair until 9:51 A.M. when staff transferred her to a wheelchair. Observation on 02/20/15 at 11:55 A.M. revealed staff transferred Resident #52 from her wheelchair into a dining room chair for her meal without a pressure reduction cushion. Observation of Resident #52 on 02/24/15 at 11:52 A.M. revealed the resident was transferred from her wheelchair with a Posey (type of pressure reduction cushion) cushion into a dining room chair which had no cushion in place. Observation on 02/25/15 at 8:00 A.M. revealed the resident was observed to be sitting in a dining room chair with no pressure reduction cushion in place eating her meal. Further observation revealed the resident was transferred at 8:28 A.M. from the dining room chair, without a pressure reduction cushion, into her wheelchair with a Posey cushion. Interview with the Director of Nursing (DON) on 02/24/15 at 12:15 P.M. verified Resident #52's Posey cushion (pressure ulcer reduction cushion) that was used in her wheelchair was indicated for use on residents who were at low risk for pressure ulcers. The DON verified the Posey cushion did not meet the needs of Resident #52 who had a Stage IV pressure ulcer. Interview with Assistant Director of Nursing (ADON) #2 on 02/24/15 at 3:23 P.M. verified Resident #52's physician ordered a pre-[MEDICATION NAME] level on 12/31/15 which was not completed as ordered at that time. Interview with RD #1 on 02/25/15 at 9:32 A.M., confirmed her recommendation from 11/20/14 for Resident #52 included to continue the Resource supplement three times daily. RD #1 stated she was not aware the supplement had been discontinued, including when she completed her progress note on 12/11/14. RD #1 confirmed on 12/11/14, she did not review and revise Resident #52's nutritional care plan which identified the Resource supplement to still be in place. Further interview with RD #1 and the DON verified RD #1 ' s recommendation for Resident #52's sugar free mighty shake was never communicated to the physician and therefore, the nutrition recommendation was not implemented until 02/25/15. RD #1 verified that Resident #52's coccyx wound had increased in size. Interview with the DON on 02/25/15 at 9:32 A.M. verified Resident #52 was being placed in a dining room chair without a pressure ulcer reduction cushion. The DON stated it was during the time when the resident would eat her three meals in the dining room. Interview with ADON #2 on 02/25/15 at 9:50 A.M. revealed, the Resource supplement was discontinued at the family request due to the cost of the supplement and resident refusal of the supplement. Further interview with ADON #2 on 02/25/15 at 11:10 A.M. confirmed the MVI recommended by RD #1 on 11/20/14 was not ordered until 12/11/14. ADON #2 could not explain why it took so long to get the physician's order. Interview with Physician #3 on 02/25/15 at 12:30 P.M., revealed he added the new [DIAGNOSES REDACTED]. Physician #3 further stated the priority right now was to rule out osteo[DIAGNOSES REDACTED] and the resident will go for testing in two weeks. Interview with the family member of Resident #52 on 02/25/15 at 6:30 P.M. revealed the family did not refuse supplements for the resident and stated the facility informed them that resident was refusing the supplement and only taking a sip or two and that was a waste. The family member further indicated the facility did not talk to the family about food alternatives and other nutritional supplementation to try. Review of the manufactures " Posey Economy Foam Cushion " seating and positioning document dated 2009 revealed indication for use was for patients at low risk for pressure sores and/or requiring posture support. Review of the facility's undated policy titled "Prevention of Pressure Ulcers," revealed the policy explanation and compliance guidelines include re-distribute pressure (repositioning, protecting heels, etc.), minimize exposure to moisture and keep skin clean, provide appropriate pressure redistributing support surfaces, and maintain or improve nutrition and hydration status when feasible. Review of facility's undated policy titled "Pressure Ulcer Prevention and Management," revealed the facility shall establish and utilize a systematic approach for pressure ulcer prevention and promotion of pressure ulcer healing that includes efforts to identify risk, stabilize, reduce or remove underlying risk factors, monitor the impact of the interventions, and modify the interventions as appropriate. Assessment and treatment of [REDACTED]. Review of the National Pressure Ulcer Advisory Panel (NPUAP) 2014 Prevention and treatment of [REDACTED]. Consider the condition of the individual and the pressure redistribution support surface in use when deciding if repositioning should be implemented as a prevention strategy. Establish pressure relief schedules that prescribe the frequency and duration of weight shifts regularly assess the individual's skin condition and general comfort. Reconsider the frequency and method of repositioning if the individual is not responding as expected to the repositioning regime. Reposition the individual in such a way that pressure is relieved or redistributed. Avoid positioning the individual on bony prominences with existing non-blanchable [DIAGNOSES REDACTED]. Avoid subjecting the skin to pressure and shear forces. Additional recommendations for individuals with existing pressure ulcers included were do not position an individual directly on a pressure ulcer, continue to turn and reposition the individual regardless of the support surface in use, and establish turning frequency based on the characteristics of the support surface and the individual's response. Recommendations for repositioning the individual with existing pressure ulcers in a chair included were to minimize seating time and consult a seating specialist if pressure ulcers worsen on the seating surface selected, consider periods of bed rest to promote ischial and sacral ulcer healing, and avoid seating an individual with an ischial ulcer in a fully erect posture (in chair or bed). Recommendations for repositioning documentation included to record repositioning regimes, specifying frequency and position adopted, and include an evaluation of the outcome of the repositioning regime. Recommendations for repositioning for preventing heel pressure ulcers to ensure that the heels are free of the surface of the bed. Review of nutritional recommendations revealed the focus of nutrition assessment should be on evaluating energy intake, unintended weight change and the effect of physiological stress or neuropsychological problems. Additionally, assessment should include a determination of the individual's caloric, protein and fluid requirements.