Every finding on record at Buhler Sunshine Home

The facility had a census of 50 residents. Based on observation, record review, and interview, the facility failed to implement a water management program for Legionella disease (Legionella is a bacterium spread through mist, such as air-conditioning units in large buildings. Adults over the age of 50 and people with weak immune systems, chronic lung disease, or heavy tobacco use are most at risk of developing pneumonia caused by legionella). This deficient practice placed the residents at risk of contracting infectious processes. Findings included: - On 02/13/25 at 10:17 AM, Maintenance Staff U stated he was not aware of whom managed the waterborne pathogen prevention program that included the prevention of Legionella disease. On 02/13/25 at 10:43 AM, Administrative Staff A reported he was not aware of further monitoring programs for Legionella disease. Administrative Staff A stated the facility had not mapped the water system for possible dead-end water sources. Upon request, the facility failed to provide a waterborne pathogen policy. The facility failed to implement a water management program to test and manage waterborne pathogens. This deficient practice placed the residents who resident in the facility at risk of contracting Legionella pneumonia.

The facility had a census of 50 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to notify the physician of episodes of syncope (fainting or passing out) and lightheadedness of one resident, Resident (R) 32. This placed the resident at risk for further decline and a delay in treatment. Findings included: - The Electronic Medical Record (EMR) documented R32 had diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin) type two, and arteriosclerotic heart disease (buildup of plaque in the arteries [blood vessels that carry blood away from the heart]). The Significant Change Minimum Data Set (MDS), dated [DATE], documented R32 had intact cognition. R32 was dependent upon staff for transfers and toileting. R32 required substantial assistance with dressing and did not ambulate. The MDS documented R32 was frequently incontinent of bladder and bowel and had lower functional impairment on one side. The Quarterly MDS, dated [DATE], documented R32 had moderately impaired cognition. R32 was dependent upon staff for dressing, transfers, mobility, and toileting. The MDS documented R32 was frequently incontinent of bladder and bowel and had lower functional impairment on one side. The Care Plan dated 01/14/25, initiated on 06/14/23, directed staff to use a sit-to-stand lift for all transfers. The update, dated 06/17/24, directed staff to use a full mechanical lift (a medical device used to assist individuals with mobility limitations in transferring between surfaces) and two staff members. The care plan lacked direction to staff if the resident should become lightheaded or have a syncope episode during transfers. The Nurse's Note dated 06/07/24 at 05:50 PM, documented, R32 was sat up in the sit-to-stand lift and because lightheaded. Staff sat R32 down and R32 stated that she felt strange, Staff encouraged R32 to drink more water and rest. The EMR lacked documentation the physician was notified of the episode. The Nurse's Note dated 06/17/24, documented during a transfer with the sit-to-stand lift, R32's eyes rolled into the back of her head, and she stated, Put me down. R32 was lowered back into her wheelchair and R32 stated, I just saw stars. The note stated the assistant director of Nursing (ADON) would talk with R32 regarding the use of a full lift mechanical lift. The EMR lacked documentation the physician was notified of the episode. The Nurse's Note dated 06/18/24 at 08:00 PM, documented R32 was unhappy with the use of the full mechanical lift. R32 stated she had multiple syncope episodes with the sit-to-stand lift. R32 stated she was being hooked up to the lift too long or she was being stood too high. The note documented staff explained to R32 that staff barely had her stood up when she would have the episodes and that it was not safe to use the sit-to-stand lift. On 02/12/25 at 12:46 PM, CNA M and CNA N attached the sling to the full lift raised R32 from the bed, and transferred her to the recliner. R32 did not appear to be afraid or had any health issues while up in the sling and thanked the CNAs after she was lowered into the recliner. On 02/12/25 at 01:00 PM, CNA M stated there had not been any more episodes of passing out since they changed from a toileting sling to a regular sling. On 02/13/25 at 08:45 AM, Licensed Nurse (LN) H stated she was unsure why R32 kept getting lightheaded or passing out. LN H verified she could not find any information that the physician had been notified of the episodes. LN H verified there was no direction for staff in the care plan should R32 have any more episodes of lightheadedness or syncopal episodes. On 02/13/25 at 12:55 PM, LN G stated the physician should have been notified when R32 had the syncopal episodes so that he would be aware and could find out why it kept happening. On 02/13/25 at 01:45 PM, Administrative Nurse G stated she was unaware of the syncope episodes R32 kept having. Administrative Nurse D stated that if she had been aware, she would have provided interventions in the care plan for staff. Administrative Nurse D further stated she expected staff to notify the physician for direction or treatment for R32. The facility's Guidelines for Notifying Physicians of Clinical Problems undated policy documented the physician would be notified whenever there was a significant change in the resident's condition. The physician would be notified to see if there would be a need to alter any treatments significantly. The LN had the responsibility of contacting a physician any time they believed a resident had developed a clinical problem, which required physician intervention. The LN, prior to contacting the physician, must have performed an assessment of the resident to provide to the physician. The facility failed to notify R32's physician of episodes of syncope and lightheadedness. This placed the resident at risk for further decline and a delay in treatment.

The facility had a census of 50 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to revise a care plan with direction to staff for interventions when one resident has periods of syncope and lightheadedness, Resident (R) 32. This placed the resident at risk for decline. Findings included: - The Electronic Medical Record (EMR) documented R32 had diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin) type two, and arteriosclerotic heart disease (buildup of plaque in the arteries [blood vessels that carry blood away from the heart]). The Significant Change Minimum Data Set (MDS), dated [DATE], documented R32 had intact cognition. R32 was dependent upon staff for transfers and toileting. R32 required substantial assistance with dressing and did not ambulate. The MDS documented R32 was frequently incontinent of bladder and bowel and had lower functional impairment on one side. The Quarterly MDS, dated [DATE], documented R32 had moderately impaired cognition. R32 was dependent upon staff for dressing, transfers, mobility, and toileting. The MDS documented R32 was frequently incontinent of bladder and bowel and had lower functional impairment on one side. R32 Care Plan dated 01/14/25, initiated on 06/14/23, directed staff to use a sit-to-stand lift for all transfers. The update, dated 06/17/24, directed staff to use a full mechanical lift (a medical device used to assist individuals with mobility limitations in transferring between surfaces) and two staff members. The care plan lacked direction to staff if the resident should become lightheaded or have a syncope episode during transfers. The Nurse's Note dated 06/07/24 at 05:50 PM, documented, R32 was sat up in the sit-to-stand lift and because lightheaded. Staff sat R32 down and R32 stated that she felt strange, Staff encouraged R32 to drink more water and rest. The EMR lacked documentation the physician was notified of the episode. The Nurse's Note dated 06/17/24, documented during a transfer with the sit-to-stand lift, R32's eyes rolled into the back of her head, and she stated, Put me down. R32 was lowered back into her wheelchair and R32 stated, I just saw stars. The note stated the Assistant Director of Nursing (ADON) would talk with R32 regarding the use of a full lift mechanical lift. The EMR lacked documentation the physician was notified of the episode. The Nurse's Note dated 06/18/24 at 08:00 PM, documented R32 was unhappy with the use of the full mechanical lift. R32 stated she had multiple syncope episodes with the sit-to-stand lift. R32 stated she was being hooked up to the lift too long or she was being stood too high. The note documented staff explained to R32 that staff barely had her stood up when she would have the episodes and that it was not safe to use the sit-to-stand lift. On 02/12/25 at 12:46 PM, CNA M and CNA N attached the sling to the full lift raised R32 from the bed, and transferred her to the recliner. R32 did not appear to be afraid or had any health issues while up in the sling and thanked the CNAs after she was lowered into the recliner. On 02/12/25 at 01:00 PM, CNA M stated there had not been any more episodes of passing out since they changed from a toileting sling to a regular sling. On 02/13/25 at 08:45 AM, Licensed Nurse (LN) H stated she was unsure why R32 kept getting lightheaded or passing out. LN H verified she could not find any information that the physician had been notified of the episodes. LN H verified there was no direction for staff in the care plan should R32 have any more episodes of lightheadedness or syncopal episodes. On 02/13/25 at 12:55 PM, LN G stated the physician should have been notified when R32 had the syncopal episodes so that he would be aware and could find out why it kept happening. On 02/13/25 at 01:45 PM, Administrative Nurse D stated she was unaware of the syncope episodes R32 kept having. Administrative Nurse D stated that if she had been aware, she would have provided interventions in the care plan for staff. Administrative Nurse D further stated she expected staff to notify the physician for direction or treatment for R32. The facility's Care Plan Revisions dated 04/23, documented the care planning process including resident assessment, goal setting, and interventions. When changes in condition, medications, or approaches occur, the care plan will be updated immediately. The care plan green sheet would be added to the resident's care plan placing one copy in the communication book and one in the care plan book. The care plan would be revised when there was a change in the problems and goals. The green sheets would be reviewed with each MDS and added as indicated to the resident's long-term care plan. Problems that are no longer applicable would be archived for possible future review or retrieval. The facility failed to revise R32's care plan with direction to staff when R32 had periods of lightheadedness and syncope. This deficient practice placed the resident at risk for decline.

The facility had a census of 50 residents. The sample included 13 residents, with eight reviewed for falls. Based on observation, record review, and interview, the facility failed to evaluate the effectiveness of fall interventions and change or modify the ineffective interventions at preventing falls for Resident (R) 16. This placed the resident at risk for further falls and injury. Findings included: - The Electronic Medical Record (EMR) for R16 documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), hypertension (high blood pressure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), arteriosclerotic heart disease (buildup of plaque in the arteries [blood vessels that carry blood away from the heart]), and edema (swelling resulting from an excessive accumulation of fluid in the body tissues). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R16's moderately impaired cognition. R16 required supervision with transfers but was independent with eating, dressing, mobility, personal hygiene, mobility, and ambulation. The MDS documented R16's no functional impairment, two or more falls with injury, and daily use of a bed and chair alarm. The Quarterly MDS, dated [DATE], documented R16 had severely impaired cognition. R16 required supervision with personal hygiene, transfers, dressing, and ambulation, and was independent with mobility. The MDS documented R16 had no functional impairment, had two or more falls with injury, and used a bed and chair alarm daily. The Fall Risk Assessments, dated 01/22/24, 04/22/24, 07/11/24, 10/11/24, and 01/09/25, documented R16 was at risk for falls. R16's Care Plan dated 01/28/25, initiated on 05/03/23, directed staff to provide gripper socks when barefoot in his room and ensure R16 laid on top of his blankets to decrease slipping. The update, dated 05/01/23, directed staff to remind R16 to ask for assistance with long-distance mobility, keep personal frequently used items within reach, and provide proper, well-maintained footwear. The update, dated 05/22/23, directed staff to educate R16 to slow down and take his time. The update, dated 10/03/23, directed staff to place non-skid socks on after he returned from supper. The update, dated 01/02/24, directed staff to place silent pressure alarms on while in bed and chair. The update, dated 03/09/24, directed staff to educate R16 on making sure gripper socks were on properly before attempting to ambulate. The update, dated 04/29/24, directed staff to place a stop sign in view of the recliner to call for assistance. The update, dated 06/07/24, directed staff to educate R16 on calling and waiting for assistance. The update, dated 09/21/24, directed staff to educate R16 on the risk of falling when he ambulates independently and for staff to continue to provide verbal reminders. The update, dated 10/15/24, directed staff to offer R16 a drink after he toilets during the night. The update, dated 01/14/25, directed staff to review with R16 the importance of staff assistance with ambulation. The Risk Note dated 03/14/24 at 10:40 AM, documented R16 had a fall on 03/09/24 at 11:00 AM. R16's feet slipped on the floor when he got out of bed, and he fell to his buttocks. R16 denied pain and was assisted to stand, R16 had one sock off and the other sock was worn upside down. R16 was educated to keep both gripper socks on and make sure the grippers were on the bottom of his feet. The note further documented R16 had another fall on 03/11/24 at 11:45 AM. R16 transferred to his recliner, failed back up far enough, and slid down to the floor. R16 sustained a superficial (occurring on the surface of the skin) abrasion (scrape) to the top of his left knee, had his pants down, and had on socks. The Risk Note dated 04/04/24 at 10:45 AM, documented R16 had a fall on 04/01/24 at 12:50 PM when he tried to get something from his refrigerator and lost his balance. R16 sustained a skin tear to his right elbow. The Risk Note dated 05/02/24 at 03:49 AM, documented R16 had a fall on 04/29/24 at 03:53 AM. R16 attempted to take himself to the bathroom and did not use his call light. R16 stated he reached for the grab bar, missed, and fell . R16 sustained a 3.3 centimeter (cm) x 0.3 cm abrasion with dark purple discoloration to the outer left arm. R16 was reminded to use his walker and call for assistance. The Risk Note dated 06/13/24 at 12;28 PM, documented R16 had a fall on 06/06/24 at 04:00 AM. R16 took himself to the bathroom, fell , on his left elbow, and then took himself back to his bed. The note documented staff responded within a minute of his pressure pad alarm being activated and observed R16 getting back into bed. R16 sustained a skin tear to his left inner elbow which measured 1 cm x 1 cm, a bruise to his right elbow which measured 1.5 cm x 0.5 cm, and another bruise to the outer right elbow that measures 2 cm x 1.5 cm. R16 was educated on the importance of using his call light or staff assistance. The Risk Note dated 10/11/24 at 10:40 AM, documented R16 had two noninjury falls on 10/06/24. The first fall at 08:20 PM, R16 attempted to get blankets from the top shelf of his closet. When he grabbed the blankets, they fell on top of him which caused him to lose his balance and fall. The second fall occurred at 09:00 PM when R16 wanted to move his wheelchair closer to his bed, lost his balance, and sat down on the floor. R16 was re-educated to call for assistance. The Risk Note dated 10/18/24 at 11:5 AM, documented R16 had a fall on 10/15/24 at 06:10 AM. R16 fell after he tried to get a drink of water from his pitcher in the refrigerator, lost his balance, and fell , R16 denied hitting his head and had no injuries. The Risk Note dated 01/16/25 at 12:32 PM, documented that R16 had a fall on 01/14/25 at 08:00 AM. R16 fell in his room when he attempted to ambulate independently. R16 attempted to get himself up from the floor as staff entered the room. R16 had redness to his left knee, with an abrasion below the knee. R16 was reminded to use his call light for staff assistance. The Risk Note dated 02/06/25 at 12:40 PM, documented R16 had a fall on 02/05/25 at 06:30 AM. R16 got up from his bed to ambulate unassisted, his legs weakened, and he fell . Staff noticed his pressure pad alarm had not alerted staff, as it was in the recliner, and he had been in bed. On 02/12/25 at 01:06 PM, Certified Nurse Aide (CNA) M placed a gait belt around R16's waist and with CNA N's assistance, R16 stood and transferred from his wheelchair into his recliner. R16 stated he was weak and could not understand why he was so tired after he was transferred. On 02/12/25 at 1:15 PM, CNA M stated he was very impulsive and would not wait for any assistance from staff. She stated he has had a lot of falls and staff checked on him frequently to remind him to call. CNA M stated that they keep an alarm on his bed and chair, and they have placed nonskid strips in front of his recliner and bed to keep him from slipping if he stands up alone. On 02/13/25 at 12:45 PM, Licensed Nurse (LN) G stated R16 was going to do whatever he wanted and would never call for assistance due to his dementia. R16 had silent alarms for his bed and chair and staff were to get him up right away in the morning or he would get up unassisted. LN G stated with R16s dementia he does not remember to call, and his family just wanted him kept injury-free. On 02/13/25 at 01:37 PM, Administrative Nurse D stated R16 could tell staff what he was doing at the time of the fall but due to his cognitive impairment, he does not remember to call for assistance. Administrative Nurse D verified the interventions on the care plan had not been effective due to his cognitive impairment. The facility's Fall Prevention and Management Protocol, revised 04/29/24, documented each resident would be assessed for the risk factors for falls at the time of move-in, return from a health care facility, and after a fall in the facility. After a fall, the resident was assessed for injuries and given the care/treatment needed at the time. The physician would be notified of the fall and would make the clinical decision to transfer to the hospital or be monitored. The falls would be investigated using a root cause analysis and would implement corrective action. A green care plan sheet in the fall packet was completed with fall interventions to be implemented. All falls with interventions are reported, and reviewed in a weekly risk meeting. The care manager would document in resident progress notes and the falls are reviewed in quarterly Quality Assurance and Performance Improvement (QAPI) and safety meetings. The facility failed to evaluate the effectiveness of fall interventions and change or modify the interventions that were ineffective at preventing falls for R16. This deficient practice placed the resident at risk for further falls and injury.

The facility had a census of 50 residents. The sample included 13 residents, with five reviewed for unnecessary medication. Based on observation, interview, and record review, the facility's pharmacist consultant failed to request an approved indication for the use of Seroquel (an antipsychotic -class of medications used to treat psychosis and other mental-emotional conditions), and the required physician-written clinical rationale for the continued use of Seroquel for Resident (R) 18. This deficient practice placed R18 at risk of receiving unnecessary antipsychotic drugs. Findings included: - R18's Electronic Medical Record (EMR) documented a diagnosis of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure) with late-onset. The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 99, short and long-term memory loss with severely impaired cognition. The MDS documented R18 was dependent on staff for all activities of daily living. R18 received antipsychotic medication without a gradual dose reduction (GDR) and the MDS stated the physician had documented a clinical rationale on 12/04/24. R18's Care Plan, dated 12/17/24, directed staff to obtain lab work, and vital signs as ordered by the physician, and request GDRs per regulations with physician review for possible dose reduction. The care plan directed staff to observe R18 for changes or decline in cognitive status, provide one-to-one observation when indicated, and a psychiatric evaluation as indicated. The Physician Order, dated 05/21/24, directed staff to administer Seroquel 25 milligrams (mg), by mouth, at bedtime for severe anxiety. The Pharmacist Reviews, dated 11/25/24, recommended a GDR for Seroquel. The physician declined to perform a GDR and failed to provide a written clinical rationale for the use of the antipsychotic for anxiety. On 02/12/25 at 11:35 AM, Certified Medication Aide (CMA) S administered cyclobenzaprine (muscle relaxant) in pudding, at the dining table. R18 took the medication without problems. On 02/13/25 at 10:15 AM, Administrative Nurse D verified that the consultant pharmacist had not continued to request a written thorough clinical rationale for the use of the antipsychotic for anxiety. The facility's Consultant Pharmacist Services Provider Requirements policy, dated October 2019, stated that the consultant pharmacist provided pharmaceutical services including a review of the medication administration record (MAR) to ensure proper documentation of medication orders and administration of medication. The consultant pharmacist would communicate to the physician and the director of nursing potential or actual problems detected and other findings related to medication therapy orders. The facility's pharmacist consultant failed to request an approved indication for the use of Seroquel, and the required physician-written clinical rationale for the continued use of Seroquel for R18. This deficient practice placed R18 at risk of receiving unnecessary antipsychotic drugs.

The facility had a census of 50 residents. The sample included 13 residents, with five reviewed for unnecessary medication. Based on observation, interview, and record review the facility failed to obtain an approved indication for use for Seroquel (antipsychotic -class of medications used to treat psychosis and other mental emotional conditions), and the required physician-written clinical rationale for why any attempted dose reeducation would be likely to impair the resident's function or cause psychiatric instability for Resident (R) 18. This deficient practice placed R18 at risk of receiving unnecessary antipsychotic drugs. Findings included: - R18's Electronic Medical Record (EMR) documented a diagnosis of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure) with late-onset. The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 99, short and long-term memory loss with severely impaired cognition. The MDS documented R18 was dependent on staff for all activities of daily living. R18 received antipsychotic medication without a gradual dose reduction (GDR) and the MDS stated the physician had documented a clinical rationale on 12/04/24. The care plan, dated 12/17/24, directed staff to obtain lab work, and vital signs as ordered by the physician, and request GDRs per regulations with physician review for possible dose reduction. The care plan directed staff to observe R18 for changes or decline in cognitive status, provide one-to-one observation when indicated, and a psychiatric evaluation as indicated. The Physician Order, dated 05/21/24, directed staff to administer Seroquel 25 milligrams (mg), by mouth, at bedtime for severe anxiety. The Pharmacist Reviews, dated 11/25/24, recommended a GDR for Seroquel. The physician declined to perform a GDR and failed to provide a written clinical rationale for the use of the antipsychotic for anxiety. On 02/12/25 at 11:35 AM, Certified Medication Aide (CMA) S administered cyclobenzaprine (muscle relaxant) in pudding, at the dining table. R18 took the medication without problems. On 02/13/25 at 10:15 AM, Administrative Nurse D verified the physician had not written a thorough clinical rationale for the use of the antipsychotic for anxiety. The Psychotropic Medication Use and Management policy, dated October 2018, stated the facility would use and administer psychotropic medication appropriately working with the physician interdisciplinary team to ensure the appropriate use, evaluation, and monitoring. The drug dosage must be periodically reduced, with the goal of discontinuing it or replacing it with another less potent prescription. All antipsychotics would be tapered as a gradual dose reduction unless clinically contraindicated by the physician. The facility failed to obtain an approved indication for use for the antipsychotic drug Seroquel or the required physician-written clinical rationale, placing R18 at risk of receiving unnecessary antipsychotic drugs.

The facility had a census of 50 residents. The sample included 13 residents. Based on observation, interview, and record review, the facility failed to administer the correct physician-ordered dose of Ativan (antianxiety drug - a class of medications that calm and relax people) at the scheduled time for Resident (R) 20, placing R20 at risk for adverse effects resulting from the incorrect dose. Findings included: - R20's Electronic Medical Record (EMR) documented diagnoses of dementia (a progressive mental disorder characterized by failing memory, and confusion) and anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment. The MDS documented R20 required supervision to maximum staff assistance with activities of daily living and received antianxiety medication. R20's Care Plan, dated 02/11/25, directed staff to observe for anxiety or restlessness, strange noises, getting up or down, delusions or hallucinations, resisting cares, being stiff with cares or grabbing, obsession over items, or paranoia. R20's care plan directed staff to inform the nurse for documentation and notify hospice, and his physician as indicated. The Physician Order, dated 08/02/24, directed staff to administer Ativan 0.5mg, (1/2 tablet 0.25mg) two times per day (AM and 1 PM) for anxiety/ restlessness. The Physician Order, dated 11/07/24, directed staff to administer the following: Ativan 0.5mg daily at HS (bedtime) for anxiety for anxiety disorder. Ativan 0.5mg, (1/2 tablet 0.25mg) two times per day (AM and PM) for anxiety or restlessness. The Physician Order, dated 12/04/24, had the following: Ativan 0.5mg, daily at bedtime for anxiety for anxiety disorder. Ativan 0.5mg, (1/2 tablet 0.25mg) two times per day (AM and 4 PM) for anxiety or restlessness. Ativan 0.5mg, under tongue every 4 hours as needed for anxiety or restlessness for 6 months. The Progress Note dated 09/05/24 at 02:12 PM, documented a Certified Medication Aide (CMA) alerted this nurse that R20's noon dose of Ativan was not administered yesterday by error. R20 had not shown any increased anxiety or restlessness from the missed dose at that time. The Progress Note dated 10/08/24 at 10:34 AM, documented a CMA alerted this nurse of finding a medication error from last night. R20 had Ativan 0.5mg at bedtime scheduled but received Ativan 0.25mg last night. R20 had some restlessness this morning without being able to redirect. R20 had been climbing out of chairs and trying to walk. Staff tried to redirect with a magazine, 1:1, and a busy box. R20 continued to be restless and trying to leave for work. Staff attempted multiple times to redirect and the nurse instructed the CMA to give as needed (PRN) Ativan to help manage anxiety. The Progress Note dated 11/05/24 at 09:20 AM documented R20 had not received the scheduled dose of Ativan on 11/03/2024 at 02:00 PM. Staff education was performed, and the time of administration was adjusted. The Progress Note dated 12/16/24 at 08:25 AM, documented a CMA reported to this nurse that the narcotic book showed that R20 received Ativan 1 mg at bedtime instead of the scheduled Ativan 0.5mg at bedtime. Staff education on checking correct dosages prior to giving medications was provided. The Progress Note dated 12/23/24 documented a CMA reported R20 received the incorrect dose of Ativan at bedtime on 12/21/24 and 12/22/24. The Progress Note dated 02/05/25 at 06:15 AM, documented the evening CMA reported a medication error on 02/04/25 at 06:15 PM. R20 was scheduled to receive Ativan 0.5 mg tab in the AM and PM. The morning shift CMA recorded administration on the MAR (Medication Administration Record), but the narcotic box check indicated that Ativan was not given. This nurse and evening CMA rechecked the narcotic medication and record, confirming it was not administered. On 02/12/25 at 11:02 AM, R20 sat in his wheelchair at a dining table and ate lunch independently. After sneezing several times, he started fidgeting, rolling his wheelchair back and forth. On 02/13/25 at 10:35 AM, Administrative Nurse E stated one-to-one education had been provided to CMAs. On 02/04/25 administration removed the CMA from medication passes until her education was done. The facility also had the physician change the times for the scheduled Ativan. On 02/13/25 at AM, Administrative Nurse D verified that staff were to administer physician orders as scheduled. The facility's Reporting a Medication Error policy, dated 12/17/2015, stated all medication errors were to be reported to the Director of Nursing following the guidelines listed. The guidelines stated the person discovering the error would report to their supervisor and the supervisor would review information. Staff were to notify the physician and family. The error would be discussed at the weekly high-risk meeting. The facility failed to administer the correct physician-ordered dose of Ativan at the scheduled time for R20. This deficient practice placed R20 at risk for adverse effects resulting from the incorrect dose.

The facility reported a census of 45 residents. The facility had one main kitchen. The kitchen served food to two dining areas. Based on observation, interview, and record review, the facility failed to properly store food in the main kitchen refrigerators due to foods left uncovered, boxes placed directly on the floor in the kitchen area, and staff failed to discard expired foods in accordance with professional standards for food service safety, to prevent food borne illness to the residents. Findings included: - During the brief initial tour of the kitchen, on [DATE] at 08:27 AM, observation revealed the following concerns: 1. The walk-in refrigerator had six 16-ounce (oz) containers of grated parmesan cheese with a use by date of [DATE]. 2. The kitchen had approximately four various food boxes stored directly on the floor with 14 boxes stacked on top of those boxes. 3. The refrigerator had an undated box of lettuce, open to air and wilted. 4. The kitchen had five cutting boards with scratches that covered most of the surface of each of them (making them uncleanable). 5. The kitchen refrigerator had a tray of four oz juice cups with various dates, the front two stacks dated [DATE], with the following rows had 10 cups of juice dated [DATE], and five cups of juice dated [DATE]. The juice in the back revealed a date of [DATE]. On [DATE] at 08:45 AM, Dietary Staff D stated staff should date and seal any unused food products. She stated the juice cups were dated when they were taken out of the freezer. She verified the boxes of food should not be stored directly on the floor. On [DATE] at 02:22 PM, Dietary Manager (DM) C confirmed boxes should not be stored directly on the floor. DM C confirmed staff should discard the expired cheese. DM C stated the juices being in the refrigerator were only good for two to three days. In addition, staff should rotate the juice in the refrigerator. The facility's policy Food Storage revised in 2015 documented all food items would be stored on shelves. All packaged food items would be properly sealed. Refrigerated items should follow a rotation procedure. The facility failed to properly store food in the main kitchen refrigerators due to the boxes being directly on the floor and the open food items, also the expired food items for food service to the residents of this facility.

The facility had a census of 45 residents with 12 included in the sample. Based on observation, interview, and record review the facility failed to develop a comprehensive care plan for one Resident (R) 10 of the 12 sampled residents, related to comfort care status. Findings included: - Resident (R) 10's signed physician orders dated 04/06/23, included the following diagnoses: dementia (progressive mental disorder characterized by failing memory, confusion), chronic kidney disease (inability of the kidneys to excrete wastes, concentrate urine and conserve electrolytes), hypertension (elevated blood pressure), history of alcohol dependence, major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness) and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The Quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident required supervision with daily cares including personal hygiene. No dental concerns noted. The resident received antipsychotic (class of medications used to treat psychosis and other mental emotional conditions), antidepressant (class of medications used to treat mood disorders and relieve symptoms of depression), and antibiotic daily through the seven-day look-back observation period. Review of the annual MDS dated [DATE] revealed intact cognition. The resident was independent for activities of daily living (ADL's). No dental issues and received the same medications with no changes made. Review of the Activities of daily living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 03/02/23, revealed the resident was alert and orientated with intact cognition. The resident was able to make her own decisions and preferred comfort care measures only as she did not want any labs, X-rays or interventions done. The resident was independent in ADL's and was ambulatory with her rolling walker and had a steady gait. The Care Plan dated 11/23/21, revealed the resident had a self-care deficit. The care plan lacked staff guidance in reference to her comfort care status and her preferences of what care she did not want. On 04/17/23 at 11:35 AM, the resident reported she could take care of herself and did not want all that doctor stuff. She was okay how she was. On 04/18/23 at 01:45 PM, Certified Medication Aide D reported the resident was very independent. She absolutely refused staff to clean her teeth. The last time the nurse tried helping her clean her dentures the resident tried to bite her. She is on comfort care and refuses to see doctors or have lab drawn. She sometimes has behaviors where she is mean when staff try to assist her. On 04/19/23 at 08:02 AM, Licensed Nurse (LN) F reported the resident was independent in her room and would not accept assistance for care. She was comfort care and received no physician or dental appointments per her choice. On 04/19/23 at 09:43 AM, Administrative Nurse B reported staff should care plan the resident decision for comfort care and her preferences were. Those are her preferences, and comfort care is not included on the MDS or physician orders. The facility lacked a policy for comfort care. The facility failed to develop a comprehensive care plan for Comfort Care that included the resident preferences and wishes.

The facility reported a census of 45 residents, with 12 sampled, including four residents sampled for activities of daily living (ADL). Based on observation, interview, and record review, the facility failed to review and revise the care plan for Resident (R) 29 regarding shower preferences. Findings included: - The 09/29/22 Electronic Health Record (EHR) documented R29 had the following diagnoses of Alzheimer's (progressive mental deterioration characterized by confusion and memory failure) and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The 09/28/22 Admission Minimum Data Set (MDS) documented a brief interview for mental status (BIMS) of six, indicating severely impaired cognition. R29 was independent with set up assistance of one staff for all ADL, and no bathing occurred in the seven-day look-back period. The 09/28/22 ADL Functional/Rehabilitation Potential Care Area Assessment (CAA) documented R29 was independent with ADL. The 03/31/23 Care Plan documented R29 preferred early morning showers twice weekly, R29 required one assist for bathing transfers, with clothing management and drying off. The Spa Documentation Sheet for January through April 2023 documented R29 was on the schedule for the evening shift. On 04/17/23 at 10:36 AM, R 29 observed sitting in his room in his recliner with long facial hair growth, greasy/oily appearing hair, and a dirty shirt. On 04/18/23 at 01:24 PM, Certified Nurse Aide (CNA) R revealed R29 was on the evening shift schedule. On 04/18/23 at 03:45 PM, CNA E confirmed R29 was on the evening bathing schedule, but she had not given him a shower. On 04/18/23 at 04:02 PM, Licensed Nurse (LN) G revealed the admission nurse would obtain the resident's preferences and add them to the care plan. LN G stated whichever nurse talked to the family or resident concerning a change in their care would be responsible for updating the care plan. LN G reported she remembered hearing the resident wanted showers in the evening, and staff placed him on the evening schedule, however, she verified the care plan indicated he preferred morning showers. On 04/06/23 at 10:14 AM, Administrative Nurse D revealed she expected her staff to update and follow the care plan for the care of the residents. The facility Comprehensive Care Plan revised 07/21/2017, documented the care plans are prepared by a care plan team which included nursing, dietary, activities, and social services. This would include information from the physician, the resident, and the family. The care plan will be updated by charge nurses and care coordinators as events occur. The facility failed to update R29's care plan to guide staff related to this resident's shower preferences.

The facility reported a census of 45 residents, with 12 sampled, including four residents sampled for activities of daily living (ADL). Based on observation, interview, and record review, the facility failed to provide care consistent with standard of practice for Resident (R) 29 to maintain good grooming and personal hygiene related to showers and facial hair removal. Findings included: - The 09/29/22 Electronic Health Record (EHR) documented R29 had the following diagnoses of Alzheimer's (progressive mental deterioration characterized by confusion and memory failure) and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The 09/28/22 Admission Minimum Data Set (MDS) documented a brief interview for mental status (BIMS) of six, indicating severely impaired cognition. R29 was independent with set up assistance of one staff for all ADL. The 09/28/22 ADL Functional/Rehabilitation Potential Care Area Assessment (CAA) documented R29 was independent with ADL, and that bathing did not occur. The 3/17/23 Quarterly MDS documented R29 required physical help in part of bathing by one staff. The 03/31/23 Care Plan documented R29 preferred early morning showers twice weekly, R29 required one assist for bathing transfers, with clothing management and drying off. The Progress Notes from January 2023 through March 2023, lacked documentation of the resident's refusals of showers/baths. The Spa Documentation Sheet for January 2023 documented out of nine scheduled opportunities, R29 received five showers, with no shaving noted. The Spa Documentation Sheet for February 2023 documented out of eight scheduled opportunities, R29 received five showers, two with shaving noted, and one refusal noted. The Spa Documentation Sheet for March 2023 documented out of nine scheduled opportunities, R29 received six showers, three with shaving noted, and no refusals noted. On 04/17/23 at 10:36 AM, R29 observed sitting in his room in his recliner with long facial hair growth, greasy/oily appearing hair, and a dirty shirt. On 04/17/23 at 10:36 AM, R29 stated he would like assistance with showering and shaving. On 04/18/23 at 08:02 AM, R29 observed sitting in his room in his recliner with long facial hair growth, greasy/oily appearing hair, and the same dirty shirt. On 04/17/23 at 08:02 AM, R29 revealed he had gotten no help to shave or shower. On 04/18/23 at 01:24 PM, certified nurse's aide (CNA) F, revealed she was the shower aide assigned to showers for the day. She stated she would try three times to give a shower to a resident, if they refused all three, she would get the charge nurse. She stated showers were to be documented in the electronic record and on a shower sheet. CNA F revealed R29 was on the evening shift schedule. On 04/18/23 at 03:45 PM, CNA E revealed there was not one CNA assigned to give showers on the evening shift, they would just give them per the bath schedule. CNA E stated staff should document them in the electronic record and on the shower sheet whether the resident received a bath or refused. CNA E confirmed R29 was on the evening schedule, and she had not given him a shower. On 04/18/23 at 04:02 PM, Licensed Nurse (LN) G revealed staff should document showers in the electronic record as well as on Spa documentation sheets. LN G confirmed R29 had long facial hair. On 04/06/23 at 10:14 AM, Administrative Nurse D revealed she expected her staff to provide bathing as per the residents' preference, to document it in the electronic record, and on the Spa documentation sheet. The facility Bathing policy dated 03/14/15, documented team members who assist residents with bathing would focus on making the bathing experience enjoyable for the resident. Staff were to review the information about bathing found on the resident's bath sheet regarding if the resident wanted a bath or shower. The facility failed to provide care consistent with professional standard of practice, for this resident that required assistance with bathing and facial hair removal, to maintain good grooming, and personal hygiene.

The facility census totaled 45 residents with 12 included in the sample, with one resident sampled for catheter care. Based on observation, interview, and record review, the facility failed to provide necessary services to decrease the risk of a urinary tract infection by the failure to ensure the catheter tubing remained below the level of the bladder for one resident. Resident (R) 6. Findings included: - Resident (R) 6's signed physician orders dated 04/06/23 revealed the following diagnoses: traumatic subdural hemorrhage (collection of blood on the surface of the brain) without loss of consciousness, chronic obstructive pulmonary disease- COPD (progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), type 2 diabetes mellitus (when the body cannot use glucose, not enough insulin is made or the body cannot respond to the insulin) benign prostatic hyperplasia with lower urinary tract symptoms (non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency and urinary tract infections (UTI). The Significant Change in Status Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12 indicating moderate cognitive impairment. The resident required total dependence with daily cares. The resident had an indwelling urinary catheter. The Urinary Incontinence Indwelling Catheter Care Area Assessment (CAA) dated 03/16/23 revealed the resident fatigued easily with repositioning side to side for linen changes and catheter care. The resident received Levaquin (an antibiotic medication) for UTI. Review of the Care Plan dated 02/23/23 revealed R 6 required an indwelling urinary catheter related to urinary retention. The care plan guided staff to report symptoms of UTI, avoid obstructions, change the catheter monthly, keep the catheter system in a closed system as much as possible, manipulate the tubing as little as possible during cares, position the bag below the level of the bladder, and provide catheter cares. Review of the progress notes on 02/19/2023 at 11:20 AM revealed the resident required admission to the hospital for his COPD and UTI. He returned to the facility on [DATE]. The physician ordered levofloxacin (antibiotic), 500 milligrams, daily for five days for UTI. Observation on 04/17/23 at 10:16 AM, Licensed Nurse (LN) I and certified nurse's aide (CNA) J entered the resident room to transfer the resident to the toilet for a bowel movement. The sling under the resident as he sat in his wheelchair was then attached to the sit to stand lift. CNA J hung the catheter bag on the mechanical lift above the level of the resident's bladder. Staff transferred the resident to the toilet. When the resident sat on the toilet, the urinary catheter bag, still attached to the mechanical lift, was at the approximate level of the resident's shoulders. CNA J and LN I stood in the bathroom doorway as the resident sat on the toilet. After observation of the urinary catheter at the resident's shoulder height of approximately three minutes, the surveyor questioned the height of the catheter bag. CNA J abruptly grabbed the bag, without answering the question, and placed it on a lower bar on the lift. LN I failed to advise CNA J about the placement of the urinary catheter bag. On 04/18/23 at 1:50 PM, Certified Medication Aide (CMA) H reported the resident was dependent on staff for his care and transferred with a sit to stand lift. The resident had a urinary catheter and had a UTI. On 04/19/23 at 07:28 AM CNA J reported the resident was total assistance of two staff with a sit to stand lift. The resident had a urinary catheter. The resident had problems with UTIs. On 04/19/23 at 07:50 AM, LN G reported the CNAs were to do catheter care at least once a shift. Staff should keep the resident's urinary catheter below the level of his bladder. On 04/19/23 at 10:30 AM administrative Nurse B reported she expected all nursing staff to know how to care for a catheter. Review of the facility policy called Catheter Care dated 03/14/15 revealed the tubing is not to be positioned higher than the bladder. The facility failed to provide necessary services to decrease the risk of a urinary tract infection by the failure to ensure the catheter tubing remained below the level of the bladder for this resident.

The facility reported a census of 45 residents. The facility had one main kitchen where food was stored and prepared serving two dining rooms. Based on observation, interview, and record review the facility failed to properly store food in a snack fridge due to lack of temperature monitoring and failed to ensure the dishes and cookware were washed under sanitary conditions, due to the lack of chemical or temperature monitoring. Findings included: - Observation on 10/18/21 at 11:39 AM revealed no temperature or chemical log available for the dishwasher in the Memory Care Unit (MCU). Interview on 10/18/21 at 11:39 AM CMA J stated the staff in the MCU washed their own dishes with a dishwasher which used chemicals and were metered in by the machine. The dishwasher light indicated when it was hot and ready to wash. She did not know of temperature monitoring or testing required for chemical strength. CMA J stated the maintenance staff came in periodically and checked the dishwashing machine. Interview on 10/19/21 at 08:07 AM Maintenance Staff (MS) E stated the dishwasher in the MCU was not tested by the maintenance department periodically for heat or chemical sanitization. MS E stated the dietary department managed the testing for sanitization on the dishwasher in the MCU. Observation on 10/19/21 at 10:52 AM revealed the snack room refrigerator temperature log was not present on one of the halls. Interview on 10/19/21 at 11:15 AM Dietary Staff (DS) B stated there were no temperature monitoring procedures in place for the MCU dishwasher. DS B stated the machine was only a few months old and had no problems heating up to the acceptable temperature range. Observation on 10/19/21 at 12:47 PM revealed the main kitchen dishwasher temperature log book was closed on the shelf. The binder instructed staff to log temperatures on the log sheets once each shift at 10:00 AM and 04:30 PM. Staff provided three log sheets from the log book upon request for copies. The log sheets were not labeled with a month or year date. The first log sheet had 16 blank spaces during the morning shift and 27 blank spaces during the afternoon shift. The second log sheet had three blank spaces on the 22nd, 23rd, and 25th during the morning shift. There were 23 blank spaces during the afternoon shift. The third log sheet had three blank spaces from the 29th to the 31st during the morning shift and 21 blank spaces during the afternoon shift. Interview on 10/19/21 at 12:47 DS K stated she wrote down the main kitchen dishwasher temperatures in the log book. She wrote the temperature on whichever page was open at the time. DS K stated if the temperatures were out of the acceptable range she would just write it down. Interview on 10/19/21 at 02:14 PM DS B stated the main kitchen dishwasher was a high heat dishwasher that rinsed at 180 degrees Fahrenheit (F) for 15 seconds. He expected the dishwasher temperature log sheets to be labeled with the month and year and expected the staff to record the temperatures twice daily morning and evening. Interview on 10/20/21 at 01:34 PM, Housekeeping Staff (HS) C stated the housekeeping department used to check the temperatures for the refrigerator and freezer in one of the halls for a snack room but had not done so in about a year. HS C stated dietary had overseen the temperature checks for the snack room fridge since the change last year. Interview on 10/20/21 at 02:15 PM, DS S stated he never checked and logged the temperature for the refrigerator and freezer in the one hallway's snack room. He stated he thought there was a temperature log in the room but could not locate one. He thought the nurses logged the temperatures in the MCU. The facility's Dish Machine Temperature Log Policy dated 05/03/05 revealed Dishwashing staff will monitor and record dish machine temperatures to assure proper sanitizing of dishes. The Facility Refrigerator Policy updated September 2019 stated, Refrigerator temperatures will be checked daily and reported to Worxhub (maintenance management tool) when over 41 degrees F. A log will be posted on the refrigerator for daily checks. Housekeeping is responsible for weekday checks, and nursing for weekends and holidays. The facility failed to properly store food items and wash dishes and cookware under sanitary conditions.

The facility census totaled 45 residents, with 12 included in the sample. Based on observation, interview, and record review the facility failed to revise the care plan for Resident (R)24 related to the use of oxygen (O2). Findings included: - R24's Electronic Health Record (EHR) revealed the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] .) The Admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score 15, which indicated intact cognition. R24 was not on O2 therapy. The Quarterly MDS dated [DATE] revealed a BIMS 15, which indicated intact cognition and R24 received O2 therapy. The Pressure Ulcer/Injury Care Area Assessment (CAA) dated 01/20/21 revealed R24 denied being short of air at rest or with exertion. R24 had crackles in the bilateral lower lobes of her lungs. R24 stated she did not wear O2 at home prior to moving to the facility. Review of R24's Care Plan lacked any interventions concerning the use of O2. A Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation on 10/18/21 at 11:17 AM revealed O2 tubing connected to an O2 concentrator with the no date on the tubing During an interview on 10/21/21 at 01:29 PM, Certified Nurse Aide (CNA) T stated R24 used oxygen continuously. CNA T stated she thought the O2 tubing was changed out once a week and either the nurse or medication aides changed it, but she did not know on which shift. CNA T stated the O2 tubing should be dated. Interview on 10/20/21 at 02:38 PM, Licensed Nurse (LN) U stated, R24 used oxygen on a PRN bases in order to keep her O2 saturation level above 88%. LN U stated nurses, medication aides or CNAs could change out the oxygen tubing at least every two weeks and this was documented in the EMAR. LN U stated the O2 tubing should be dated. Interview on 10/21/21 at 10:57 AM, Administrative Nurse V stated the use of oxygen should be included in the care plan and stated the nurses filled out a green sheet, put it in the resident care plan notebook, and she updated the care plan off of the sheets when a care plan meeting took place. Administrative Nurse V verified there was no green sheet filled out for the use of oxygen for R24 and the care plan was not updated to include use of O2. Interview on 10/21/21 at 01:41 PM, Administrative Nurse A stated the use of oxygen should be included on the care plan. The Comprehensive Care Plan policy revised 07/21/17 revealed The care plan is .reviewed and revised quarterly . The facility failed to revise the care plan for R24 to include information concerning the use of O2.

The facility census totaled 45 residents, with 12 included in the sample, and one resident reviewed for oxygen (O2) use. Based on observation, interview, and record review the facility failed to provide necessary respiratory care and/or services consistent with professional standards of practice when they failed to change, and date disposable O2 equipment for Resident (R)24. Findings included: - R24's Electronic Health Record (EHR) revealed the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] .) The Admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score 15, which indicated intact cognition. R24 was not on O2 therapy. The Quarterly MDS dated [DATE] revealed a BIMS 15, which indicated intact cognition and R24 received O2 therapy. The Pressure Ulcer/Injury Care Area Assessment (CAA) dated 01/20/21 revealed R24 denied being short of air at rest or with exertion. R24 had crackles in the bilateral lower lobes of her lungs. R24 stated she did not wear O2 at home prior to moving to the facility. Review of R24's Care Plan lacked any interventions concerning the use of O2. A Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The August 2021 - October 2021 Electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .cannula and tubing every two weeks, PRN on Tuesday when O2 was in use (label and date/initial). There were no entries on the EMAR to show that this was completed. An observation on 10/18/21 at 11:17 AM revealed O2 tubing connected to an O2 concentrator with the no date on the tubing During an interview on 10/21/21 at 01:29 PM, Certified Nurse Aide (CNA) T stated R24 used oxygen continuously. CNA T stated she thought the O2 tubing was changed out once a week and either the nurse or medication aides changed it, but she did not know on which shift. CNA T stated the O2 tubing should be dated. Interview on 10/20/21 at 02:38 PM, Licensed Nurse (LN) U stated, R24 used oxygen on a PRN bases in order to keep her O2 saturation level above 88%. LN U stated nurses, medication aides or CNAs could change out the oxygen tubing at least every two weeks and this was documented in the EMAR. LN U stated the O2 tubing should be dated. Interview on 10/21/21 at 01:41, Administrative Nurse A stated R24 used O2 and her expectation was the O2 tubing should be dated when changed every two weeks. The undated Oxygen, Administration of policy revealed, Masks, cannulas, tubing will be replaced at every two weeks. The facility failed to ensure R24's O2 tubing was changed out and dated as ordered.

The facility identified a census of 48 with one main kitchen where the facility kept the Quat sanitizing solution (a surfactant cleaning chemical that is typically used in hospitals and food processing plants) for use of sanitizing kitchen and dining surfaces. Based on record review, observation, and interview, the facility failed to maintain the Quat sanitizer solution concentration levels when they did not test and record results or maintain logs of the sanitizer concentration results. Findings included: - Review of the records located in the main kitchen lacked evidence of test result logs for the Quat sanitizing solution. During an observation on 12/17/19 at 10:13 AM, Dietary Staff (DS) CC tested the Quat sanitizer solution in a bucket used to sanitize kitchen food prep surfaces and dining tables, which resulted 150 parts per million (ppm). During an interview on 12/17/19 at 10:44 AM DS CC reported results of 150 ppm were too low, and effective Quat sanitizer solution concentration levels resulted at or above 200 ppm. DS CC stated she replaced the Quat sanitizer solution and the washcloth in the bucket(s) every two hours, but she . never tested it, or maintained a log for the Quat sanitizing solution. An interview on 12/17/19 at 10:48 AM with DS BB stated the company for the Quat sanitizer solution came to the facility about once per month to maintain the sanitizer and he fully depended on that visit to maintain effective concentration levels. DS BB reported the concentration levels were checked only when there was a concern and he never kept a log for the Quat sanitizer solution. The facility did not provide a policy regarding the use and/or maintenance of Quat sanitizing solutions. The facility failed to maintain the Quat sanitizer solution concentration levels when they did not test and record results or maintain logs of the sanitizer concentration results.

The facility census totaled 48 residents. Based on observation, interview, and record review the facility failed to ensure a safe environment when the facility had an unlocked security exit door on the 300 hall. This had the potential to affect two residents who were cognitively impaired and independently mobile. Findings included: - Observation of the exit door at the end of the 300 hall on 12/16/19 at 11:56 AM revealed the door easily opened, with no alarm activated. Further observation of Licensed Nurse (LN) G revealed she obtained a key from on top of the 300 hall exit door mechanism and re-activated the alarm to the door, which worked correctly after re-activation. Review of Sunshine[NAME]300-Hall Exit Door Check dated 12/10/19 at 10:05 AM revealed the alarm engaged and worked correctly at that time. Interview with Maintenance Staff (MS) U on 12/16/19 at 12:13 PM revealed MS V opened the exit door on 12/12/19 at 04:19 PM. MS U stated maintenance checked door alarms every Monday and believed the facility would have identified the issue during the next routine door check. An interview with Administrative Nurse D on 12/17/19 at 03:35 PM revealed the 300-hall exit door should always be an alarmed door. Interview with Administrative Staff A on 12/16/19 at 12:16 PM revealed staff did not normally use the 300-hall exit door and he expected the door to always be locked and alarmed appropriately. Review of Elopement Sunshine[NAME]Retirement Community policy dated 04/2016 revealed maintenance would test door alarms weekly, or as needed. The facility failed to ensure one exit door remained locked and alarmed.

The facility census totaled 51 residents. Based on record review and interview the facility failed to develop a grievance policy that included the contact information of the grievance official with whom a grievance could be filed, and failed to include a residents right to obtain a written decision regarding his/her grievance. This had the potential to affect all residents. Findings included: - Review of the facility's undated grievance policy identified the Director of Nursing as the contact person for reporting a grievance but failed to include his/her contact information to report a grievance. The policy also failed to include the resident's right to obtain a written decision regarding his/her grievance. During an interview on 6/6/17 at 4:30 PM administrative staff A stated the policy had just been revised in August 2016 and thought it had the appropriate information needed. Staff A stated administrative nursing staff B would be more informed about the new regulations and their changes. The facility failed to have a grievance policy that included appropriate information on how a resident/family/or staff could contact the grievance officer and obtain a written decision about their grievance.

The facility census totaled 51 residents. Based on interview and record review the facility failed to notify police when a resident initially stated he/she wanted to call the police and alleged he/she had been raped by direct care staff G. Findings included: - Review of resident #10's signed physicians orders dated 5/22/17 included a [DIAGNOSES REDACTED]. Review of the admission minimum data set assessment ((MDS) dated [DATE] revealed a brief interview for mental status (BIMS) score of 13 indicating no cognitive impairment. The resident had no hallucinations (sensing things while awake that appear to be real, but the mind created), delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue) and no inappropriate behaviors. The resident required extensive assistance of 1 staff for bed mobility, transfers, and toileting. The resident had continence of bowel and bladder. Review of the 12/2/16 [MEDICAL CONDITION] medication care area assessment (CAA) revealed the resident received [MEDICATION NAME] (an antidepressant medication) which increased the resident's risk for falls. The resident had a history of [REDACTED]. Review of the 12/2/16 activities of daily living CAA revealed the resident fell on ce since admission. The resident had impaired gait and weakness and needed staff assistance with toileting and used the call light for assistance as needed (PRN). Review of the quarterly MDS dated [DATE] revealed a BIMS score of 12, indicating moderate cognitive impairment. The resident required extensive assistance of 2 staff for bed mobility, transfers and toileting. Review of the care plan last reviewed on 3/7/17 revealed the resident had alteration in behavior related to inappropriate sexual overtures towards staff, pulling staff in bed with him/her. Family reported the resident had a long history of viewing care takers in a romantic /sexual perception. Interventions included: Female staff to request assistance of male staff PRN. Staff educated to keep appropriate distance when approaching the resident. May give handshake, pat his/her hand or back. Staff needed to maintain a calm, slow, understandable approach with the resident. Praise the resident when his/her behavior was appropriate. Set expectations and limits for the resident. Explain to the resident that staff were there to help and not for romantic purposes, and utilize two staff when providing care. When the resident started to become socially inappropriate, provide comfort measures for basic needs such as pain, hunger, toileting, or too hot/cold. Review of the facility's investigation dated 5/18/17 revealed administrative nursing staff D told social service staff C the resident stated he/she had been raped the night of 5/17/17. Social service staff C met with the resident and he/she denied being raped by direct care staff G and that he/she asked staff G if he/she wanted to have fun and they engaged in consensual sex. The investigation revealed that per direct staff G at no time during cares on the night of 5/17/17 were there any sexual conversations with the resident or inappropriate touching by her or the resident. The investigation revealed that around 5:00 PM on 5/18/17, 11 hours after the original statement of the resident being raped and wanting the police called, the resident reported to social service staff C that the incident may have been a dream. Review of the progress notes revealed the following: 5/18/17 at 11:02 PM revealed administrative nursing staff D informed social service staff C the resident reported sexual events occurred last night. Staff C spent much time with the resident asking for details and facts. The resident's story changed throughout the interview. Several staff and administrative nursing staff B were consulted. Staff C contacted the resident's family and he/she reported the resident had a history of [REDACTED]. 5/18/17 at 3:48 PM the resident stopped social services staff C and stated that he/she had thought about recent events and believed his/her thoughts were more fantasy than reality. The progress notes included documentation every shift form 5/18/17 to 5/26/17 that the resident did not have any type of sexual behaviors. During an interview on 6/6/17 at 10:11 AM the resident denied every being physically or sexually abused though the resident had difficulty following conversation. During an interview on 6/6/17 at 8:45 AM social services staff C reported the resident did not want the police notified when he/she interviewed the resident. The longer staff C talked to the resident the more his/her story changed. Staff C stated by the time he/she got to the resident to talk to him/her the resident thought he/she might want to call the police and then the residents said he/she did not want to because it was consensual sex. During an interview on 6/6/17 at 1:27 PM social services staff C stated if he/she thought there was anything of credence to the resident's story he/she would have called the police. During an interview on 6/6/17 at 1:50 PM licensed nursing staff H stated the resident had sexual fantasies but had not accused anyone of sexual abuse. During an interview on 6/6/17 at 3:30 PM licensed nursing staff I reported if a resident alleged raped he/she would contact the police and the administrator right away. On 6/6/17 at 11:46 AM administrative nursing staff J stated he/she would have notified administrative nursing staff B and then notified the police unless he/she was told not to. During an interview on 6/6/17 at 12:10 PM administrative staff A reported he/she had heard about the incident during a meeting at 8:30 AM. Staff A stated he/she did not know why social service staff C took the liberty to not call the police first thing that morning but did not think the outcome would have been any different had the police been notified. Review of the Prevention of Abuse, Neglect, and Misappropriate of resident property policy dated 12/13/16 revealed sexual abuse included, but not limited to, sexual harassment, sexual coercion, or sexual assault. If there is any evidence that the incident meets the definition of rape local law enforcement would be notified by the administrator, director of nursing or social worker. Team members would continue their investigation, and defer to law enforcement when requested. The facility failed to contact law enforcement when a resident alleged rape.

The facility census totaled 51. Based on observation, interview and record review the facility failed to transfer 1 of 4 residents reviewed for accidents, according to his/her care plan by failure to use a Hoyer lift (an assistive device that assisted residents to be transferred between a bed and a chair or other similar resting places, using hydraulic power) when a resident could not transfer safely after two attempts and the facility further failed to transfer the resident by the use of a gait belt which led to resident #68 requiring sutures for a laceration to his/her shin. Findings included: - Review of the resident #68's signed physician orders [REDACTED]. Review of the resident's 5 day minimum data set ((MDS) dated [DATE] revealed the resident had a brief interview for mental status (BIMS) of 14, which indicated intact cognition. The resident required extensive assistance of one staff for transfers. The resident had no falls identified on the assessment. Review of the activity of daily living (ADL) care area assessment (CAA) dated 1/3/17 revealed the resident reported he/she had concerns related to not being full of energy. The resident had chronic left hip pain. The resident declined physical therapy and his/her pain pills, at times. Recently the resident was sometimes unable to get up from his/her chair. The resident had difficulty bearing weight with an unstable gait. The resident required 24 hour nursing care. Review of the resident's care plan revealed: 12/28/16 - The resident had a risk for falls related to a cognitive deficit, lack of physical limitations and safety awareness, chronic left hip pain and unsteady gait. 2/13/17 -The care plan directed staff to handle the resident with care during direct care, his/her skin was fragile. 2/20/17 - The resident required extensive assist of 2 staff for transfers with Hoyer lift (an assistive device that assisted residents to be transferred between a bed and a chair or other similar resting places, using hydraulic power) at all times. Review of the care plan change form dated 2/23/17 directed staff to use a Hoyer lift if a resident could not get him/herself up after two attempts. Review of the resident's care plan change form dated 3/14/17 revealed the resident had a large laceration to the right shin and required antibiotics. The care plan directed staff to keep the resident's wound clean/dry until healed and administer antibiotics for 10 days. Staff would use a full lift if the resident resisted treatment or became hard to get up. The care plan directed staff to keep the resident's wheelchair away from the resident until he/she stood up. Review of the progress note dated 3/14/17 revealed the resident had a laceration to his/her right shin from his/her wheelchair related to resistance when he/she got up and the resident locked his/her legs. Review of the progress note dated 3/14/17 revealed the resident returned from the physician's office where sutures were applied to the laceration. The writer could not tell how many sutures the resident had because the physician wrapped the resident's leg. The resident received a physician's orders [REDACTED]. The resident would have his/her sutures removed in 10 days. Staff were directed to keep the resident's wound clean and dry. Review of the facility investigation regarding the laceration revealed the resident received an injury to the right shin. The facility investigation revealed the resident's shin probably hit the resident's wheelchair when the resident was scared and resisted staff while assisting him/her up. The resident had confusion at the time of the injury. Facility staff did not use a Hoyer lift when the resident could not get up on his/her own. Staff present at the time of the injury, knew the resident had confusion and was scared at times. Staff did not follow the resident's care plan regarding transferring the resident. The investigation further revealed staff lifted the resident by getting under each arm and attempted to transfer the resident. An observation on 3/22/17 at 7:38 AM revealed licensed nursing staff G felt the resident's lower right leg for warmth after he/she observed redness/swelling around a Coban wrap (a self-adherent wrap used to secure dressings). Staff G removed the Coban wrap and a dressing from the resident's right shin. The resident reported itching, but no pain in the right leg. Observation of the resident's right leg from mid shin down to the ankle revealed a red color. Nurse G reported he/she used a wound cleanser, dressing, gauze and Coban to secure a dressing to the resident's leg. Once staff removed the old dressing, it revealed a small amount of dark red blood dried on to gauze covering. The resident had sutures in place with no signs or symptoms of infection or further irritation noted to the area. Nurse G cleaned and re-dressed the area on the resident's shin and applied a loosened Coban wrap to the resident's leg to secure the dressing. An interview with direct care staff F at approximately 3:30 PM on 3/22/17 revealed he/she assisted the resident to transfer on the day the resident injured his/her right shin. Staff F tried to let the resident stand up twice. He/she reported the resident's left foot stayed in place on safety strips (stickers on the resident's floor used for traction when trying to stand up). Staff F stated he/she had to put his/her foot in front of the resident's right foot because it kept slipping forward and did not have a safety strip in place. Staff F stated the resident must have hit the wheelchair one of the times the resident's right foot slipped forward. Staff F reported he/she did not use a gait belt (a device used to transfer people from one position to another) or a Hoyer lift on the resident. Staff F and another staff member put their hands under the resident's under arms to assist him/her during the transfer. Once the resident sat down, staff F noticed blood on the floor and began looking for the injury on the resident. Staff F stated the resident had an injury to the right shin. Staff F reported facility staff used a lift since the resident's injury that required the resident to get sutures to his/her shin. An interview with licensed nursing staff G on 3/22/17 at 11:26 AM revealed he/she monitored direct care staff to ensure they performed care according to the care plan by direct observations of resident care, which included transfers. Staff G stated the resident did not always feel like he/she needed help from facility staff. Direct care staff were to give the resident 2 attempts to stand up on his/her own before they used a lift. An interview with administrative nursing staff A on 3/23/17 at 11:30 AM revealed he/she expected residents to be transferred using a gait belt. He/she did not expect direct care staff to use their hands under the resident's under arms to lift residents. He/she expected direct care staff to provide care to residents according to their care plans. Review of the undated facility policy Two-Person Stand Pivot Transfer revealed one caregiver would be on each side of the resident and they would hold on to a gait belt during transfers. The facility failed to transfer resident #68 according to his/her care plan by failure to use a Hoyer lift when a resident could not transfer safely after two attempts and the facility further failed to transfer the resident by the use of a gait belt which led to the resident requiring sutures for a laceration to his/her shin.

The facility census totaled 52 residents with 19 sampled. Two residents were reviewed for death. Based on interview and record review, the facility failed to provide the necessary care and services for resident #42, after a health decline involving an elevated temperature, in spite of antibiotic administration, abnormal vital signs, including low oxygenation, and which required immediate hospitalization for pneumonia and dehydration from a physician office appointment. The resident died four days later. This deficient practice placed the resident in immediate jeopardy. Findings included: - Review of resident #42 ' s signed admission orders [REDACTED]. Review of the physicians progress note dated [DATE] included the following Diagnoses: [REDACTED]. Review of the admission MDS (Minimum Data Set, a required assessment) dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 14 indicating no cognitive impairment. The resident required supervision with 1 staff assistance for most ADLs (Activities of Daily Living) except he/she ate independently. The resident had a fever and shortness of breath when lying flat. The resident had mouth pain or difficulty with chewing, and abnormal mouth tissue. The resident received as needed (PRN) pain medications but did not receive routinely scheduled pain medications. The resident had pain almost continuously that affected his/her sleep, limited his/her activities, and he/she rated the pain a 10, indicating the worst pain possible. Review of the CAAs (Care Area Assessment) dated [DATE] revealed: ADL Functional/Rehabilitation Potential: Resident #42 transferred to the nursing unit from an assisted living apartment after having extensive dental work done for an abscess (cavity containing pus and surrounded by inflamed tissue), extraction, and removal of his/her permanent bridge. The resident could perform most of his/her ADLs with supervision and fed him/herself independently. The resident received a regular soft diet and did not have much of an appetite. The resident needed reminders to rinse out the wound in his/her mouth after each meal. DENTAL: The resident ' s oral wound healed slowly and since the oral surgery, the resident could not eat well and lost weight. Review of the care plan dated [DATE] revealed the resident had weight loss and dental pain with the following interventions: *Rinse out oral surgical site wound with water pick after each meal *Assess condition of oral cavity, teeth, tongue, lips *Encourage resident to consume enough fluids to keep mouth moist *Monitor for decline in cognition *Obtain blood pressures (b/p) as ordered by the physician *Use non medicated pain relief measures, the resident liked staff to apply a cool pack to his/her jaw line where abscess and extractions were *Notify physician of a status change The resident ' s care plan revealed the resident did not require the use of oxygen or any notification parameters for the resident ' s b/ps. Review of the physician standing orders, signed upon the resident ' s admission on [DATE], revealed a standing order for oxygen at 2 Liters/nasal cannula (L/NC) or mask PRN for dyspnea (difficulty breathing) until the doctor could be consulted. Review of the physician progress notes [REDACTED]. The resident reported his/her mouth was ok and did not have much pain. The resident rarely took pain medications. A review of systems indicated no fevers, chills, and no shortness of breath. It also noted a plan to have the facility call him/her if the resident developed fevers again. Review of the vital signs log and nurse notes revealed the following vitals that were outside of normal ranges and/or needed alteration in treatment plan which according to the facility ' s policy needed physician notification of the change in resident status: *On [DATE] at 12:30 AM staff obtained the resident ' s oxygen saturation at 83%. The facility had to initiate oxygen at 2 liters per minute via a nasal cannula per the facility standing orders. According to the Mayo Clinic the normal pulse oximeter readings ranged from 95 to 100 percent, under most circumstances. Values under 90 percent were considered low. At 12:49 AM, the resident had an elevated temperature of 101.9 °F (Fahrenheit). At 6:44 PM, the resident ' s temperature remained elevated at 101.2 °F. The facility failed to notify the physician at any point of the resident ' s abnormal vital signs. The facility also failed to consult the primary physician or the medical director regarding the initiation of oxygen for resident #42. * Review of the nurse note dated [DATE] revealed the resident developed acute heavy breathing and increased confusion. The facility failed to notify the physician. *On [DATE] at 8:47 AM the resident again had a low oxygenation level of 86% with oxygen on at 2 L/NC. Again, staff failed to notify the physician of the change in the resident ' s condition. *On [DATE] at 3:30 PM, the resident had an elevated temperature of 101.3 °F had increased anxiety, increased heart rate of 100, and a low oxygen saturation of 79%. Staff placed oxygen on the resident at 2 L/NC and his/her oxygen saturations increased to 90%. Staff then increased the oxygen to 4 L/NC and his/her oxygen saturation increased to 92%. The resident stated he/she did not feel well. Still, the staff did not notify the physician. * On [DATE], early in the day, the resident had a rapid, fluctuating heart rate between 82 and 107 beats per minute and low oxygen saturation of 84%. At 10:23 PM the resident spiked an elevated temperature of 103.1 °F with respirations at 32 per minute. The nursing staff gave the resident [MEDICATION NAME] which lowered the temperature to 102 degrees F and the respiratory rate also decreased to 24 per minute. Even though the resident had an elevated temperature, low oxygenation, and a breathing rate of nearly double the normal rate, staff did not notify the physician and no changes were made to his/her care. * On [DATE] at 8:15 AM the resident developed acute shaking, shortness of breath and reported he/she felt cold. The resident ' s oxygen saturation was 71% on room air (without oxygen) and he/she had a fever of 100.3 degrees F. The nursing staff put oxygen on the resident at 4 L/NC and contacted the resident ' s family, 3 days after the recurrence of an elevated temperature and significant changes in the resident status. The resident ' s family agreed he/she needed to see the physician, so staff made the resident a physician appointment. *On [DATE] at 11:59 AM the facility was notified the resident admitted to the hospital. *On [DATE] at 1:54 PM the facility was notified from the hospital the resident deceased . Review of the physician visit progress note dated [DATE] revealed the physician assessment included fever. The physician ' s plan was to admit the resident, administer intravenous fluids for dehydration, obtain a chest x-ray, labs, and cultures. The physician noted the resident came in for a sick call appointment with a fever of 103.1 degrees F and he/she was very shaky. The physician wrote the resident started having fever again today up to 103 degrees F. The resident ' s lung sounds were decreased on both sides. Review of a Discharge Summary from the hospital dated [DATE] revealed at the time of death the resident had pneumonia. He/she admitted with fever, chills, and pneumonia. The resident rapidly declined showing marked [MEDICAL CONDITION] (inadequate oxygenation) and expired on [DATE]. Review of a Post Mortem (after death) form dated [DATE] at 12:35 AM revealed the primary cause of death listed as respiratory arrest. During an interview on [DATE] at 9:38 AM the resident ' s family stated the resident ' s death was unexpected and he/she did not think the resident would die from a mouth infection. The resident ' s family stated the facility contacted him/her about a fall he/she had during the night and again when the facility wanted to send the resident to the doctor, but did not notify him/her of the resident ' s fevers or the need to wear oxygen until the resident got so sick he/she needed to see the physician. He/she stated the resident never wore oxygen before the episode prior to his/her death and did not really have any other health problems. The family member stated he/she was very surprised the resident continued to decline. During an interview on [DATE] at 3:19 PM direct care staff A stated the resident had major dental issues, had a bad infection in his/her mouth that was his/her main problem. The resident came from assisted living. Staff A stated towards the time the resident left the facility, the resident had oxygen on, had a lot of mouth pain, had an elevated temperature and one time his/her oxygen was 79% and the nurse put oxygen on and it came up to 90%. Then the nurse increased the oxygen and the residents saturation increased to 94%. Staff A stated the resident lived in the facility only for a short while. During an interview on [DATE] at 3:31 PM direct care staff B stated the resident came from assisted living and needed very little assistance. During an interview on [DATE] at 12:53 PM licensed nursing staff C stated the resident came over from assisted living and had a lot of teeth problems with mouth pain. The resident received different antibiotics but his/her mouth did not seem to get better. The resident continued to decline, but per staff C ' s report, the doctor would not do anything else for the resident while he/she lived in assisted living, so the resident admitted to long-term care. Staff C stated the family knew of the resident ' s condition and they kept trying to get the resident into the hospital but the doctor would not order it. Staff C stated before the resident went to the doctor he/she started to breathe heavier almost like he/she was septic (a systemic blood infection) from having so much mouth pain. Staff C stated the resident seemed dehydrated, and staff tried to get him/her to drink but the resident would not drink much because of the pain. Staff C stated after the nurse talked to the family member, staff called the physician again and got an appointment for the resident. Staff C reported resident #42 admitted to the hospital for dehydration. During an interview on [DATE] at 2:38 PM licensed nursing staff D stated if there was anything pertinent in a physician progress notes [REDACTED]. In regards to the physician progress notes [REDACTED]. During an interview on [DATE] at 2:57 PM administrative nursing staff E stated the facility met not that long ago and discussed physician notes were not considered orders. Staff E stated even with the physician documenting for the facility to contact him/her if the resident developed a fever again it was not an order. Staff E stated there was another form that went with the resident to the appointment for the physician to write any orders. Staff E stated it could be ,[DATE] days or even longer before the facility received the progress notes from the physician. During an interview on [DATE] at 10:23 AM administrative nursing staff E stated with the primary care physician not responding to the nursing staff concerns while the resident was in assisted living and then still not addressing concerns in long-term care, staff should have contacted the medical director to have him/her step in and see if he/she could get the physician do something more than oral antibiotics. During an interview with physician F on [DATE] at 1:11 PM revealed the facility notified him/her of the resident ' s fevers and rapid decline in the time directly before admission to the hospital. The physician stated he/she did not know if the facility used oxygen for the resident. Physician F reported he/she did not have any notification parameters for vital signs. He/she reported he/she expected the nurses to use their clinical judgment to notify him/her if needed. During an interview on [DATE] at 3:37 PM physician G stated it would be appropriate for nursing staff to inform the physician when a resident developed a fever after being on antibiotics. He/she also stated if the nursing staff initiated anything off of the standing orders such as oxygen the physician needed to be notified. Review of the guidelines for notifying physicians of clinical problems dated ,[DATE] revealed staff were to notify the resident ' s physician whenever there was a significant change in the resident ' s condition or a need to alter treatment significantly. It also revealed the licensed nurses had the responsibility of contacting a physician any time they believed a resident developed a clinical problem which required physician intervention. It also revealed the resident ' s legal representative or interested family member should be notified of a significant change in the resident ' s status unless the resident had specified otherwise. It also directed staff to notify the physician immediately for an oral temperature greater than 101 degrees F, respirations greater than 28, and/or an acute onset of shortness of breath/labored breathing. It also identified immediate notification meant a physician should be informed at the time the event occurred directly via an electronic or telephone call system. Review of the standing orders policy dated ,[DATE] revealed standing orders were to be used in stipulated clinical situations when a physician was not readily available and the physician determined that a licensed nurse may use clinical judgement without direct consultation prior to the nursing intervention. The facility failed to provide the necessary care and services for resident #42, who experienced a significant change in condition involving poor oxygenation and elevated temperatures. The staff failed to notify the physician for interventions, which led to direct hospitalization with pneumonia and dehydration, and ultimately death. This failure placed the resident in immediate jeopardy. The immediate jeopardy deficient practice was abated from a scope and severity of a J to a scope and severity of a G on [DATE] when the facility educated licensed nursing staff regarding physician and medical director notification, and updating their policy for Notification of the Physician.

The facility reported a census of 52 with 19 residents included in the sample. Based on observation, interview and record review the facility failed to assess the resident's for risk of falls, and develop and implement interventions for resident #39 to prevent further falls with fractures. Findings included: - Review of resident #39's signed physician orders [REDACTED]. Review of the significant change MDS (minimum data set) dated 5/7/15 although not signed as completed till 5/20/15 revealed a BIMS (brief interview for mental status) score of 5, indicating severe cognitive impairment. The resident required extensive assist of one with bed mobility, transfers and toileting. The resident was non-ambulatory in the halls and ambulated in the room with assist of one staff and use of a walker. The resident used a wheelchair for all other mobility. The resident had occasional urinary incontinence and frequent bowel incontinence. No falls were documented on the MDS. The resident received an antidepressant and a diuretic 7 days a week. The resident used oxygen. Review of the CAAs (care area assessments) dated 5/22/15 revealed the following: ADL (activities of daily living) CAA- The resident had a lot of confusion and recently fell resulting in fractures to the wrist. The resident needed extensive assistance with all ADLs. The resident would have a tab alarm whenever he/she lay in bed. The resident used a wheelchair as he/she could not put any weight on his/her right upper extremity to be able to use a walker. Fall CAA- The resident fell on [DATE] in the evening. The resident's room was at the end of the hall. The resident had a lot of confusion and got up by him/herself at times. Staff were to supervise the resident with transfers and ambulation. The resident received a fractured wrist from the fall and continued to be at risk for falls with injury. A silent alarm (an alarm that triggers the staff's pagers and did not have an audible alarm) needed to be on the resident when he/she lay in bed. The wheelchair needed to be next to the bed. Review of a fall risk assessment completed on 7/15/15 indicated the resident had an increased risk for falls. No other fall assessments were found in the electronic record. Review of the care plan with a date of 4/2/15 revealed: Resident had an increased risk for falls related to unsteady gait. Approaches included: - Assure the resident wore eye glasses. Assure they were clean and in good repair. - Give the resident verbal reminders not to ambulate/transfer without assistance. - Keep the call light within reach. - Keep personal items and frequently used items within his/her reach. - Provide proper, well-maintained footwear. - Provide an environment free of clutter. - Provide toileting assistance before and after meals, before bed and PRN (as needed). Staff made the following updates to the care plan: 5/18/15 to include: - Use a hi/lo bed (a bed that could be lowered with the mattress almost touching the floor or can be elevated for care giving) - Use of a silent alarm when in bed. 5/28/15 to include: - Check for UTI (urinary tract infection). - Toilet the resident around 10 p.m. rounds. - Use a silent alarm in bed and wheelchair. - Keep his/her wheelchair next to the bed with the brakes locked. - Use a body pillow in bed to aide in positioning. - The resident needed a different nightgown not made of silk for the tab alarm. 7/26/15 to include: - Use longer oxygen tubing. Review of the temporary care plan dated 7/31/15 revealed the resident returned to the facility following a fall and fractured femur after surgical repair. The resident had a history of [REDACTED]. The resident required assistance of 2 staff with transfers. Review of the nurse notes dated 5/9/15 revealed FALL: The resident was on the floor in the doorway to his/her room, when asked what he/she was doing the resident stated that's a good question. The resident denied hitting his/her head but had an abrasion above the right eye, and reported the right wrist hurting. ROM intact, neurological (neuro) checks started. Hospice contacted. Staff assisted the resident back to bed, and the nurse placed a cold compress on the right side of his/her forehead. No other injuries noted. Review of the facility investigation for a fall on 5/9/15 revealed: At 8:50 p.m., the resident was found in the doorway to his/her room. When asked what he/she was doing, she stated that's a good question. The resident denied hitting his/her head, but had an abrasion above the right eye. The resident complained of his/her right wrist hurting. ROM (range of motion) and vitals were WNL (within normal limits).Licensed nurse I started neuro checks (a group of assessments including grip, muscle strength and size of eye pupil to monitor for brain injury) notified Hospice. Staff assisted the resident back to bed with cold compress placed on right side of his/her forehead. The root cause included resident did not call for assistance and did not use the walker, but did not address what the resident needed at the time of the fall that caused him/her to get up unassisted. On 5/13/15, his /her physician saw the resident because of continued pain in his/her right wrist. Review of the physician visit form revealed the resident had the wrist x-rayed, which revealed 2 fractures. The physician placed a Velcro brace on the resident's right wrist. The resident was also instructed not to use the walker and no weight bearing on the right arm. The nurse on duty contacted the DPOA (durable power of attorney) with the results of the x-ray and physician orders [REDACTED]. No walker and no weight to wrist. The resident had pain medication ordered for pain. Review of the CNA/CMA witness statement dated 5/9/15 at 8:50 p.m. direct care staff H reported last seeing the resident at 7:30 p.m. after the movie in the common area ended. The CMA (certified medication aide) gave the resident his/her medication and the resident was toileted at 7:45 p.m. with staff assistance. The resident was in bed with the call light attached. Review of the witness statement from licensed nurse I dated 5/9/15 revealed observing the resident in bed when taking ice cream to another resident on the hall at 8:40 p.m. At 8:50 p.m. the resident fell . On 5/12/15 at 6:41 p.m., the primary care physician returned a fax sent to him/her regarding continued pain in wrist. The fax had an order to have the resident ' s wrist x-rayed on 5/13/15. On 5/13/15, x-ray revealed 2 fractures. The physician placed a Velcro wrist brace on the resident's right wrist. Review of the nurse's notes dated 5/10/15 revealed the resident resting in bed. Neuros WNL. The Hospice nurse here to see resident and requested the resident receive PRN (as needed) Tylenol for right wrist pain. Review of the nurse's notes dated 5/10/15 revealed family here to visit, concerned about the resident ' s complaint of pain in wrist. Resident given Tylenol and an ace wrap applied to the wrist. Family requested to be informed if the Tylenol and the ace wrap did not ease the pain, and at that point, the family will decide whether they want the resident to have x-ray done. Review of the nurses notes dated 5/10/15 at 2:26 p.m. revealed the resident alert with confusion. The resident denied pain in his/her wrist at that time and rested in bed. Review of the nurses' notes dated 5/11/15 at 12:14 p.m. revealed the family reported they may take the resident to the doctor today to have an x-ray. Review of the nurse note dated 5/28/15 at 3 AM revealed the resident fell at 11 p.m. The nurse notified the physician, family, and hospice of the fall. The resident rested in bed with his/her eyes closed. Staff offered the resident water throughout the night and ensured his/her call light remained within reach. Staff monitored the resident closely. Review of the facility fall investigation dated 6/3/15 revealed on 5/27/15 at 11:00 p.m. the resident was on the floor next to his/her bathroom at 11:00 p.m. The resident stated he/she was trying to go to the bathroom. The tab alarm had slipped off his/her silk nightclothes. The resident had a rug burn to his/her forehead and nose. Neuro checks were started and the resident complained of pain to the right wrist fractured in a previous fall on 5/9/15. Resident was on hospice services and lived on the memory care unit. Interventions that were put in place included a silent pressure alarm, a hi-lo bed, and toileting at 10 p.m. rounds. Dipstick urine was negative for a UTI (urinary tract infection). Staff failed to document the last time when the resident was last toileted. The investigation failed to determine a root cause for the fall to determine if a different toileting plan was necessary. Review of the nurse note dated 7/27/15 this nurse was called to MCU (memory care unit) due to staff finding resident #39 on the floor from a fall. The resident sat on his/her buttock with his/her back close to the wall. The left leg sat out straight in front of him/her and the right leg sat bent at a 45 degree angle outwards. The resident could move all extremities except the right leg. The resident could move and feel his/her toes on the right foot. When the nurse attempted to do slight passive ROM (range of motion) to the right leg or the resident attempted to move the right leg, he/she started crying in pain. While at rest, the pain decreased. The nurse notified the physician and Hospice and after hospice spoke with resident's family, the physician ordered to send resident #39 to the ER (emergency room ) by ambulance for further examination. The resident left by ambulance at 7:30 a.m. Review of the witness statements dated 7/26/15 revealed direct care staff K was heading down the hall to help get residents up at 6:40 a.m. when a staff member hollered that a resident had fallen. The resident was sitting on the floor leaning with his/her right side against the wall. The resident's right leg was bent and he/she could not straighten it out. Review of the facility investigation dated 7/30/15 revealed: on 7/26/15, staff observed the resident on the floor in his/her bedroom at 6:41 a.m. The resident sat on his/her buttocks with his/her back close to the wall and his/her oxygen on and the tube stretched out. The resident's left leg sat straight in front of him/her, and his/her right leg was bent at a 45 degree angle outwards. The resident complained of pain when the right leg slightly moved. Staff notified the physician and received orders to send the resident to the ER (emergency room ) by ambulance. The resident was diagnosed with [REDACTED]. The resident had a BIMS score of 5 and resided in the memory care unit. All fall interventions were in place at the time of the fall, which included hi-lo bed in lowest position, body pillow in place to aid in positioning, silent alarm, and w/c parked next to his/her bed. The alarm went off but staff were in other resident rooms. The resident had been toileted at 5:00 a.m. The investigation failed to determine a root cause for the fall to what the resident was trying to do. Observation on 8/4/15 at 3:14 p.m. revealed the resident in bed sleeping. The resident lay on his/her left side with pillows and a body pillow behind the resident. An alarm was on the bed and call light attached to the positioning bar. The bed was in the low position. Observation on 8/5/15 at 8:11 a.m. revealed direct care staff J and direct care staff K took the resident from the dining room to his/her room to lay down following breakfast. Staff J and staff K placed a sling for the total body lift behind the resident and staff K lifted the resident's right leg to slide sling under the fracture side. Staff J and K then transferred the resident to bed. Staff K sat the resident up to remove the sling. Staff J and K gently turned the resident to the left side with a pillow under the right leg and a body pillow behind. The resident had a bandage running the length of the upper thigh that was clean and ace wrapped from the upper thigh to the toes. The resident denied any pain with transfer. During an interview on 8/4/15 at 3:15 p.m., direct care staff L reported the resident required total care with all ADLs since he/she returned from the hospital after his/her fall on 7/26/15. Staff offered toileting at least every 1 1/2 hours. The resident voided when staff offered toileting but then tried to get up on his/her own right after the fall on 7/26/15. During an interview on 8/4/15 at 4:00 p.m., direct care staff M reported the resident was very impulsive and if he/she wanted to get up he/she would get up. The resident's room was clear at the end of the hall and when the resident's alarm went off staff M reported it was hard to hear. So when staff checked on the resident he/she would be on the floor. During an interview on 8/5/15 at 7:05 a.m. direct care staff N reported at the time of this last fall on 5/27/15 he/she heard the alarm but by the time staff got to his/her room the resident had tried taking him/herself to the bathroom and was on the floor on 7/26/15. During an interview on 8/5/15 at 7:25 a.m., direct care staff K reported he/she could hear the alarm but thought staff could get to the resident faster if the resident lived closer to the common area and not the last room on the hall. During an interview on 8/4/15 at 3:30 p.m. licensed nurse D reported when a resident fell on the memory care unit after the care coordinator had left for the day the nurse from one of the other units covered the MCU and took care of falls or whatever else needed done. During an interview on 8/4/15 at 4:00 p.m. administrative nurse O reported that the resident fell on [DATE] but nurse O did not add updates to the care plan till 5/18/15 due to being on vacation. Nurse O reported he/she did not think to do another significant change assessment following the fall with fractures since he/she was still completing the last MDS During an interview on 8/5/15 at 11:30 a.m. administrative nurse E reported that the facility had started a new fall program using the 10 questions form asked of staff as to why the resident had fallen. The facility was collecting the data but had not developed a program to utilize the data for prevention of falls. The resident's falls were discussed in weekly risk meeting but he/she did not know if the committee identified the root cause analysis for the falls. Review of the policy Fall Prevention and Management Protocol dated 6/2014 revealed: Each resident will be assessed for the risk factors for falling at move in, return from a health care facility and after a fall in the facility. The facility failed to assess the resident for risk of falls, and develop and implement interventions for resident #39 to prevent a fall resulting in a fracture.

The facility census totaled 50 residents, with 17 included in the sample. One resident was reviewed for burns related to hot foods. Based on observations, record review, and interview the facility failed to ensure appropriate assistive devices (reusable bowl and a tray) to prevent hot food from spilling on 1 resident's thighs causing second degree burns (#10). Three residents were reviewed for falls. Based on observations, record review, and interview, the facility failed to thoroughly investigate all falls and implement effective fall interventions to prevent accidents for 1 of the 3 residents (#53). Based on observations, record reviews, and interviews the facility failed to ensure the residents' environment remained free of accident hazards by the failure to properly secure chemicals. This had the potential to affect 16 cognitively impaired and independently mobile residents. The facility also failed to ensure the residents' environment remained as free of accident hazards as possible related to the failure to maintain hot water temperatures in a safe range in resident accessible areas. This had the potential to affect 25 independently mobile residents. Findings included: - Review of resident #10's significant change MDS (Minimum Data Set) dated 11/19/13 revealed a BIMS (Brief Interview for Mental Status) score of 15, indicating no cognitive impairment. The resident had no difficulty understanding others or making him/herself understood. He/she had no impairment in range of motion. The resident admitted to the facility on [DATE]. Review of the quarterly MDS dated [DATE] revealed a BIMS score of 15, indicating no cognitive impairment. The resident had no difficulty understanding others or making him/herself understood. He/she had no impairment in range of motion. Review of the ADL (Activities of Daily Living) Functional Status/Rehabilitation CAA (Care Area Assessment) dated 11/19/13 revealed, the resident became more independent with activities of daily living. Review of the Nutrition CAA dated 11/26/13 revealed, when the resident did not feel good he/she would order a room tray. Review of the resident's care plan initiated 8/12/13, revealed interventions directed staff to allow the resident to choose a supplemental diet if possible. The care plan alerted staff the resident received a regular diet three times a day and he/she could choose between cafe and buffet style meals. An undated revision to the care plan notified staff the resident requested to eat meals in his/her room at times, directed staff to serve the resident on a tray and educate the resident on food temperatures as well as safe strategies to keep food on his/her table. An undated revision to the care plan alerted staff the resident experienced pain with his/her burn and the resident would remain free from pain. Interventions directed staff to address the resident's pain with medications, apply a hot or cold compress as ordered, assess the effectiveness of pain medications, assess the characteristics of the resident's pain and encourage the resident to report any pain. Review of a nursing note dated 3/23/14 at 6:53 p.m. revealed the resident wanted to stay in his/her room for supper and asked the staff for chicken noodle soup. Staff warmed a can of soup in the microwave in a Styrofoam bowl and then placed a small Styrofoam plate underneath it. Staff took the bowl and plate to the resident's room and placed it on his/her tray next to him/her. Staff told the resident it was hot and asked if he/she wanted anything else. The resident requested ice cream and coffee. Staff went to the nutrition room and got the ice cream and as the staff took it into the resident, the resident spilled the soup from the Styrofoam bowl on his/her lap and the bowl fell to the floor. Staff got some cool washcloths and placed them on the resident's lap immediately. Staff then removed the resident's pants and placed the cool washcloths on his/her skin which was reddened. Staff applied icepacks covered with towels to the resident's thighs. Staff notified the physician and received an order to transfer the resident to the emergency room (ER). Review of ER Discharge Instructions dated 3/23/14, revealed the resident had a [DIAGNOSES REDACTED]. The wounds were cleaned and covered with Neosporin and gauze. On examination the right thigh had blistering and slough (dead tissue, usually cream or yellow in color) to medial (extending toward the middle) aspect and ran to the buttock which covered approximately 3% of the thigh. The resident's left thigh had blistering and no slough which covered 2% of the thigh. Review of a nursing note dated 3/23/14 at 10:33 p.m. revealed the resident returned to the facility with orders for a dressing change daily with Triple Antibiotic Cream and Vaseline and to follow-up with the physician in 1-2 days. Review of a nursing noted dated 3/24/14 at 3:54 p.m. revealed a new order for Silvadene (cream containing antimicrobial agent) cream to burn areas. Review of a nurse to physician fax dated 3/28/14, revealed a new order for Keflex 500 mg (milligrams) three times a day for 7 days due to green, purulent (producing or containing pus), and foul drainage, and to change the wound dressing to Xeroform (type of wound dressing) every other day and as needed until it healed. Observation on 4/9/14 at 11:08 a.m. revealed licensed nursing staff N went into the resident's room to change the right thigh dressing. The resident sat in the recliner. His/her right inner thigh had reddish-purple discoloration, peeling skin, and scabs. Staff N cleansed the area with wound cleanser, patted it dry, and applied a dressing. The resident winced when Staff N touched the area and had a painful facial expression. The resident's left thigh had redness, peeling skin, and remained open to air. Observation on 4/14/14 at 11:30 a.m. revealed dietary staff O took the temperature of chicken noodle soup on the steam serving table, recorded a temperature of 192 degrees Fahrenheit (F). He/she also recorded a temperature of 184 degrees F for the taco soup on the steam table. Interview on 4/9/14 at 3:00 p.m. with the resident revealed he/she received the thigh burns spilling soup. He/she reported a staff member brought the soup in a flimsy cup and placed the cup in his/her lap while he/she sat in the recliner. The resident thought the soup was made in the microwave and was too hot. Interview on 4/9/14 at 3:53 p.m. with direct care staff P revealed the resident sometimes ate in his/her room. Staff P reported the wounds on the resident's thighs were from soup burns which occurred while the resident ate in his/her room during lunch. Staff P thought the resident sat in the recliner and was unsure if the spill was witnessed. He/she reported the resident did not normally have difficulty with eating. Interview on 4/10/14 at 11:32 a.m. with direct care staff Q and R revealed hot soup spilled on the resident during second shift while the resident ate in his/her room. Interview on 4/10/14 at 2:03 p.m. with direct care staff R revealed new interventions to prevent the resident from burning him/herself with food required staff to check the temperature of food with a thermometer when the staff warmed food for the resident and staff were to put the food on the resident's table. Staff R stated the resident liked to put his/her food on his/her lap. Interview on 4/10/14 at 3:08 p.m. with licensed nursing staff S revealed the resident spilled something on him/herself and staff S did not know if the resident was in his/her room or the dining room when it happened. Staff S did not know if interventions were in place to prevent the resident from burning him/herself again. Interview on 4/14/14 at 9:15 a.m. with licensed nursing staff N revealed the staff performed the resident's dressing changes to the burn areas. Staff N reported the burn happened on a weekend due to spilled soup while the resident was in the recliner in his/her room. He/she reported new interventions since the burn directed staff to use a thermometer to check food temperatures and to serve food to the resident in a regular bowl on a tray with all necessary utensils. Interview on 4/14/14 at 1:45 p.m. with dietary staff T revealed he/she did not like to serve food in resident rooms due to the possibility of accidents. Staff T also reported the resident who received burns had been served the soup in a Styrofoam bowl on his/her lap. Staff T revealed he/she expected staff to serve food in a regular bowl on a tray and use a thermometer to take the temperature of the soup. He/she also stated since the incident that he/she had directed staff to serve hot items between 115-140 degrees F. He/she reported he/she had not thought to examine the practice of serving hot soup from the main kitchen either before or after the incident related to the burn. Interview on 4/15/14 at 9:53 a.m. with administrative nursing staff C revealed, at the time of the burn the resident wanted to watch television in his/her room and requested a bowl of soup. The staff heated the soup in a microwave in the nutrition room, put it in a Styrofoam bowl, took it to the resident, and educated the resident that the soup was warm. The resident placed the Styrofoam bowl in his/her lap and it spilled. Staff C confirmed interventions to provide trays when serving food on the unit so the resident could eat with the tray in his/her lap, change the type of bowl from Styrofoam to a microwaveable, insulated bowl, and thermometers were placed in the nutrition room as well as a listing of safe heating temperatures were added to the resident's care plan after the burn. Staff C reported staff members had served soup in Styrofoam bowls to residents in their rooms and had not had any other incidents in the past. During a meeting on 4/15/14 at 4:00 p.m. administrative nursing staff D revealed he/she served the resident the soup on 3/23/14. At the time of the incident Staff D reported he/she put the soup in a Styrofoam bowl, placed the bowl on the resident's side table, and the resident put the bowl on the resident's lap. Interview on 4/16/14 at 3:04 p.m. with physician Z revealed treatment to the resident's burns began with applying Silvadene daily, but the resident did not like the treatment and continually pulled the dressing off. Physician Z changed the dressing to apply Xeroform daily and the resident was more satisfied with this treatment. He/she revealed when he/she last saw the resident the left thigh wound had healed satisfactory with some dryness and the right thigh wound was a deeper wound approximately 1 x 3 cm (centimeters). Physician Z reported he/she had concerns about superficial, greenish drainage reported by staff and started the resident on an antibiotic to prevent secondary infections. The facility did not have a policy for safe food temperatures when requested on 4/14/14 at 1:45 p.m. The facility failed to serve food in a reusable bowl with a tray. Resident #10 accidentally spilled food served in a Styrofoam bowl on his/her lap resulting in in a second degree burn to the resident's thighs. - Review of resident #53's signed history and physical sheet dated 4/11/13, revealed he/she had the following Diagnoses: [REDACTED]. cannot use glucose, not enough insulin is made or the body cannot respond to the insulin) without mentions of complications, Ileus of bowel (an obstruction of the intestines, cause by immobility of the bowel) and urinary incontinence. Review of the annual MDS (Minimum Data Set) dated 12/12/13 revealed a BIMS (Brief Interview for Mental Status) score of 14, indicating the resident had no cognitive impairment. The resident had moderate difficulty hearing and unclear speech. He/she usually made self understood and understood others. The resident had moderately impaired vision with use of corrective lenses. The resident did not exhibit wandering, rejection of care or any other behaviors. The resident required limited assistance for bed mobility, transfers, dressing, toilet use and personal hygiene. He/she required supervision with walking in room, corridor and locomotion on/off the unit. The resident had a steady gait at all times for walking and turning around. The resident did not have a steady gait but able to stabilize with staff assistance for moving from seated to standing, moving on and off the toilet and surface to surface transfers. The resident had frequent incontinence of bladder and a trial toileting program had not been attempted. The resident did not have any incontinent episodes of bowel. The resident had a fall in the month prior to admission. The resident had a fracture related to a fall in the six months prior to admission. He/she had not had a major injury fall and he/she had one minor injury fall. During the seven day look back period the resident received an anticoagulant. The resident received occupational and physical therapy. He/she admitted to the facility on [DATE]. Review of the quarterly MDS dated [DATE] revealed a BIMS score of 15, indicating he/she had no cognitive impairment. The resident had moderate difficulty hearing and unclear speech. He/she usually made self understood and understood others. The resident had moderately impaired vision with use of corrective lenses. He/she did not exhibit rejection of care. The resident was independent with bed mobility, transfers, walking in room and corridor, locomotion on/off the unit, toilet use and personal hygiene. The resident required supervision with dressing and eating. The resident had a steady balance at times. The resident had occasional incontinence of bladder and a toileting program had been attempted. The resident did not have a toileting program at the time of the assessment. The resident did not have any incontinent episodes of bowel. The resident had a fall since admission or reentry. He/she had no major injury falls and one minor injury fall. During the seven day look back period the resident received an antidepressant. The resident did not receive any therapy or restorative nursing. Review of the Visual Function CAA (Care Area Assessment) dated 12/18/13 revealed the following, the resident had a previous cataract surgery which helped his/her vision. The resident had weak eye muscles secondary to Parkinson's Disease and [DIAGNOSES REDACTED] (a rare brain disorder that causes serious and progressive problems with control of gait and balance, along with complex eye movement and thinking problems), and had developed double vision. Review of the Communication CAA dated 12/18/13 revealed the following, the resident had a [DIAGNOSES REDACTED]. The resident had difficulty hearing and refused to wear hearing aids. The resident responded slowly and often mumbled words. The resident had good visuo-spatial skills, fair recall ability and poor orientation to time. Review of the ADL Functional Status/Rehabilitation and Fall CAA dated 12/18/13 revealed, the resident was initially admitted to assisted living, he/she moved to the nursing home for one month of rehabilitation, then returned to the assisted living for three days and had increased back pain during that time. He/she had to be hospitalized and then readmitted to the nursing home. The resident required stand-by assist to limited assist for transfers and ambulation. He/she used a walker for ambulation. Review of the Urinary Incontinence CAA dated 12/18/13 revealed, the resident reported occasional incontinence. Prior to admission to the hospital the resident wore a pad with underwear. He/she wore a pull-up at the time of assessment. The resident had been educated to pull his/her call light when he/she needed assist with toileting due to problems with clothing management. Occupational therapy worked with the resident on those skills. Review of the resident's care plan for Falls initiated 12/19/13 revealed, interventions directed staff to assure the resident wore eye glasses and assure the glasses were clean and in good repair. The care plan alerted staff to provide the resident with verbal reminders not to ambulate or transfer without his/her assistive device. The care plan also directed staff to keep the bed in the lowest position with brakes locked; keep the call light, personal items and frequently used items in the resident's reach; and provide proper well-maintained footwear. Review of the care plan for ADL (Activities of Daily Living) Functional Status/Rehabilitation initiated 12/19/13 revealed, interventions directed staff to instruct the resident in proper ambulation techniques, and keep the area free of clutter and obstacles. Revision on 4/4/14 revealed, intervention alerted staff to provide stand-by assist when the resident requested. Review of the care plan for Visual Function dated 12/19/13 revealed, interventions alerted staff to assure the floor remained free of glare, liquids and foreign objects; and encourage the resident to report any changes in vision. An undated revision directed staff to encourage the resident to use the call light when he/she felt dizzy or weak and install a second call light for easy access. A revision dated 4/7/14 revealed an intervention alerted staff the resident had been non-compliant with a stool riser with handles placed in the resident's bathroom. Review of a fall investigation dated 11/3/13 revealed, staff found the resident sitting on his/her buttocks in his/her bedroom at 9:45 a.m. The resident walked in his/her room without stand-by assist and lost his/her balance before the resident reached his/her wheelchair and fell on his/her buttocks. The resident had a small bruise on his/her back. Staff last checked on the resident at 9:15 a.m. and assisted the resident to the bathroom. He/she had his/her last meal at 8:30 a.m. Review of a nursing progress note dated 3/15/14 revealed, the resident fell at 3:45 a.m. and called for help, staff found the resident on the floor in the bathroom. He/she had a red mark and scrape on the lower left side of his/her back. The facility did not identify the root cause of the resident's fall. Review of a fall investigation dated 4/1/14 revealed staff found the resident on the floor in front of his/her recliner with an abrasion (a scraping or rubbing away of a surface, such as skin, by friction) to his/her mid-back. The facility did not identify the root cause of the resident's fall. Review of a fall investigation dated 4/7/14 revealed the resident walked into his/her bathroom using a walker, he/she walked backward out of the bathroom holding a stool riser placed on his/her toilet and fell . Observation on 4/9/14 at 11:39 a.m. revealed the resident ambulated from his/her room to the dining room using a chair walker and assist of a family member. He/she had a slow, steady gait. Observation on 4/9/14 at 1:52 p.m.-2:30 p.m. the resident laid in bed with his/her door door closed and 14 staff members passed by his/her room without checking on the resident. The resident did have a call light in place near the bed and one near the recliner. Interview with the resident on 4/10/14 at 3:45 p.m. revealed, the resident fell on [DATE] when he/she took him/herself to the bathroom and his/her walker was not in reach. Interview on 4/14/14 at 9:05 a.m. with direct care staff Q revealed, staff assist the resident to the bathroom when the resident felt weak. The resident did not require assistance unless he/she had back pain, then staff assisted the resident with transfers and ambulation. Staff Q reported the resident used his/her chair walker to ambulate. The resident fell a couple weeks ago in the morning when the resident tried to remove a stool riser placed on his/her toilet, the resident did not have any injuries from the fall. Staff placed the riser in the resident's bathroom due to the toilet being too low. Interview on 4/14/14 at 2:04 p.m. with direct care staff U revealed, he/she did not think the resident had any falls as of recent. Staff U checked the care plan for interventions to prevent the resident from falling. Interview on 4/14/14 at 9:25 a.m. with licensed nursing staff N revealed, the resident asked for assistance as needed. Staff N reported the resident requested assistance to the dining room over the weekend. Staff N reported he/she encouraged the resident to ask for help if the resident felt weak. He/she revealed a fall occurred due to the resident attempted to remove a toilet riser placed in the resident's bathroom, which the resident did not like, while walking backwards the resident lost his/her balance and fell . Staff N reported the resident came to the nursing unit for rehabilitation from assisted living, but once the resident returned to assisted living he/she had another fall. Staff N reported after a resident fell he/she would make sure the call light was in place, the floors were not cluttered, notify the family and physician within 30 minutes of the fall and, update the care plan. Interview on 4/14/14 at 2:25 p.m. with licensed nursing staff V revealed, the resident had a fall within last 30 days. Staff V reported the resident used a walker had non-skid strips in front of his/her chair, and the resident had two call lights in his/her room. Interview on 4/15/14 at 10:00 a.m. with administrative nursing staff C revealed, after a fall he/she would expect staff to check the resident's Medication Administration Record (MAR) for new medications; correct any immediate safety concerns in the resident's room such as non-skid strips, clutter, and furniture that had been rearranged. He/she would also expect staff to assess the resident for a change in the resident's cognition; dehydration; a UTI (urinary tract infection), and a footwear problem. He/she expected staff to determine the root cause of the fall immediately, then during the QA (Quality Assurance) Committee meeting Staff C would assess the root cause of the fall. Staff C compiled a report weekly and quarterly with numbers analyzing falls per shift and hall and he/she would know if staff need additional education and training. Review of the facility's Fall Prevention and Management Protocol, revised, 8/11, revealed each resident would be assessed for risk factors for falls at move in, return from a health care facility, and after a fall in the facility. After a fall, each fall would be investigated and corrective actions would be implemented. In the Interdisciplinary Notes the circumstances around the fall and corrective actions would be documented. The facility failed to investigate the root cause of the resident's falls to implement appropriate fall interventions and to prevent further falls for resident #53. - Observation on 4/7/14 at 3:11 p.m. revealed in a resident accessible bathroom on the administration hall a can of dry air fresher deodorizer and Purell sanitization wipes with a label warning to keep out of reach of children on the shelf of small cabinet next to toilet. Observation on 4/7/14 at 3:20 p.m. revealed fingernail polish, paint, glue and tough algae controller, batteries, odor eliminator with warnings of keep out of reach of children and hazardous to humans and domestic animals in unlocked cabinets above the charting desk near the living room in a resident accessible area. Observation on 4/7/14 at 3:27 p.m. revealed rubbing alcohol with a warning to keep out of reach of children and Zorbi (liquid solidifying powder for human waste) with a warning to keep out of reach of children in a box on the administration hall accessible to residents. Interview on 4/7/14 at 3:29 p.m. with housekeeping staff DD revealed the bathroom on the administration hall was for office personnel use only and staff watched the area for residents and redirected residents who came into the area. Staff DD stated the box on the administration hall had "press to open" on the outside of the box with the rubbing alcohol and Zorbi in it and staff continually walk in and out of the area. Observation on 4/7/14 at 3:30 p.m. revealed Expo white board cleaner with a warning to keep out of reach of children in an unlocked cabinet in a resident accessible staff work room on the administration hall. Observation on 4/7/14 at 3:32 p.m. revealed in a resident accessible, public restroom in the dining room Purell sanitization wipes with a warning label to keep out of reach of children. Interview on 4/7/14 at 3:32 p.m. with direct care staff EE revealed the restroom in the dining room was for independent residents otherwise staff accompanied the resident to the restroom. Observation on 4/7/14 at 3:34 p.m. revealed a bottle of liquid nails and carpet cleaner with warnings to keep out of reach of children in an unlocked door to a mechanical fire panel room near the dining room accessible to residents. Observation on 4/7/14 at 3:41 p.m. revealed 2 tubs of Purell sanitizing wipes with a warning label to keep out of reach of children on the counter in the dining room accessible to residents. Observation on 4/7/14 at 3:45 p.m. revealed Aspercreme (a medicated cream), alcohol prep, glue, paint, nail polish remover with warning labels to keep out of reach of children in the Memory Care Unit (MCU) nurses' station in unlocked cabinets accessible to residents. Observation on 4/7/14 at 3:52 p.m. revealed in a staff only restroom accessible to residents on the MCU disinfectant spray with a warning to keep out of reach of children. Observation on 4/7/14 at 3:52 p.m. revealed acrylic paint and algae cleaner with warnings to keep out of reach of children in unlocked cabinets in the living area. Interview on 4/7/14 at 3:52 p.m. with administrative nursing staff B revealed the paints and algae cleaner should be locked and he/she removed the chemicals from the cabinet in the living area. Interview on 4/7/14 at 3:58 p.m. with direct care staff AA the staff only bathroom on the MCU was not for residents, but there are gloves in there because staff were not always able to catch the residents before they go in to use the restroom. Observation on 4/7/14 at 4:12 p.m. revealed Re-juv-nal (hospital grade disinfectant/detergent cleaner) with a warning label of hazardous to humans and animals under the sink in an unlocked soiled utility room accessible to residents between the 100 and 300 halls. Observation on 4/7/14 at 4:17 p.m. revealed sanitation wipes with a warning label to keep out of reach of children in a cabinet above the computers near the 300 hall. Observation on 4/7/14 at 4:18 p.m. revealed Purell sanitization wipes in a cabinet above the toilet in a public restroom accessible to residents between the 100 and 300 hall. Interview on 4/7/14 at 4:29 p.m. with licensed nursing staff GG revealed he/she confirmed the Re-uv-nal needed be locked up and he/she removed it. Staff GG also confirmed the Purell sanitization wipes above the computers were usually locked up and removed them. Interview on 4/7/14 at 4:55 p.m. with administrative staff HH revealed the staff room on the administration hall was for employees only. On 4/10/14 at 8:30 a.m. on an environmental tour with maintenance staff II revealed the administration hall area was accessible to residents and he/she confirmed chemicals should not be in resident accessible areas, but he/she felt like the administration hall was a continually supervised area. Observation on 4/14/14 at 10:00 a.m. revealed approximately 10 full bottles of Dyna foam oven cleaner and grill cleaner with warnings to keep out of reach of children in an unlocked dietary only bathroom/supply closet in the dining room. Review of the facility's policy for Hazardous Chemicals, last revised 6/11, failed to address that chemicals should be locked and stored away from residents. The facility failed to ensure the residents' environment remained free of accident hazards by the failure to properly secure chemicals in resident accessible areas. - Observation on 4/7/14 at 3:40 p.m. revealed water temperatures of 131.9 degrees Fahrenheit (F) and 131.1 degrees F at a public sink in the cafe area accessible to residents. Observation on 4/7/14 at 3:42 p.m. revealed a water temperature of 129.2 degrees F in a resident accessible bathroom on the administration hall. Interview on 4/7/14 at 3:50 p.m. with maintenance staff II revealed water temp in coffee shop 132 F. Water should be 115 degrees F or below. Staff II confirmed a water temperature of 130.5 degrees F in the public bathroom on the administration hall. Staff II reported there were no resident rooms on the same line as water heater and he/she stated he/she changed the water heater the week prior. Staff II did not document routine checks of the water temperatures. According to Studies of Thermal Injury II. The Relative Importance of Time and Surface temperatures in the Causation of Cutaneous Burns by A.R. Moritz and F.C. Henriques Jr. revealed water temperatures at 133 degrees F for 15 seconds could cause 3rd degree burns. Review of the facility's undated Water Temperature Policy revealed water temperatures were to be check once a month or upon a change of water heating equipment. The policy did not include safe water temperatures for resident accessible areas. The facility failed to ensure the residents' environment remained as free of accident hazards as possible related to the failure to maintain hot water temperature in a safe range in resident accessible areas.

The facility census totaled 49 residents with 10 included in the sample. Based on observation, interview, and record review, the facility failed to ensure staff investigated falls to determine the root cause for 2 of 3 residents reviewed for falls and implement planned fall interventions (#41 and #56). The facility also failed to maintain safe water temperatures in a hand sink accessible to facility residents. Findings included: - During an observation on 6/25/14 at 11:29 a.m. an accessible sink, to facility residents, in the restaurant dining area reached a temperature of 126.3 degrees Fahrenheit (F). At 11:31 a.m. maintenance staff O used a different thermometer and obtained a temperature of 125.6 degrees F. Staff O reported he/she had been checking water temperatures regularly, and he/she did not know what might have changed that the water temperatures were now too hot. During an interview on 6/26/14 at 9:22 a.m. with maintenance staff O revealed he/she checked the water temperatures monthly and usually checked the public bathroom on the office side of the facility. Staff O thought it was the first sink on the line, but after some investigation on his/her part, he/she found it was instead the last sink on the line. Staff O confirmed he/she did not check the water temperature of the hand sink in the restaurant dining area where the temperature measured 126.3 degrees as described previously. Review of the facility work order check, dated 6/3/14, revealed maintenance staff check the water temperature of a sink in the office wing, but did not check the sink in the restaurant dining area. According to Studies of Thermal Injury: II. The Relative Importance of Time and Surface Temperatures in the Causation of Cutaneous Burns by A.R. Moritz and F.C. Henriques Jr. revealed water temperatures at 127 degrees F for 1 minute could cause 3rd degree burns Review of the facility ' s undated Water Temperature policy revealed water temperatures were to remain between 100 degrees F and 120 degrees F. Water temperatures were to be checked once a month, or upon any change of water heating equipment. The facility failed to ensure the resident environment remained free of accident hazards by the failure to maintain safe water temperatures in resident accessible areas. - Review of resident #41's significant change MDS (minimum data set) dated 4/15/14 revealed a BIMS (brief interview for mental status) score of 03, indicating severe cognitive impairment. The resident required extensive assistance of 2 or more staff for bed mobility, transfers, and personal hygiene. He/she required total dependence on 2 or more staff for toileting. The resident did not walk. The resident had one minor injury fall since the prior assessment. Review of the Falls CAA (care area assessment) dated 4/17/14 revealed the resident used a sit to stand lift for transfers inside of his/her room. He/she used a wheelchair in and out of his/her room and the staff propelled the resident to activities and meals. The resident had [DIAGNOSES REDACTED]. The resident was at risk for falls due to a history of falls, dementia, weakness, incontinence, and daily antipsychotic usage. The resident wore pressure alarm at all times. He/she was on a restorative program as tolerated to maintain strength/mobility and prevent contractures. The resident had most frequently used items within reach, a hi/low bed in the low position when he/she was in it, and a body pillow beside him/her while in bed on the outer edge of the bed to give security and stabilization. Review of the resident's care plan for Falls, initiated 2/4/14, revealed interventions directed staff to use a body pillow beside the resident while in bed on the outer edge to give security and stabilization, place the hi/low bed in low position when the resident was in bed, keep frequently used items within reach at all times, the resident was on a restorative program as tolerated to maintain strength/mobility. A revision dated 4/7/14 directed the staff to provide range of motion to prevent contractures and use a sit to stand lift for all transfers. A revision on 4/28/14 revealed the resident was often delusional when falls occurred, and the staff provided validation of feelings as the resident allowed. Review of the facility fall report dated 6/24/14 revealed the resident had a fall on 6/20/14 at 4:45 a.m. when the resident decided he/she missed supper and tried to get up on his/her own. The resident ended up on his/her knees facing the bed with no injuries. The report did not include an investigation. Review of the fall event report dated 6/20/14 revealed at 4:45 a.m. the resident had an unwitnessed fall. Prior to the fall, the report indicated the resident lay in bed, but it did not indicate when staff visualized the resident last prior to the fall. The report indicated previously recommended interventions were not in place at the time of the fall. Staff listed dementia as the root cause of the resident's fall. The report did not indicate when staff had toileted the resident prior to the fall or when the resident had eaten prior to the fall. Staff indicated immediate interventions were put in place to include a bed alarm and adaptive equipment. The report indicated staff updated the care plan, but review of the care plan revealed it was not. Review of a progress note dated 6/20/14 at 6:32 p.m. revealed a fall follow-up. The resident denied pain and was alert and oriented to him/herself. He/she was cooperative with transfers and cares with no signs of distress. The note indicated the resident had voiced no needs or complaints. The resident transferred with a sit to stand lift to a wheelchair and required full assistance with moving his/her wheelchair. Review of a progress note dated 6/21/14 at 2:22 a.m. revealed a fall follow-up. The note revealed the resident rested quietly in bed with his/her eyes closed during the night shift. Range of motion was in normal limits for the resident. He/she denied any discomfort/pain. The note reported no new injuries were noted from the recent fall on 6/20/14. The resident had a floor/fall mat beside his/her bed, his/her bed alarm was positioned, on, and operating, and the staff performed frequent visual checks for safety/monitoring. Review of the resident's progress notes dated 6/1/14-6/30/14 revealed none of the progress notes contained what actually happened to cause the resident to be on fall follow-up. During an observation on 6/25/14 at 9:28 a.m. revealed the resident lay in bed with the bed not in low position as directed by the care plan. During an observation on 6/30/14 at 2:28 p.m. revealed the resident lay in bed with the bed not in low position as directed by the care plan. During an interview with direct care staff N on 6/30/14 at 7:29 a.m. revealed the resident had a body pillow to put beside him/her, a pressure alarm when in bed, and a pull tab alarm while up in the chair. Staff N revealed the resident had fallen out of bed a few nights ago. During an interview with direct care staff E on 6/30/14 at 2:29 p.m. revealed the bed was supposed to be in low position and he/she confirmed it was not. Staff E then went and lowered the bed. During an interview with licensed nursing staff G on 6/30/14 at 3:30 p.m. revealed the resident had fallen about 2-3 weeks ago, but was not on fall follow-up currently. Staff G reported the resident had a concave mattress, his/her bed in low position, and a fall mat beside the bed when the resident was in it. Staff G thought the nurse or the unit coordinator updated the care plan, he/she reported he/she left a note the unit coordinator if he/she had a concern. Interview with administrative nursing staff B on 6/30/14 at 4:22 p.m. revealed the purpose of the fall event was to determine the root cause of the fall and determine what interventions were needed to prevent further falls. Staff B expected the investigation for an unwitnessed fall to include when the resident was last seen or toileted. Staff B expected a fall event report to be completed with each fall. Review of the facility policy for Fall Prevention and Management, last revised 6/11, revealed after a fall the staff were to investigate the fall and implement corrective actions. Documentation located on the fall event was to include circumstances around fall, possible contributing factors, the root cause, interventions, and review/update of the care plan. The facility failed to investigate all falls to determine the cause of the fall and implement planned fall interventions as directed by the care plan. - Review of resident #56 ' s signed physician order sheet dated 8/26/13 revealed a [DIAGNOSES REDACTED]. Review of the resident's quarterly MDS (minimum data set) dated 2/25/14 revealed the resident had a BIMS (brief interview of mental status) of 5 indicating severe cognitive impairment. ADLs (activities of daily living) indicated the resident required limited assistance of one for bed mobility, independent for transfers, and supervision for ambulation. The resident had fallen two or more times since the last assessment without injury. The resident was steady at all times during transitions and walking, and used a walker. Review of the significant change MDS dated [DATE] revealed a BIMS score of 2, indicating severe cognitive impairment. The resident required extensive assistance of one staff for bed mobility, transfers, walking in the room and corridor, locomotion on and off the unit, dressing and personal hygiene. The resident required extensive assistance of 2 or more staff for toileting. The resident was not steady and only able to stabilize with staff assistance during transitions and walking. The resident used a walker and wheelchair for mobility. The resident experienced delusions but did not exhibit any behaviors or wandering. The resident's behavior remained the same as the prior assessment. The resident had fallen two or more times since the prior assessment without injury. Review of the Falls CAA (care area assessment) dated 6/4/14 revealed the resident was increasingly unsteady in his/her gait and required assistance from staff to stabilize. He/she had four falls in April and one fall in May. No acute infection had been noted during the assessment look back period. The resident had frequent complaints of pain in his/he back. An x-ray of spine, taken on 5/14/14, revealed mild [DIAGNOSES REDACTED] (abnormally large) and degenerative changes, but no compression fractures. Review of the Cognitive Loss/Dementia CAA dated 6/4/14 revealed the resident had a [DIAGNOSES REDACTED]. His/her previous assessment BIMS score was 5, which indicated severe cognitive impairment. His/her current BIMS score was 2, which indicated severe cognitive impairment. The social worker completed an assessment with a BCRS (brief cognitive rating scale) score of 5.8 which indicated Early Stage Dementia and moderately severe cognitive impairment which was a significant deterioration in cognition by one whole stage in the past 6 months. No acute infection noted during this assessment look back period. The doctor increased the resident ' s Seroquel (an antipsychotic medication) at bedtime to 50 mg (milligrams) and added Seroquel 25 mg in the morning for increased hallucinations and agitation associated with his [DIAGNOSES REDACTED]. Review of the resident ' s care plan, initiated 12/13/13, revealed the resident required a pressure alarm at all times to prevent falls due to increased confusion (added 5/15/14). Staff were directed to remind the resident to use call light and ensure assistive devices were available. Staff also to ensure the resident had proper footwear when ambulating, and ensure the resident areas were free of hazards. Staff were to redirect the resident when he/she entered unsafe areas, and work with therapy to increase safety and ADL completion. Staff were to provide cues and supervision when the resident performed ADLs and use reminders as needed. The resident used a walked and needed reminders to use it. Staff were directed to provide stand-by assistance when the resident ambulated outside his/her room. The care plan lacked anything regarding the falls the resident had on 6/3/14. Review of an event note dated 6/3/14 at 9:50 p.m. revealed staff found the resident on his/her knees next to the bed. The note revealed the resident lay in bed prior to the fall, but lacked when staff visualized the resident prior to the fall. The investigation listed dementia and neurological disorders as possible contributing factors to the fall and for root cause of the fall, staff wrote the resident had a history of [REDACTED]. It did not include when the resident was last toileted, when the resident ate last, or what the resident ' s unmet need was that caused him/her to try and get up. Review of an event note dated 6/3/14 at 10:10 p.m. revealed the resident was in bed, and a CMA (certified medication aide) heard the pressure alarm sounding and went to the resident ' s room right away. Staff found the resident kneeling on the floor beside his/her bed. Two staff members assisted the resident up off the floor and assisted him/her back to bed. ROM (range of motion) of all extremities were within normal limits and the resident displayed no signs or symptoms of pain. The fall was unwitnessed. The event report lacked when staff had last visualized or toileted the resident prior to the fall. Recent medication changes were listed as possible contributing factors to the fall. The report indicated the immediate interventions put in place were rest, analgesics, and a bed alarm. Review of an event note dated 6/3/14 at 10:30 p.m. revealed the resident ' s pressure alarm sounded again and a CMA went right to his/her room and found the resident on his/her knees again beside the bed. Then the resident sat down on the floor and leaned to his/her left side with his/her legs extended & slightly bent. The resident exhibited no signs or symptoms of pain due to the fall. ROM of all extremities were within normal limit. Two staff members assisted the resident up off floor. The resident was confused & restless but no more than his/her usual state. Staff assisted the resident to his/her wheelchair and then transferred him/her to a recliner in the television room where staff could monitor him/her more closely. Staff placed a pressure alarm under him/her in the chair. Staff did not note any injury to the resident. The event report lacked when staff had last visualized or toileted the resident prior to the fall. Recent medication changes were listed as possible contributing factors to the fall. The report indicated the immediate interventions put in place were rest, analgesics, and a bed alarm. Review of a progress note dated 6/3/14 at 10:32 p.m. revealed the resident had fallen. Review of a progress note dated 6/4/14 at 3:32 a.m. revealed at 2210 and 2230 on 6/3/14 staff found the resident on his/her knees beside his/her bed. The resident rested in the recliner since the fall in television room where staff could observe him/her more closely, and staff placed a pressure alarm. A urine dipstick was done and was negative. Review of the care plan revealed no evidence of assessment for causative factors after the previously mentioned three falls, and no implementation of appropriate interventions to prevent additional falls. Observation on 6/26/14 at 2:32 p.m. revealed the resident sat in a recliner in the commons area with the foot rest up and was confused and talking about looking for a job. Direct care staff P offered the resident snacks and reassurance. The resident had a pressure alarm in place. Observation on 6/30/14 at 8:42 a.m. revealed direct care staff S assisted the resident to stand and transferred him/her from the wheelchair to the recliner in the commons area. Staff placed a pressure alarm under the resident and ensured it was in the on position. Interview with direct care staff P on 6/26/14 at 2:23 p.m. revealed the resident had fallen before and had a pressure alarm at all times. Interview with licensed nursing staff G on 6/30/14 at 3:30 p.m. revealed the resident had fallen in the past, but he/she did not know what staff were doing to prevent falls. If a resident fell , the nurse completed an assessment, checked for injury, filled out a fall event on the computer, and called to notify the DPOA (durable power of attorney) and faxed a notification to the physician. Staff G would then attempt to decide if there was any change needed to keep the fall from reoccurring. Staff G reported he/she did not update resident care plans after falls occured. Interview with licensed nursing staff F on 6/30/14 at 3:43 p.m. revealed interventions to prevent falls for the resident included: a tab alarm and pressure alarm, keep the resident around staff, and the resident enjoyed folding rags. Staff tried to keep the resident occupied. Staff F reported the resident had fallen in the past month. Staff F reported when a fall occurred the nurse would assess the resident, check ROM, check vital signs, perform neurological checks if the resident hit his/her head, and notify the doctor and family. Staff F revealed the purpose of the fall event report was to investigate the cause of the fall and identify what staff could do to prevent future falls. Staff F would update the care plan as needed with falls. Interview with administrative nursing staff B on 6/30/14 at 4:22 p.m. revealed the purpose of the fall event was to determine the root cause of the fall and determine what interventions were needed to prevent further falls. He/she expected the investigation to include when the resident was last toileted and seen for an unwitnessed fall. Staff B confirmed the investigations did not identify the causal factors of the resident ' s falls. Review of the facility ' s policy Fall Prevention and Management dated 6/2014 revealed the staff were to investigate the fall and implement corrective actions. Documentation located on the fall event was to include circumstances around fall, possible contributing factors, the root cause, interventions, and review/update of the care plan. The facility failed to attempt to identify and document the root cause of falls for resident #56 and develop appropriate interventions after the falls in an attempt to prevent additional falls.

The facility census totaled 50 with 18 residents included in the sample of those 3 residents were reviewed for nutrition. Based on observation, interview and record review the facility failed to ensure one resident (#63) of three sampled residents with a severe weight loss of 14.25 % of his/her body weight in less than 3 months was assessed by the dietician in a timely manner and the interdisciplinary team including the physician addressed changes in interventions to halt the resident's weight loss. Findings included: - Review of resident #63's Annual MDS (minimum data set) dated 10/1/12 revealed a BIMS (brief interview for mental status) score of 1 (severe cognitive impairment). The MDS revealed the resident required limited assistance of staff for eating. The resident had dentures, received a regular diet without nutritional supplements, and had no significant weight loss. Review of the resident's Quarterly MDS dated [DATE] revealed a BIMS score of 1 (severe cognitive impairment). The resident required limited assistance of one staff member for eating. The MDS revealed the resident had a significant weight loss of 5% in the last month or 10% in the past six months. Review of the resident's cognitive loss/dementia CAA (care area assessment) dated 10/7/12 revealed the resident had short and long term memory deficits with moderately impaired decision making abilities. Review of the resident's nutritional status CAA dated 10/7/12 revealed the resident had a recent weight loss and was started on 2 cal (a liquid nutritional supplement) 2 ounces QID (four times daily), staff monitored the resident's food intake via food intake logs, and the resident required encouragement and at times assistance with meal intake. Review of resident #63's care plan, dated 10/12/12, revealed he/she had a recent weight loss reported from the family prior to admission on 10/10/12. The care plan directed the staff to allow the resident extra time to eat, monitor nutritional intake via food logs, provide snacks and supplements as needed, provide cueing and feeding assistance if the resident became fatigued and monitor weight weekly. Review of the physician's telephone orders dated 10/23/12 revealed an order to continue to monitor the resident's weight and if weight loss continued to decline, add house supplements. Review of a fax to the physician dated 10/26/12 revealed staff reported the resident's weight on admission as 171.5 pounds and his/her current weight as 162.5 pounds. The facility requested an order to start 2 cal 2 ounces QID (four times a day). The facility received the order for the nutritional supplement. Review of a fax to the physician on 11/14/12 revealed staff reported the resident started coughing while eating. The staff had requested the resident received speech therapy evaluation related to the resident's mental status and the resident's inability to follow directions. The facility questioned the resident's admission weight of 171. The staff felt the scales used to weigh the resident may need to be calibrated for accurate weight monitoring. Review of the physician's orders [REDACTED]. The facility requested an order for [REDACTED]. Review of the resident's weights since admission revealed the resident had lost 14.25% of his/her body weight from 10/23/12 to 1/15/12 (less than three months): 10/23/12 171 pounds 11/05/12 159.5 pounds 11/12/12 159 pounds 11/16/12 157 pounds 11/19/12 157.5 pounds 12/04/12 151 pounds 12/14/12 149 pounds 12/18/12 146 pounds 01/15/13 146 pounds Observation on 1-17-13 at 11:15 a.m. revealed staff served the resident a pork chop, baked potato, corn, salad and cherry crisp. The resident ate independently, very slowly and consumed 1/2 of the pork chop and baked potato and a few bites of the cherry crisp. Staff did not provide assistance or encouragement with eating. The staff provided the resident with 2 ounces of 2 cal while in the dining room. Observation revealed the resident drank all of the nutritional supplement. Review of the documentation of the nutritional supplements revealed staff identified the 2-cal provided at the noon meal as the regularly scheduled afternoon supplement. Interview on 1-17-13 at 4:15 p.m. with Direct care staff R revealed the facility's expectation of the staff was to zero out the scales and weight the resident nude on the resident's bath days. Interview on 1-22-13 at 8:45 a.m. with Dietary staff K revealed the admission weight recorded for the resident of 171 was a mistake. Staff K revealed that the resident's admission weight was actually 162.5 and he/she was unsure where the staff had gotten the weight of 171. Staff K revealed the facility had experienced issues with the scales. Staff K revealed the unit managers were to provide him/her with all the resident's weights by the 10 th of each month, he/she reviewed the weights and presented them at the weekly QA (quality assurance) meeting. Staff K revealed the QA team provided suggestions to reduce weight loss and decided which residents should be referred to the registered dietician for review. Staff K confirmed that the resident had not been seen by the dietician since admission to the facility on [DATE] or had a dietary review completed upon admission and quarterly by the facility's dietary manager. Interview on 1-22-13 at 1:22 p.m. with Maintenance staff Q revealed the facility had the scales calibrated on 3/5/12 and that he/she had not had a work request to have the scale company out again since that time. Staff O revealed that he/she had tested the scales in the past two weeks per the staff's request and the most the scales were off was 2 pounds. Staff O revealed that he/she had zeroed out the scales and the staff had no further complaints. Interview on 1/17/13 at 3:20 p.m. with Administrative staff S revealed the facility reviewed the resident's weights monthly unless the resident was identified at significant risk for weight loss and those residents staff weighed weekly. The facility reviewed the weights weekly at the QA (Quality Assurance) meeting and attempted to develop a plan to reduce the risk for further weight loss. Staff S confirmed the facility failed to address the resident's weight loss and develop new plans to maintain or reduce further weight loss. Interview on 1-17-13 at 4:01 p.m. with Administrative Nurse A revealed that his/her expectation of the staff were to obtain the resident's weight during the first week of each month. The unit managers were expected to give the weights to the dietary manager for review. The dietary manager was expected to review the weights and bring any concerns to the QA meeting weekly, and contact the dietician for all changes. Staff A confirmed the dietician had seen the resident on 1-21-13 and completed a full nutritional assessment. The resident received new orders on 1-18-13 for [MEDICATION NAME] 400 mg (milligrams) by mouth daily for appetite stimulation, afternoon and bedtime snacks and half and half daily with breakfast. On 1/23/13 at 8:45 a.m., interview with Consultant staff P revealed the facility's policy included the consultant to complete a nutritional assessment on every resident upon admission and at least once yearly. Consultant P confirmed that he/she had not seen the resident until the facility called him/her on 1-18-13. Interview on 1-22-13 at 2:00 p.m. with Consulting Physician T revealed the the physician was unaware of the resident's significant weight loss. Physician T reported the nurses were not keeping him/her informed of the recent weight loss and the lack of response to the use of 2 cal 2 ounce supplement QID. The physician revealed he/she saw the resident last week when the nursing home informed him/her of the significant weight loss and placed the resident on [MEDICATION NAME] as an appetite stimulant. Review of the facility's policy for weights and weight loss, last revised September 26 th, 2012 revealed staff were to notify the resident's physician of significant weight change. The policy described a significant weight change as 5 pounds in 1 week; 5% monthly; 7.5% in 3 months; and 10% in 6 months. The facility failed to ensure a resident with a severe weight loss of 14.25 % of his/her body weight in less than 3 months was assessed by the dietician in a timely manner and the interdisciplinary team including the physician addressed changes in interventions to halt the resident's weight loss.

The facility's census totaled 48 residents with 12 residents included in the sample. Of those, 3 residents were reviewed for weight loss. Based on observation, interview and record review, the facility failed to maintain an acceptable parameter of nutritional status for 2 of 3 sampled residents (#56) and (#5), by the failure to identify a resident with significant weight loss, follow physician orders, reassess the residents' status after being identified with weight loss, and put interventions in place. Resident #56 lost 6.4 pounds (5.33%) in 30 days, and within less than another 30 days, lost an additional 6.5 pounds, a total of 12.9 pounds (10.75%, a significant amount) in less than 60 days. Resident #5 experienced a 15.7% loss of body weight since admission (within 62days). Findings included: - Resident #5's admission physician's orders [REDACTED]. The order also included "weekly weights." Review of the Nursing Admission assessment dated [DATE] revealed an admission weight of 121.8 pounds with a re-weight recorded as 118 pounds on 6/15/11. The assessment identified the resident with [MEDICAL CONDITION] of the left foot and ankle, non-pitting, received no special diet, appetite good, with weight loss in the past 90 days of 5 pounds and experienced no difficulty in chewing or swallowing. The assessment identified the resident experienced arterial insufficiency with bilateral blockages of the leg arteries. Review of the Nutrition Assessment form completed by the dietician on 6/17/11 revealed the resident's ideal/usual body weight as 120-125 lbs. The dietician noted clinical nutritional problems which included fluid volume excess. Review of the resident's admission MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 6/16/11 identified the resident with a BIMS (Brief Interview of Mental Status)score of 15/15 (cognitively intact), ate independently, with a weight of 121 pounds. The CAA's (Care Area Assessment, a required further assessment) dated 6/16/11 revealed the Nutrition Status CAA did not trigger. The ADL (Activities of Daily Living) Function CAA further identified the resident experienced increased weakness and pain related to [MEDICAL CONDITION] acutely affecting lower extremities. The Pressure Ulcer CAA identified the resident with "four arterial ulcers to his/her right foot, two of which are blackened toes...staff are to encourage adequate food and fluid intake." The physician's admission orders May alter texture or consistency of diet as needed, no added salt/may use salt substitutes, resident may have diet holiday once/month." The orders included weekly weights. Review of the resident's comprehensive care plan dated 6/21/11 revealed no nutritional interventions were developed initially, including the type of diet, texture or consistency, or the identified nutritional problem related to fluid volume excess and failed to direct staff to monitor weekly weights as ordered by the physician on 6/7/11. A handwritten revision signed by consultant D (undated) included, "Diet, resident had sig (significant) wt (weight) loss r/t (related to) fluid volume and decreased appetite from pain issues..." Interventions included "serve a well balanced regular NAS (No Added Salt) diet, send shakes BID (twice a day), monitor weight, and monitor intake." This revision matched the consultant's progress note of 8/19/11. Review of the Resident Bath List and Assessment form revealed the following dates and weights for resident #5: 06/15/11 118.0 pounds 06/23/11 116.4 pounds 07/28/11 108.2 pounds Based on the above facility's recorded weights the resident experienced a 4.13% loss of body weight from 6/7/11 to 6/23/11 (within 16 days). The Resident Bath List and Assessment form lacked weekly weight monitoring after 6/23/11. The next weight recorded was 108.2 pounds on 7/28/11. The resident experienced an additional 6.9% weight loss from 6/23/11 to 7/28/11 (within 35 days). In 51 days from admission the resident presented with an 11.03% loss of body weight. The next weight found in the medical record was located on the August 2011 Medication Administration Record (MAR). A nurse recorded a weight of 102 pounds on 8/9/11 (62 days from admission). As of 8/9/11 the resident experienced a 15.7% loss of body weight since admission, without any changes to the plan of care. Review of Dietary Progress Notes dated 6/17/11 signed by consultant D revealed the following: "unable to visit with resident as (he/she) is out of the building. (He/She) enjoys going out for meals often" Consultant D noted the resident received a therapeutic diet for fluid volume excess and the resident wanted to maintain his/her weight between 120-125 lbs. Further review of the Dietary Progress Notes revealed no further documentation from dietary staff B or consultant D regarding weight monitoring or changes in the resident's plan of care from 6/17/11 until 8/19/11. On 8/19/11 consultant D wrote, "weight of 102 lbs. (pounds) weight loss noted significant decrease 16 lbs. Resident did have issues with [MEDICAL CONDITION] and pain effecting his/her food intake. (He/She) consumes 54% at present. Has been started on health shakes BID to provide 400 calories/day plus intake of 1100 cal = 1500 cal/day. Anticipate weight will stabilize." Review of the Food Intake Record dated June and July 2011 revealed from 6/9/11 through 6/15/11 the resident ate 85-100 % of breakfast and lunch and went out for supper. On the 20th from lunch to supper and again on the 21st staff documented the resident was in the hospital for a procedure and returned by the supper meal - the intake record was marked "tray" with no percentage of intake recorded. From 6/22/11 through 6/30/11 staff failed to consistently document percent eaten for the lunch meal. The Staff documented percent of meals only two times, 70% on 6/23/11 and 15% on 6/27/11. The rest of the lunches remained blank. Further review of the resident's medical record showed on 6/20/11 the resident went to the hospital for placement of stents into his/her lower extremity's arteries to increase blood flow and returned to the facility the next day (21st). For July 2011 the resident ate 45-100% of Breakfasts, with 5 days (1st, 2nd, 3rd, 9th, and 28th) staff failed to document food intake. On these days the spaces remained blank. For lunch meals the resident ate between 0-75% of the food with 9 days (2nd, 3rd, 9th, 13th, 19th, 20th, 21st, 26th, and 28th) staff failed to document food intake. For suppers the resident ate between 35-100% range. The resident's medical record lacked any food intake record for the month of August. The facility failed to consistently monitor the resident's food intake. On 9/27/11 at 12:45 p.m. during an interview dietary staff B reported his/her weight record for this resident showed different weights, Staff B reported he/she had wrong weights recorded. Staff B reported one weight recorded was around 141 pounds in July, "which obviously isn't right, this must have slipped by me". Staff B reported at that time he/she only received monthly weights from administrative nursing staff A. During a telephone interview on 9/27/11 at 3:00 p.m. consultant D reported he/she remembered the resident came in with some [MEDICAL CONDITION] problems. Consultant D reported residents who experience weight loss were placed on weekly weights and staff monitored food intake. Consultant D reported he/she was unaware that the resident had a continued weight decline until 8/19/11 and confirmed the resident experienced a significant weight loss. On 9/28/11 at 10:15 a.m. dietary staff B reported the facility "now has a plan to move weight loss to their risk management meetings so that it forces them to look at it weekly." On 9/28/11 at 1:10 p.m. administrative nursing staff A reported he/she looked at monthly weights. Staff A reported he/she did not know who was monitoring weekly weights. Staff A confirmed he/she indentified the resident with weight loss on August 11th and sent dietary staff B an e-mail informing him/her of the significant weight loss. Staff A reported the health shakes were documented on the Medication Administration Record (MAR). Review of the resident's Medication Administration Record (MARs) from 6/7/11 through 7/31/11 revealed no health shakes listed. The MARs included "Check weekly weight" with no documented weights recorded. Review of the August 2011 MARs revealed no health shakes listed. The MARs included "Check weekly weight" with only one weight recorded of 102 pounds for the entire month of August. August 3rd, 17th, 24th, and 31st remained blank. The facility failed to consistently monitor the resident's ordered weekly weights and failed to monitor the health shakes twice daily as recommended by consultant D. The medical record lacked any evidence that the staff implemented the health shakes to prevent further weight loss. Review of the Interdisciplinary Notes (IDN) from 6/8/11 through 6/24/11 revealed a nurse documented on 6/8/11 at 6:40 p.m. and again on 6/9/11 at 1:00 p.m. the resident experienced "non-[MEDICAL CONDITION] noted to Right lower extremity." An IDN dated 6/24/11 at 4:00 p.m. showed a the nurse documented "resident reporting increased nausea over last week. Daughter concerned [MEDICATION NAME] (a narcotic pain medication) may be causing this...Noted 4+ [MEDICAL CONDITION] to left lower leg/ankle. Dr. (physician's name)'s nurse notified of this states to monitor at this time..." Further review of the IDNs from 6/24/11 through 8/21/11 revealed no further monitoring of [MEDICAL CONDITION], no documentation of whether the resident continued with [MEDICAL CONDITION] problems. On 8/22/11 at 10:30 a.m. a nurse documented "no swelling" in reference to right foot and ankle. The facility failed to adequately and consistently monitor the resident's [MEDICAL CONDITION] in relation to the resident's weight loss. Review of a Physician Fax Communication form dated 7/19/11 revealed a nurse notified the physician of the resident's continued reports of nausea almost daily but failed to inform the physician of the continued decline in the resident's weight. Further review of the resident's medical record revealed [REDACTED]. The facility discharged the resident on 8/31/11 to his/her assisted living apartment. On 9/27/11 at 1:55 p.m. administrative nursing staff A, after looking at the resident's medical record, confirmed he/she could not find any documentation to support that staff notified the doctor of the significant weight loss identified on 8/19/11. Staff A also confirmed he/she could not find any documentation to show the health shakes were implemented even after the significant weight loss was identified by consultant D. On 9/28/11 at 8:10 a.m. during an interview, administrative nursing staff M reported he/she would expect to see daily weights done to monitor for fluid excess and he/she would expect to have weekly weights done for any residents experiencing weight loss. The facility failed to maintain an acceptable parameter of nutritional status for resident #5 by the failure to timely identify, consistently monitor, follow physician's orders [REDACTED]. The resident lost 15.7% of body weight since admission (within 62 days). - Review of resident #56's History and Physical dated 8/4/11 identified the resident with a past medical history of [REDACTED]. Review of the resident's Quarterly MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 7/11/11 identified the resident with a BIMS (Brief Interview for Mental Status) score of 12 (8-12 indicated moderately impaired cognition). It also identified the resident as independent with eating, had a height of 63 inches and a weight of 121 pounds, and noted the resident did not receive a mechanically altered diet. Review of the resident's Signficant Change MDS assessment with an ARD of 9/15/11 revealed it had not been completed. Review of a Nutrition Risk assessment dated [DATE] identified the resident with a score of 8 (8 or greater indicated at high risk for impaired nutritional status) A Dietary Progress Note dated 3/24/11 revealed, "Res (resident) and family signed waiver after res refuses thickened liquids as suggested by ST. Goal is to maintain wt (weight) and consume 75-100% of meals." Review of a signed Nursing Home/Skilled physician's orders [REDACTED]. Another Dietary Progress Note dated 8/19/11 revealed, "Res cont (continues) to have a stable wt. (Gender) cont to refuse thickened liquids or altered consistency and understands the risks and precautions. Nutritional intake appears adequate as evidenced by stable wt." Review of an Interdisciplinary Dietary Note, dated 9/24/11, revealed, "resident is receiving a regular mechanical soft diet with ground meat 3x (3 times) daily in Wheatland dining room. Often refuses breakfast or has room tray, food intake is poor, less than 25% at meals. Weight is down this month to 113# (pounds), down 7# from month before, will monitor weight and food intake." The record lacked any updates or additional notes regarding the weight loss. Review of the resident's care plan, last signed 9/13/11, identified the resident needed increased assistance with activities of daily living due to increased weakness, decreased balance, declining cognition, and receiving comfort care. It also identified the resident ate independently but needed increased monitoring/cueing/set up help. It identified the resident refused thickened liquids and mechnaical soft diet as recommended by ST (Speech Therapy) for the safest swallowing, but identified the resident received a regular mechanical soft diet with ground meat 3x (daily) and directed staff to encourage socialization during meals, and to encourge use of the alternative meal if the resident disliked what they were served. It also directed staff to weigh the resident weekly, provide a snack of the resident's choice daily, encourage chin tucking and small sips to decrease aspiration risk, assist to cut food into small pieces when resident allowed, and noted the resident refused healthshakes at that time. Observation on 9/27/11 at 9:30 A.M. in the dining room revealed the resident received cold cereal, eggs and toast, ground meat (the consistency staff documented the resident normally refused), milk and juice. The resident ate most of the cereal, but ate none of the other food items. Observation on 9/27/11 at 11:15 A.M. in the dining room revealed the resident again received ground meat (again, the consistency of meat the resident normally refused), along with potatoes, and a vegetable. The resident ate none of the food offered at the noon meal. On 9/27/11 at 4:34 P.M. Direct Care staff H reported the resident had not been eating lately. Direct Care staff H reported he/she gave snacks to residents who didn't eat well at lunch or who wanted one, and nurses gave certain snacks to certain resident but he/she did not know if resident #56 was one of those residents. Direct Care staff H reported he/she tried to give a snack at times, but the resident refused because, "(gender) won't wake up." On 9/28/11 at 9:54 A.M. Licensed Nursing staff C reported the resident had a stroke a couple of weeks ago and declined since then. Staff C did not know if the resident had weight loss, but did know encouragement helped the resident. Staff C reported the resident liked to be independent, but almost needed to be at a table for residents needing increased assistance. Staff C confirmed the resident did not receive any scheduled snacks during the day. Review of a Food Intake Log for August and September revealed multiple blank and crossed out places or "room tray" written without any percentage the resident consumed. Dietary staff F on 9/28/11 at 8:32 A.M., reported blanks meant staff did not complete the intake charting, and lines or circles meant the resident ate nothing. The log lacked consistent monitoring of the resident's food intake at mealtimes. Review of the resident's Bath List and Assessment sheet identified the resident with the following, post-hospital stay weights: 8/9/11 120 pounds 8/12/11 117.3 pounds 8/16/11 115 pounds 8/19/11 115 pounds 8/23/11 115 pounds 8/26/11 115 pounds 8/30/11 114.3 pounds 9/2/11 114.3 pounds 9/6/11 113.6 pounds 9/9/11 113.6 pounds (5.33% loss in 30 days) 9/13/11 112.6 pounds 9/16/11 112.6 pounds 9/20/11 111.3 pounds 9/23/11 111.3 pounds On 9/27/11 at 1:24 P.M. Direct Care staff I reported the resident weighed 107.7 pounds (down another 3.6 pounds in 4 days). Observation revealed Direct Care staff J, on 9/28/11 at 11:15 A.M. pushed the resident in the resident's wheelchair onto the weight scale while the resident wore a shirt, sweater, pants and shoes, and confirmed a resident and wheelchair weight of 144.1 pounds. Staff J reported the resident's wheelchair had been weighed moments before, and measured 35 pounds. On 9/28/11 at 11:48 A.M., Administrative nursing staff A reviewed the "Resident Weights" policy, last updated 12/27/07, and confirmed since staff weighed the resident with clothing and shoes on, 2 pounds needed to be subtracted from the weight shown by the scale. Staff A confirmed, based on the weights taken by staff, the resident currently weighed 107.1 pounds (10.75% weight loss in less than 60 days). At 2:43 P.M. on 9/27/11 Dietary staff B reported nursing figured weights, then he/she double checked them and placed the weights into a spreadsheet. Staff B confirmed the September spreadsheet identified the resident with a 7 pound, or 6% loss, but since the resident first gained from 117 pounds to 120 pounds before losing weight, Staff B confirmed he/she would have waited until the next month before doing anything about the loss. Staff B stated, " We probably need to make it so we go back and look at weight losses weekly instead of monthly," and also stated, "I look at the 6 month range more than the 1 month range." Staff B reported the resident currently was on "comfort care," and revealed the following note in the chart dated 9/9/11, from (Medical Center) "Orders for Sunshine Meadows, comfort care, consult hospice (-family wishes to put a hold on this, signed by nurse on 9/13/11), oral meds as able to take" and listed new medication orders. On 9/28/11 at 9:29 A.M. Staff B confirmed he/she failed to notify the dietician regarding the loss, and reported "we" are now going to incorporate weights and weight loss into the Risk Management, or Quality Assurance program, and look at those weights weekly. On 9/27/11 at 3:28 P.M. Administrative nursing staff E reported, for residents on "comfort care", staff did not push issues with weight, but confirmed staff still tried to manage weight loss, implemented health shakes (or other interventions), and asked the dietician to overlook things. Consultant D at 10:34 A.M. on 9/28/11 reported he/she did not know if the facility had a system in place for identifying and treating weight loss prior to the weight loss becoming significant. Consultant D reported he/she knew the resident's weight had decreased to 113 pounds, but reported the facility told Consultant D the facility would change seating arrangements and the facility expected for that to solve the resident's weight issue. Consultant D confirmed staff failed to notify Consultant D of continued weight loss. At that time, Consultant D also reported the resident refused ground meat and had issues with consistency. Consultant D stated, "I thought (gender) was getting regular (consistency). (Gender) pushes mechanical soft away." On 9/28/11 at 10:53 A.M. when asked about the resident's current diet, Dietary staff B reported he/she thought the chart had something in it regarding the resident's wishes not to eat mechanical soft meat. Staff B reported it was a "texture thing", and confirmed the resident did not like mechanical soft diets. At 10:58 A.M that day, Staff B reported he/she had a current order in the kitchen dated 8/5/11 for the kitchen to serve the resident a mechanical soft diet. On 9/28/11 at 11:48 A.M., Administrative Nursing staff A reported he/she monitored for 5% weight loss at 30 days, and 10% weight loss at 180 days (significant losses), then notified the dietician of those weight losses. Staff A confirmed the resident lost weight and reported he/she determined on 9/13/11 a significant change MDS needed to be completed, but had not completed it yet. Staff A reported the care plan team previously planned to move the resident to an assisted table during meals, but after talking with the family, decided it may do more harm than good. Staff A confirmed he/she failed to notify the dietician after that about any further weight loss, and failed to put any dietary or nursing interventions into place to prevent further weight loss other than increased cueing from staff. Staff A confirmed he/she failed to report the loss to the physician to receive input regarding the resident's weight loss and also reported the resident still received the mechanical soft diet even though the resident did not like it. Staff A reported he/she didn't remember hearing that the resident disliked the diet, and reported he/she never saw the note regarding the resident's refusal of mechanical soft meats in order to identify the need to change/adjust the resident's diet. The facility failed to implement interventions to prevent a potentially avoidable significant weight loss in 30 days of 6.4 pounds (5.33%), or implement interventions after identifying the weight loss, and the resident lost another 6.5 pounds, a total of 12.9 pounds (10.75%, a significant amount) in less than 60 days.