Every finding on record at Carington Park

Based on record review, interview, observation, and review of the Certified Nursing Assistant job and nursing job descriptions, the facility failed to ensure qualified staff administered enteral feedings in accordance with Resident #10's care plan. This affected one (Resident #10) out of two residents reviewed for tube feeding. The facility census was 149. Findings include:Review of the medical record for Resident #10 revealed an admission date of 08/15/22. Diagnoses included chronic obstructive pulmonary disease, type II diabetes, dysphagia, hypertension, bilateral hypertensive retinopathy, peripheral vascular disease, anxiety, major depressive disorder, and paranoid schizophrenia. Review of Resident #10's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severe cognitive impairment. Resident #10 was dependent on two staff members for all activities of daily living (ADL). Review of Resident #10's care plan dated 07/27/26 revealed the resident had the potential for alteration in nutrition and hydration related to alternative nutrition via feeding tube. Interventions all to be done by nurses included assessing and reporting signs of edema, assessing for signs and symptoms of aspiration, checking for residual, elevating the head of bed, flushes as ordered, medications as ordered, monitor of signs and symptoms of dehydration, monitor for tube feed intolerance, monitor labs as ordered, monitor tolerations of tube feed, and administer tube feed as ordered and adjust as needed. Review of Resident #10's physician orders dated August 2026 revealed orders for Nutren 2.0 (nutritional supplement) 60 milliliters (mL)/hour (hr) continuous times 24 hours, and flush percutaneous gastrostomy tube (PEG) tube every four hours with 315 ml of water. Review of the Certified Nursing Assistant (CNA) job description revealed there was no evidence the CNA was to do anything pertaining to the resident's tube feed. Review of the Licensed Practical Nurse (LPN) job description revealed under Responsibilities and Major Duties number two the LPN will administer and document direct resident care, medications, and treatments per physician orders and accurately record all care provided additionally they will follow established standards of nursing practices and implement facility policies and procedures. The LPN is also responsible for the clinical direction and management of the CNA duties with then the assigned nursing unit. Review of the Registered Nurse (RN) job description revealed under Responsibilities and Major Duties number two the RN will administer and document direct resident care, medications, and treatments per physician orders and accurately record all care provided additionally they will follow established standards of nursing practices and implement facility policies and procedures. The RN is also responsible for the clinical direction and management of the CNA duties with then the assigned nursing unit. Observation on 08/03/26 at 2:55 P.M. of Resident #10 tube feed revealed it was currently paused, and CNA #609 walked into the residents room and turned the pump back on. An interview on 08/03/26 at 3:00 P.M. with CNA #609 revealed she stated she turns Resident #10's tube feed pump on and off all the time. She stated the nurses are too busy to come down and do it. She also stated she was probably not allowed to do this but was too busy to wait for the nurse. An interview on 08/03/26 at 3:05 P.M. with the Director of Nursing (DON) revealed CNAs are not allowed to turn off or turn on tube feed pumps this is out of their scope of practice. She also confirmed it is not in the CNA job description to perform this task, and it should only be done by the LPN or RN.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, medical record review, hospital record review, facility policy review, medication manufacturer guideline review and interview, the facility failed to ensure Resident #94 was free of a significant medication error. Actual Harm occurred beginning on 12/12/24 when Resident #94, who had a diagnosis of schizoaffective disorder, returned from the hospital with orders to continue the medication, Perphenazine, an anti-psychotic; however, Registered Nurse (RN) #604 and Licensed Practical Nurse (LPN) #601 failed to transcribe the order, or notify Resident #94's guardian and/or Psychiatrist #608 of the medication not being continued. As a result, Resident #94 had an exacerbation of symptoms including being impulsive, non-adherent to care, and had an increase in delusions. Resident #94 began having the delusion other residents were peeing on him and began to isolate in his room due to fear. Resident #94's guardian stated she voiced her concerns regarding the increased behaviors repeatedly (to staff) including at a care conference, 03/21/25, where it was identified Resident #94 was not receiving the Perphenazine. Resident #94 was then restarted on a low dose of Perphenazine and Psychiatrist #608 implemented a plan to gradually increase the dose while monitoring for improvement. This affected one resident (#94) of three residents reviewed for medication administration. The facility census was 150. Findings include: Review of the medical record for Resident #94 revealed an admitted [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), diabetes, hypertension, and schizoaffective disorder. Review of a Letter of Guardianship dated 03/07/23 revealed Resident #94 was deemed incompetent per Probate Judge #611 and awarded Resident #94's sister guardian of person indefinitely. Review of the admission physician orders on 08/28/24 revealed Resident #94 had an order for Perphenazine four (4) milligrams (mg) one tablet by mouth in the morning and Perphenazine 4 mg two tablets by mouth at bedtime. Review of the care plan dated 09/05/24 revealed Resident #94 experienced alteration in mood and/or behavior: feeling tired, having little energy, and feeling down. Resident #94 could be sexually inappropriate with staff. Interventions included allowing the resident to vent, validating the resident's feelings as needed, attempting to determine what triggers the behaviors, attempting to identify triggers, encouraging communication, and encouraging to keep in contact with family. There was nothing in the care plan regarding Resident #94 having delusional behaviors including stating other residents were peeing on him. Review of the care plan dated 09/05/24 revealed Resident #94 was at risk for adverse effects related to psychoactive medications as he had schizoaffective disorder and his medications included Perphenazine. Interventions included assessing behaviors for which drugs were being given for, assessing for adverse effects of medications, giving medications as ordered, psych evaluations and treatment as indicated, and reporting changes in behaviors. Review of the nursing note dated 12/11/24 at 11:34 A.M. and completed by LPN #613 revealed Resident #94 had complained of sharp and intermittent chest pain. He was transferred to the hospital for evaluation and subsequently admitted . Review of the Discharge Summary- Encounter Notes dated 12/12/24 at 11:06 A.M. and completed by Hospital Physician #610 revealed Resident #94 was admitted to the hospital on 12/11/24 due to hypertension, and he was discharged on [DATE]. Hospital Physician #610 ordered to hold his Lisinopril (medication used to treat high blood pressure) and added Amlodipine (medication used to treat high blood pressure) instead. There were no active hospital problems, and his condition improved. The discharge summary included his discharge medications which also included starting Amlodipine 5 mg one tablet by mouth once a day and continuing taking the following medications which included perphenazine. The discharge summary listed to stop taking only one of his medications which was Lisinopril 5 mg tablet. The discharge summary also included prior to admission Resident #94's medications which also included Resident #94 was taking Perphenazine 4 mg by mouth once a day in the morning and 8 mg at bedtime. Review of the After Visit Summary dated 12/12/24 revealed Resident #94 was to start taking Amlodipine 5 mg one tablet by mouth once a day. The medication list had a list of medications Resident #94 was to continue upon discharge which included Perphenazine 4 mg in the morning and 8 mg at bedtime. There was a handwritten X over the Perphenazine. The medication list listed all the other medications that Resident #94 was to continue and there was a handwritten checkmark by each medication. The medication list revealed the facility was to change how Resident #94 took the following medication: acetaminophen (analgesic) two tablets by mouth every six hours as needed for pain. Review of the nursing note dated 12/12/24 at 3:35 P.M. and completed by LPN #601 revealed Resident #94 was readmitted back to the facility. Resident #94 was diagnosed with chest pain. The note included Primary Care Physician (PCP) #612 was informed of all orders and verified. The note revealed a comprehensive evaluation of admission orders including evaluation of pre-admission medications had been completed. Comparisons of resident's medications taken prior to admission, to those prescribed upon admission have been reviewed using available records, transfer documents, discharge summaries, resident/family discussions, recent history and physical, medication lists, and/or progress notes. Medications were reviewed to identify and potentially prevent significant medication adverse consequences as soon as possible. The note revealed a care conference was offered upon admission, and referral to social service for scheduling. Baseline care plan and admitting paperwork was obtained and agreed. Review of the Interdisciplinary Team (IDT) Plan of Care Review Summary dated 12/27/24 revealed the team included but not limited to Licensed Social Worker (LSW) #600, Director of Nursing (DON), Administrator, Assistant Director of Nursing (ADON)/LPN #603 and Resident #94's guardian (by phone) met and discussed the guardians recent concerns, answered questions, discussed continuous positive airway pressure (CPAP) machine care, smoking, and recent weight loss. The notes revealed no revisions were made to the care plan. There were no other details noted on the notes including review of recent hospitalization (12/11/24) and/or medications including Resident #94 not being on Perphenazine. Review of the nursing note dated 01/02/25 at 11:14 P.M. and completed by the DON revealed the IDT reviewed behaviors as well as family concerns voiced. Resident #94 continued to be sexually inappropriate at times. Review of the nursing note dated 01/08/25 at 1:16 P.M. and completed by the DON revealed the IDT reviewed behaviors as well as family concerns. Resident #94 continued to be sexually inappropriate. Review of the IDT Plan of Care Review Summary dated 01/10/25 revealed the team included but not limited to LSW #600, DON, ADON/LPN #603, Resident #94's guardian and Resident #94 discussed concerns regarding communication, therapy, staffing, nails too long, electric wheelchair, business office concerns regarding cigarettes and account, showers, shower times, call lights being answered, cleaning equipment, clothing, and activities. There were no other details noted on the notes including review of medications. Review of the nursing note dated 01/10/25 at 10:05 A.M. and completed by the DON revealed the IDT reviewed care conference as family's concerns voiced were histrionic with no current similar complaints since concerns were addressed. The note revealed Resident #94's family often brought up concerns as if they were new; however, the concerns were already addressed when clarified. The note revealed the family reported Resident #94 was impulsive, non-adherent with care including hygiene, getting out of bed, and getting dressed. The note also revealed the family reported Resident #94 was more impulsive around smoke time and would run people down to get to the smoke pass. Review of the nursing note dated 01/17/25 at 10:15 A.M. and completed by the DON revealed the IDT reviewed the resident's behaviors as well as family concerns. Resident #94 continued to be sexually inappropriate. Resident #94 remained impulsive and was non-adherent with care despite staff education and encouragement. Review of the nursing note dated 02/03/25 at 1:33 P.M. and completed by the DON revealed the IDT reviewed behaviors, and Resident #94 continued to be sexually inappropriate. Resident #94 remained impulsive, and non-adherent with care despite staff education and encouragement. Review of the nursing note dated 02/07/25 at 6:40 P.M. and completed by the DON revealed Resident #94 was being sexually inappropriate with staff. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #94 had impaired cognition with a Brief Interview for Mental Status (BIMS) score of four out of 15. During the assessment period he had other behavioral symptoms not directed towards others one to three days of the seven-day assessment reference period. The MDS revealed the resident was not on anti-psychotic medication. Review of the IDT Plan of Care Review Summary dated 03/21/25 revealed the team included but not limited to LSW #600, DON, ADON/LPN #603, Resident #94's guardian and the resident discussed psych medications, and when Resident #94 was going to smoke in the dining room, Resident #94 stated, they are pissing on me as he was experiencing delusions. The note revealed Resident #94 had a decrease in his mood as he was more accusatory. The note included PCP #612 restarted his psych medication (Perphenazine) at a low dose. Review of the nursing note dated 03/21/25 at 11:47 A.M. and completed by ADON/LPN #603 revealed PCP #612 gave new orders to restart Resident #94 on Perphenazine at lower dose: Perphenazine 2 mg by mouth twice a day and follow up with Psychiatrist #608. Resident #94's guardian was notified of medication change. Review of the nursing note dated 04/02/25 at 1:55 P.M. and completed by the DON revealed the IDT reviewed Resident #94's behaviors as well as family concerns voiced. Resident #94 remained impulsive, and non-adherent with care at times including getting dressed, getting out of bed, and hygiene. Resident #94 remained paranoid and delusional as he thought peers were urinating on him in the smoke room. Review of the nursing note dated 04/15/25 at 9:21 A.M. and completed by ADON/LPN #603 revealed Resident #94 had a telehealth appointment with Psychiatrist #608 and his mood was discussed including how the last two days he was coming down to the dining room for meals. Psychiatrist #608 increased his Perphenazine to 2 mg by mouth in the morning and 4 mg at bedtime for two weeks and then increase the Perphenazine to 4 mg by mouth twice daily. The note revealed Resident #94's guardian was present during the appointment. Review of Hospital Ombudsman #609's letter dated 04/16/25 to Resident #94's guardian revealed she was writing in response to the telephone conversation regarding Resident #94 and what the hospital sent to the facility regarding his medication. The letter revealed from review the medication in question (Perphenazine) was continued, and the hospital had no record this medication was discontinued. Review of the nursing note dated 05/10/25 at 12:15 P.M. and completed by LPN #601 revealed staff reported to the nurse that while in the dining room Resident #94 made a delusional statement as he was stating a peer was urinating on him. Resident #94 was reassured that peer was not urinating on him and offered to assist resident to the bathroom which he declined. On 05/14/25 at 7:46 A.M. Resident #94 was observed up in his wheelchair in his room displaying no behaviors and was smiling. At the time of the observation, an interview with the resident revealed he started the day off good as he was up and ready to eat. He denied any issues with feeling depressed or anxious at this time. He revealed he slept well and had a good appetite. During the interview, the resident had no knowledge regarding what medications he took. Interview on 05/14/25 at 9:23 A.M. with LSW #600 revealed she was responsible for setting up and arranging care conferences. She revealed Resident #94 had a care conference 12/27/24, 01/10/25, and 03/21/25. She revealed she did not recall any discussion regarding the resident's behaviors brought up by the family on 12/27/24 or 01/10/25. She revealed the family did bring up concerns regarding his behaviors on 03/21/25 that included Resident #94 acting more tired, sluggish, and his responses were not as quick. She revealed ADON/LPN #603 printed off the medication list, and Resident #94's guardian realized Resident #94 was no longer on Perphenazine 4 mg one tablet by mouth in the morning and Perphenazine 4 mg two tablets by mouth at bedtime. She revealed Resident #94's guardian stated that she was never informed this had been discontinued. PCP 612 was notified of the concern and ordered the Perphenazine back at a low dose and to follow up with Psychiatrist #608. On 05/14/25 at 9:23 A.M. and 11:17 A.M. an interview with LPN #601 revealed she routinely worked on the unit Resident #94 resided on. She recalled when Resident #94 returned from the hospital on 12/12/24 it was during shift change. She stated she did not look at the orders including to identify who had placed the X over the Perphenazine and/or place check marks next to the other medications. She revealed LPN #602 had transcribed Resident #94's orders. She revealed LPN #601 reviewed her nursing note entry dated 12/12/24 at 3:35 P.M. that stated she informed PCP #612 of the orders, verified the orders, and she performed a comprehensive evaluation of admission orders including evaluation of pre-admission medications, and comparisons of Resident #94's medications taken prior to admission. LPN #601 verified she did not look at the admission orders and/or compared Resident #94's medications that he was taking prior to admission. She verified she did not know Resident #94's Perphenazine had not been restarted. She verified she did not notify PCP #612 regarding Resident #94 not being on Perphenazine as she again verified, she did not look at the orders. When asked how she verified the medications with PCP #612 if she did not look at the medications she stated, yes, I did call the physician but no I did not share that he was not on that medication as I did not know as I did not look at the orders. She then revealed Registered Nurse (RN) #604 would have transcribed the orders and LPN #602 would have completed the double check of the orders. She revealed the nursing note she entered was a generic note used on all admissions and readmissions. On 05/14/25 at 10:17 A.M. an interview with ADON/LPN #603 revealed Resident #94 followed up with Psychiatrist #608 by telehealth as Resident #94's guardian came into the facility and completed solo with the physician. She verified Psychiatrist #608 was not notified Resident #94 had not been administered the Perphenazine since his return from the hospital on 12/12/24. She revealed Resident #94's guardian requested the care conference on 03/21/25 because she was concerned about Resident #94's behaviors as he was not going to the dining room as much and had other behaviors. She revealed at the care conference, on 03/21/25, the facility discovered Resident #94 was no longer on the Perphenazine and had not been receiving the medication since his re-admission from the hospital on 12/12/24. She stated she was unsure why the medication was stopped, as she did an investigation and nobody seemed to own up to who put the X over the Perphenazine. She revealed the investigation was completed verbally and she had nothing in writing such as witness statements. She verified yes, it fell somehow through the cracks, and I have no idea how. She verified LPN #601 should not have documented in the nursing note she had verified the orders with the physician if she did not look at the orders. She verified LPN #601 should have reviewed Resident #94's orders, compared the orders to his previous orders and noticed that the perphenazine was not restarted especially since she was an everyday nurse on the unit Resident #94 resided on. She verified previously at care conferences medications were not reviewed unless there was a need. She also verified Resident #94's guardian would not have had a medication list to review with Psychiatrist #608 during his telehealth appointment; therefore, Psychiatrist #608 would not have been aware Resident #94 was not on Perphenazine. She stated, going forward, the facility was doing things differently as now all re-admissions were reviewed by management including reviewing all their discharge medications, and now she was sitting in on Resident #94's telehealth appointments with Psychiatrist #608, and she was bringing a medication list to all care conferences. On 05/14/25 at 10:53 A.M. an interview with LPN #602 revealed Resident #94 returned from the hospital on 12/12/24. She stated she received in report from LPN #601 that Resident #94 had returned and the orders were in the computer but needed double checked. She stated she assumed LPN #601 had put the orders in but was unsure. She revealed she did not receive anything in report that Resident #94 was no longer on Perphenazine. She could not remember if the orders had checkmarks or an X by or on them but that she did not place any marks on the orders. She remembered double checking the orders but does not recall anything regarding Resident #94's Perphenazine order. On 05/14/25 at 11:46 A.M. an interview with RN #604 revealed Resident #94 was only admitted for one day at the hospital and had returned. She remembered transcribing the resident's medication orders and stated, I would have just followed to a T putting the orders in. She revealed she remembered marks on the discharge orders but could not say for sure if they were checkmarks or an X. She revealed she could not say if the Perphenazine had an X over it or not. She was not aware the resident was on Perphenazine previously and stated she does not look at what medications a resident was on prior to admission as she just goes down the list and transcribes what is on the list from the hospital. She revealed she never informed PCP #612 or Resident #94's guardian that he was not on Perphenazine or followed-up to question the Perphenazine. On 05/14/25 at 1:10 P.M. an interview with the DON verified her nursing notes dated 01/02/25 and 01/08/25 revealed Resident #94 was sexually inappropriate, and on 01/10/25 the family reported Resident #94 was impulsive, non-adherent with care including hygiene, getting out of bed, and getting dressed. She also verified on 01/10/25 the family reported Resident #94 was more impulsive around smoke time and would run people down to get to the smoke pass. She verified her nursing note entries dated 01/17/25 and 02/03/25 revealed the behaviors continued. Then, she verified on 03/21/25 the IDT team met with Resident #94's guardian regarding his behaviors: when Resident #94 was going to smoke in the dining room Resident #94 stated, they are pissing on me as he was experiencing delusions and decrease in his mood as he was more accusatory. She verified they reviewed the medication list (at this time) and determined Resident #94 was no longer on his Perphenazine. She revealed Resident #94's guardian often brings up things from the past that already had been addressed. She revealed on the hospital admission orders there was an X over the Perphenazine and that the nurses at the facility stated they had not placed the X as she felt it may have been done by the hospital. She revealed the nurses assumed the X meant to discontinue the medication. She revealed LPN #601 documented that the medications were verified with PCP #612. The DON was informed LPN #601 stated that she did contact PCP #612 and verified the orders but also verified she had never reviewed the hospital discharge orders. The DON was questioned how LPN #601 verified if she did not review the orders. She replied, I do not know. She also verified Resident #94 was on Perphenazine 4 mg one tablet by mouth in the morning and Perphenazine 4 mg two tablets by mouth at bedtime since admission, 08/28/24 and asked if nursing judgement would not be in best practice to ensure Psychiatrist #608 was notified prior to stopping the medication abruptly. She revealed, not like hospitals do not do that. She verified there was no documentation Psychiatrist #608 was notified of Resident #94's Perphenazine being discontinued 12/12/24 and of his increase in behaviors including delusions until it was discovered on 03/21/25 that he no longer was on his Perphenazine. On 05/14/25 at 1:37 P.M. an interview with Resident #94's guardian revealed she visited frequently, three to four times a week. The guardian revealed (following the December hospitalization ) Resident #94 began having increased delusions with paranoia. Resident #94 felt other residents were peeing on him as he felt his clothing was wet when it was not. This was an old behavior she had not seen for years. She revealed the resident wanted to have his door shut to his room because he was afraid the residents would come in his room and pee on him. She revealed he also was having issues controlling his anger and trying to isolate himself. She revealed his behavior got more and more bizarre. She stated she brought up her concerns to the facility multiple times regarding the resident's behaviors and felt facility staff were just blowing her off. She requested another meeting on 03/21/25 to discuss his behavior and that was when she found out on 12/12/24 when the resident came back from the hospital, the facility never restarted his Perphenazine. She revealed he had been on Perphenazine 4 mg one tablet by mouth in the morning and Perphenazine 4 mg two tablets by mouth at bedtime for a long time and the facility just cold turkey stopped the medication. She stated on 12/12/24, she was notified he returned from the hospital but was never told that his Perphenazine was not restarted or she would have ensured Psychiatrist #608 was notified. The facility never informed Psychiatrist #608 that the Perphenazine was discontinued. She revealed she always participated in Psychiatrist #608 telehealth appointments at the facility, and the facility was aware of the appointment but never sat in and/or shared a medication list with Psychiatrist #608. She revealed on 12/17/24 (after his readmission) they had a telehealth appointment with Psychiatrist #608, and they never shared Resident #94 was no longer on Perphenazine, so Psychiatrist #608 was not aware at that appointment as Psychiatrist #608 assumed he was on the same medication. She revealed she felt this was neglectful as for months the resident was displaying an increase in delusions, and the facility kept ignoring the family advocating that something was wrong with Resident #94. The resident's guardian stated she felt the resident should not have had to live for months the way he did. On 05/14/25 at 3:39 P.M. an interview with Psychiatrist #608 verified the facility did not notify him that Resident #94's Perphenazine was discontinued on 12/12/24, and Resident #94 did not receive the Perphenazine for several months. He revealed Resident #94 had symptom exacerbation and now he was raising the medication and tracking whether Resident #94 improved with the medication increase. Review of information obtained from drugs.com dated 08/03/23 revealed Perphenazine was an anti-psychotic medication used to treat psychotic disorders such as schizophrenia. The guidelines indicated not to stop using Perphenazine suddenly or that a person could have unpleasant symptoms such as nausea, vomiting, dizziness, or tremors. Review of the facility policy labeled, Physician Orders- admitted d 07/14/10 revealed the admission order would be received by licensed nurses and would be confirmed in writing by the prescriber and attending physician. The policy revealed the licensed nurse reviewed the orders from the transfer record from the acute care hospital or other entity. The policy revealed a call was placed to the admitting physician to confirm the transfer orders and request additional orders as needed. The policy revealed a nursing note was to be documented to authenticate the admission orders: Admission orders reviewed and approved per physician. The policy revealed telephone orders would be written for changes, clarifications, or orders made in addition to the original transfer orders. Review of the facility policy labeled, Physician Orders- Transcription dated 07/27/23 revealed the purpose of the policy was to ensure admission and other orders were received and transcribed in accordance with professional standards of practice. The policy revealed physician orders would be accurately transcribed and initiated in accordance with professional standards of practice. The deficient practice was corrected on 04/14/25 when the facility implemented the following corrective actions: On 03/21/25 the DON provided immediate education to the facility ADON staff (following the care conference where Resident #94's sister questioned why his Perphenazine was discontinued); education included direction to clarify any orders that were changed during audit of admission orders to ensure accuracy of new orders. Beginning 03/27/25 the facility implemented weekly risk management audits and reviews to be completed by the facility interdisciplinary team (IDT) on all admissions/readmissions. On 04/14/25 the DON provided education during an all staff meeting related to reviewing admissions/readmissions reviews, 24-hour follow-up, contacting hospital with any changes to ensure accuracy. Between 04/14/25 and 05/19/25 no additional significant medication errors were identified to have occurred. This deficiency represents non-compliance investigated under Complaint Number OH00165518.

Based on review of the medical record, hospital discharge summary review, interview, observation and facility policy review, the facility failed to ensure Resident #94's guardian and Psychiatrist #608 was notified regarding Resident #94's Perphenazine (anti-psychotic) medication being discontinued. This affected one resident (#94) of three residents reviewed for notification of changes. The facility census was 150. Findings include: Review of the medical record for Resident #94 revealed an admitted [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), diabetes, hypertension, and schizoaffective disorder. Review of the Letter of Guardianship dated 03/07/23 revealed Resident #94 was deemed incompetent per Probate Judge #611 and awarded Resident #94's sister guardian of person indefinitely. Review of the admission physician orders on 08/28/24 revealed Resident #94 had an order for Perphenazine 4 milligrams (mg) one tablet by mouth in the morning and Perphenazine 4 mg two tablets by mouth at bedtime. Review of the care plan dated 09/05/24 revealed Resident #94 was at risk for adverse effects related to psychoactive medications as he had schizoaffective disorder and his medications included Perphenazine. Interventions included assessing behaviors for which drugs were being given for, assessing for adverse effects of medications, giving medications as ordered, psych evaluations and treatment as indicated, and reporting changes in behaviors. Review of the nursing note dated 12/11/24 at 11:34 A.M. and authored by Licensed Practical Nurse (LPN) #613 revealed Resident #94 complained of sharp and intermittent chest pain. He was sent to the hospital for evaluation. He was later admitted to the hospital. Review of the Discharge Summary- Encounter Notes dated 12/12/24 at 11:06 A.M. authored by Hospital Physician #610 revealed Resident #94 was admitted to the hospital on 12/11/24 due to hypertension, and he was discharged on [DATE]. The discharge summary recommended continuing the following medications, including Perphenazine. The discharge summary listed prior to admission, Resident #94's was taking Perphenazine 4 mg by mouth once a day in the morning and 8 mg at bedtime. Review of the nursing note dated 12/12/24 at 3:35 P.M. authored by LPN #601 revealed Resident #94 was readmitted back to the facility. Resident #94 was diagnosed with chest pain. Primary Care Physician (PCP) #612 was informed of all orders and verified. The note revealed a comprehensive evaluation of admission orders including evaluation of pre-admission medications had been completed. Comparisons of resident's medications taken prior to admission, to those prescribed upon admission have been reviewed using available records, transfer documents, discharge summaries, resident/ family discussions, recent history and physical, medication lists, and/or progress notes. Medications were reviewed to identify and potentially prevent significant medication adverse consequences as soon as possible. The note revealed a care conference was offered upon admission and referred to social service for scheduling. The baseline care plan and admitting paperwork were obtained and agreed. There was no documentation regarding the notification to Resident #94's guardian regarding his return from the hospital. Review of the Interdisciplinary Team (IDT) Plan of Care Review Summary dated 12/27/24 revealed the team included but was not limited to Licensed Social Worker (LSW) #600, Director of Nursing (DON), Administrator, Assistant Director of Nursing (ADON)/LPN #603 and Resident #94's guardian (by phone) met and discussed the guardians recent concerns, answered questions, discussed continuous positive airway pressure (CPAP) machine care, smoking, and recent weight loss. The notes revealed no revisions were made to the care plan. There were no other details noted on the notes including review of recent hospitalization (12/11/24) and/or medications including Resident #94 not being on perphenazine. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #94 had impaired cognition as his Brief Interview for Mental Status (BIMS) score was four out of 15. He had other behavioral symptoms not directed towards others one to three days of the seven-day assessment reference period. He was not on antipsychotic medication. Review of the IDT Plan of Care Review Summary dated 03/21/25 revealed the team included but was not limited to LSW #600, DON, ADON/LPN #603, Resident #94's guardian and the resident discussed psych medications and when Resident #94 was going to smoke in the dining room, Resident #94 stated, they are pissing on me as he was experiencing delusions. The note revealed Resident #94 had a decrease in his mood as he was more accusatory. PCP #612 restarted his psych medication (Perphenazine) at a low dose. Review of the Hospital Ombudsman #609's letter dated 04/16/25 to Resident #94's guardian revealed she was writing in response to the telephone conversation regarding Resident #94 and what the hospital sent to the facility regarding his medication. The letter revealed from the review the medication in question, Perphenazine was continued, and the hospital had no record of this medication being discontinued. On 05/14/25 at 7:46 A.M. Resident #94 was observed up in his wheelchair in his room displaying no behavior and was smiling. At the time of the observation, an interview with the resident revealed he started the day off good as he was up and ready to eat. He denied any issues with feeling depressed or anxious at this time. He revealed he slept well and had a good appetite. During the interview, the resident had no knowledge regarding what medication he took. Interview on 05/14/25 at 9:23 A.M. with LSW #600 revealed she was responsible for setting up and arranging care conferences. She revealed Resident #94 had care conferences on 12/27/24, 01/10/25, and 03/21/25. She did not recall any discussion regarding the resident's behaviors brought up by the family on 12/27/24 or 01/10/25. The family did bring concerns regarding his behaviors on 03/21/25 that included Resident #94 acting more tired, sluggish, and his responses were not as quick. She revealed ADON/LPN #603 printed off the medication list, and Resident #94's guardian realized Resident #94 was no longer on Perphenazine 4 mg one tablet by mouth in the morning and Perphenazine 4 mg two tablets by mouth at bedtime. She revealed Resident #94's guardian stated that she was never informed this had been discontinued. PCP #612 was notified of the concern and ordered the Perphenazine back at a low dose and to follow up with Psychiatrist #608. On 05/14/25 at 9:23 A.M. and 11:17 A.M. an interview with LPN #601 revealed she routinely worked on the unit Resident #94 resided on. She recalled when Resident #94 returned from the hospital on 12/12/24 it was during shift change. She stated she did not look at the orders including identifying who had placed the X over the Perphenazine and/or place checkmarks next to the other medications. She revealed LPN #602 transcribed Resident #94's orders. LPN #601 reviewed her nursing note entry dated 12/12/24 at 3:35 P.M. that stated she informed PCP #612 of the orders, verified the orders, and she performed a comprehensive evaluation of admission orders including evaluation of pre-admission medications, and comparisons of Resident #94's medications taken prior to admission. LPN #601 verified she did not look at the admission orders and/or compare Resident #94's medications that he was taking prior to admission. She verified she did not know Resident #94's Perphenazine had not been restarted. She verified she did not notify PCP #612 regarding Resident #94 not being on Perphenazine as she again verified, she did not look at the orders. When asked how she verified the medications with PCP #612 if she did not look at the medications she stated, yes, I did call the physician, but no, I did not share that he was not on that medication as I did not know as I did not look at the orders. She then revealed Registered Nurse (RN) #604 would have transcribed the orders, and LPN #602 would have completed the double check of the orders. She revealed the nursing note she entered was a generic note used on all admissions and readmissions. On 05/14/25 at 10:17 A.M. an interview with ADON/LPN #603 revealed Resident #94 followed up with Psychiatrist #608 by telehealth as Resident #94's guardian came into the facility and completed solo with the physician. She verified Psychiatrist #608 was not notified Resident #94 had not been administered the Perphenazine since his return from the hospital on 12/12/24. She revealed Resident #94's guardian requested the care conference on 03/21/25 because she was concerned about Resident #94's behavior as he was not going to the dining room as much and other behaviors. She revealed at the care conference, on 03/21/25, the facility discovered Resident #94 was no longer on the Perphenazine and had not been receiving the medication since his re-admission from the hospital on 12/12/24. She stated she was unsure why the medication was stopped, as she did an investigation and nobody seemed to own up to who put the X over the Perphenazine. She revealed the investigation was completed verbally and she had nothing in writing such as witness statements. She verified yes, it fell somehow through the cracks, and I have no idea how. She verified LPN #601 should not have documented in the nursing notes that she verified the orders with the physician if she did not look at the orders. She verified LPN #601 should have reviewed Resident #94's orders, compared the orders to his previous orders and noticed that the Perphenazine was not restarted especially since she was an everyday nurse on the unit that Resident #94 resided on. She verified medications were not reviewed at care conferences unless there was a need. She also verified Resident #94's guardian would not have had a medication list to review with Psychiatrist #608 during his telehealth appointment; therefore, Psychiatrist #608 would not have been aware Resident #94 was not on Perphenazine. She stated, going forward, the facility was doing things differently as now all re-admissions were reviewed by management including reviewing all their discharge medications, and now she was sitting in on Resident #94's telehealth appointments with Psychiatrist #608, and she was bringing a medication list to all care conferences. Interview on 05/14/25 at 10:53 A.M. with LPN #602 revealed Resident #94 returned from the hospital on 12/12/24. She received report from LPN #601 that Resident #94 returned, and the orders were in the computer but needed double checked. She assumed LPN #601 put the orders in but was unsure. She did not receive anything in report that Resident #94 was no longer on Perphenazine. She remembered double checking the orders but does not recall anything regarding Resident #94's Perphenazine order. She verified she did not notify Resident #94's guardian regarding his return from the hospital and/or medication orders. On 05/14/25 at 11:46 A.M. an interview with RN #604 revealed Resident #94 was only admitted to the hospital for one day and then returned. She remembered transcribing the resident's medication orders and stated, I would have just followed to a T putting the orders in. She remembered marks on the discharge orders but could not say for sure if they were checkmarks or an X. She could not say if the Perphenazine had an X over it or not. She was not aware the resident was on Perphenazine previously and stated she does not look at what medications a resident was on prior to admission as she just goes down the list and transcribes what is on the hospital's list. She never informed PCP #612 or Resident #94's guardian that he was not on Perphenazine and/or followed up to question the Perphenazine. Interview on 05/14/25 at 1:10 P.M. with the Director of Nursing (DON) verified there was no documentation that Psychiatrist #608 was notified of Resident #94's Perphenazine being discontinued 12/12/24 and of his increase in behaviors including delusions until it was discovered on 03/21/25 that he no longer was on his Perphenazine. On 05/14/25 at 1:37 P.M. an interview with Resident #94's guardian revealed she visited frequently, three to four times a week. The guardian revealed (following the December 2024 hospitalization ) Resident #94 began having increased delusions with paranoia. Resident #94 felt other residents were peeing on him as he felt his clothing was wet when it was not. This was an old behavior she had not seen for years. She revealed the resident wanted to have his door shut to his room because he was afraid the residents would come in his room and pee on him. She revealed he also was having issues controlling his anger and trying to isolate himself. She revealed his behavior got more and more bizarre. She stated she brought up her concerns to the facility multiple times regarding the resident's behaviors and felt facility staff were just blowing her off. She requested another meeting on 03/21/25 to discuss his behavior and that was when she found out when the resident came back from the hospital on 12/12/24, the facility never restarted his Perphenazine. She revealed he had been on Perphenazine 4 mg one tablet by mouth in the morning and Perphenazine 4 mg two tablets by mouth at bedtime for a long time and the facility just stopped the medication cold turkey. She stated on 12/12/24, she was notified he returned from the hospital but was never told that his Perphenazine was not restarted or she would have ensured Psychiatrist #608 was notified. The facility never informed Psychiatrist #608 that the Perphenazine was discontinued. She revealed she always participated in Psychiatrist #608 telehealth appointments at the facility, and the facility was aware of the appointment but never sat in and/or shared a medication list with Psychiatrist #608. She revealed on 12/17/24 (after his readmission) they had a telehealth appointment with Psychiatrist #608, and they never shared Resident #94 was no longer on Perphenazine, so Psychiatrist #608 was not aware at that appointment as Psychiatrist #608 assumed he was on the same medication. She revealed she felt this was neglectful as for months the resident was displaying an increase in delusions, and the facility kept ignoring the family advocating that something was wrong with Resident #94. The resident's guardian stated she felt the resident should not have had to live for months the way he did. On 05/14/25 at 3:39 P.M. an interview with Psychiatrist #608 verified the facility did not notify him that Resident #94's Perphenazine was discontinued on 12/12/24, and Resident #94 did not receive the Perphenazine for several months. He revealed Resident #94 had symptom exacerbation and now he was raising the medication and tracking whether Resident #94 improved with the medication increase. Review of Drugs.com dated 08/03/23 revealed Perphenazine was an anti-psychotic medication used to treat psychotic disorders such as schizophrenia. The guidelines indicated not to stop using Perphenazine suddenly or that a person could have unpleasant symptoms such as nausea, vomiting, dizziness, or tremors. Review of the facility policy labeled, Change in Condition 10/18/01 revealed a change in condition was defined as deterioration in the health, mental, or psychosocial status of a resident including significant alteration in treatment. The policy revealed the supervisor or change nurse would notify the resident, physician, and guardian of all changes and of any other situation requiring notification. The policy revealed that the person making the notification was to document the notification. This deficiency represents non-compliance investigated under Complaint Number OH00165518.

Based on observation, interview, record review, and policy review the facility failed to administer medications that followed appropriate nursing standards of care and left medications unsecured at Resident #60's bedside. This affected one resident (#60) and had the potential to affect 90 residents (#1, #3, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #17, #18, #19, #20, #22, #25, #26, #27, #28, #29, #30, #32, #33, #34, #35, #36, #37, #38, #41, #42, #43, #45, #47, #48, #49, #51, #53, #54, #55, #57, #59, #60, #61, #62, #63, #64, #66, #69, #70, #71, #76, #78, #79, #82, #83, #84, #85, #86, #89, #91, #93, #97, #109, #110, #113, #114, #115, #116, #117, #118, #120, #122, #123, #125, #127, #129, #130, #132, #137, #139, #140, #142, #145, #147, #301, #351, #401, #402) who were independently mobile and resided on the secured unit. The facility census was 150. Findings Include: Review of Resident #60's medical record revealed an admitted [DATE] with medical diagnoses including vascular dementia with moderate behavioral disturbance, schizophrenia, symptoms and signs involving cognitive functions and awareness, bipolar disorder, heart failure, hyperlipidemia, and atherosclerotic heart disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #60 was mildly cognitively impaired with a Brief Interview of Mental Status (BIMS) score of nine of 15. Resident #60 showed behaviors of rejection of care and wandering. Review of the care plan dated 10/26/23 revealed Resident #60 experienced alteration in mood and behavior related to bipolar disorder, schizophrenia, unspecified vascular dementia with behavioral disturbance, and major depressive disorder. Resident #60 had a history of refusing care, pacing, confusion, poor safety awareness, hording, rummaging, and refusing care. Observation on 02/26/24 at 10:59 A.M. revealed a medication cup filled over halfway with oral medication tablets and capsules were on Resident #60's bedside table. Resident #60 was observed lying in bed next to bedside table with eyes closed. Interview on 02/26/24 with Licensed Practical Nurse (LPN) #565 confirmed oral medications were not observed to be administered when LPN #565 left a medication cup filled with Resident #60's medication at the bedside. LPN #565 stated that was not normal practice to leave medications at the resident's bedside, and that she was in a hurry that morning. Review of medication administration audit report dated 02/26/24 revealed on 02/26/24 at 9:23 A.M. LPN #565 documented Resident #60 was administered Wellbutrin (anti-depressant) 150 milligram (mg) tablet, Colace 100mg (stool softener) capsule, cholecalciferol 2000 units (vitamin supplement), amlodipine 5mg (anti-hypertensive) tablet, furosemide 20mg (diuretic) tablet, aspirin 81mg (blood thinner) tablet, magnesium-oxide 400mg (vitamin supplement) tablet, two capsules of fish oil 500mg, Aricept 5mg (cognition enhancing medication) tablet, metoprolol 25mg (anti-hypertensive) tablet, and two Tylenol 325mg tablets (pain reliever). Review of Resident #60's physician orders revealed there were no physician orders that state medications can be left at Resident #60's bedside. Review of facility policy titled General Guidelines for Medication Administration dated 06/21/17 revealed facility staff administer medications to residents and to remain with resident while medication is swallowed. Medication is to never be left in a resident's room without orders to so.

Based on interview and record review the facility failed to ensure accuracy of assessments when the behavior section did not accurately reflect the status of Residents #88, #159 and #161. This affected three residents (#88, #159 and #161) of four residents reviewed for behaviors. Findings include: 1. Record review revealed Resident #88 was admitted to the facility on [DATE] with diagnoses including dementia with behavioral disturbance, depression, and insomnia. Review of the behavior documentation report for April 2023 revealed Resident #88 demonstrated pacing/wandering on 04/15/23 and 04/21/23 and screaming on 04/17/23 and 04/19/23. Review of the behavior tracking log and progress notes for April 2023 revealed Resident #88 was resistive to care on 04/17/23, 04/18/23, 40/20/23 and 04/21/23. Review of the 5-day Admission Minimum Data Set (MDS) 3.0 assessment, dated 04/21/23, revealed Resident #88 was assessed in section E0200(C) for other behavioral symptoms not directed towards others (e.g., verbal/vocal symptoms like screaming or disruptive sounds) as behavior not exhibited and the response was locked on 04/17/23 prior to the assessment reference date (ARD) of 04/21/23. Section E0800 for rejection of care was assessed as behavior not exhibited and the response was locked on 04/17/23 prior to the ARD of 04/21/23. Section E0900 for wandering was assessed as behavior not exhibited and the response was locked on 04/17/23 prior to the ARD of 04/21/23. Interview on 05/04/23 at 12:18 P.M. with Social Services Designee (SSD) #608 and Licensed Social Worker (LSW) #509 verified Resident #88's 5-day Admission MDS assessment dated [DATE] did not capture all the behaviors documented during the look back period from the ARD because it was completed prior to the ARD. LSW #509 indicated it was acceptable to complete the assessment anytime within the assessment period. 2. Record review revealed Resident #159 was admitted to the facility on [DATE] with diagnoses including psychosis not due to substance or known physiological condition, dementia with behavioral disturbance, post-traumatic stress disorder, major depressive disorder, anxiety, and insomnia. Review of the behavior documentation report for March 2023 and April 2023 revealed Resident #159 demonstrated pacing/wandering and disruptive sounds on 03/30/23, and refusal of care on 04/01/23. Review of the behavior tracking log for March 2023 and April 2023 revealed Resident #159 demonstrated pacing/wandering on 03/29/23 and 03/30/23, and was resistive to care on 03/29/23, 03/30/23, 03/31/23, 04/01/23, 04/03/23, and 04/04/23. Review of the Admission MDS 3.0 assessment, dated 04/04/23, revealed Resident #159 was assessed in section E0200(C) for other behavioral symptoms not directed towards others (e.g., verbal/vocal symptoms like screaming or disruptive sounds) as behavior not exhibited and the response was locked on 03/29/23 prior to the ARD of 04/04/23. Section E0800 for rejection of care was assessed as behavior not exhibited and the response was locked on 03/29/23 prior to the ARD of 04/04/23. Section E0900 for wandering was assessed as behavior not exhibited and the response was locked on 03/29/23 prior to the ARD of 04/04/23. Interview on 05/04/23 at 12:18 P.M. with SSD #608 and LSW #509 verified Resident #159's Admission MDS assessment dated [DATE] did not capture all the behaviors documented during the look back period from the ARD because it was completed prior to the ARD. LSW #509 indicated it was acceptable to complete the assessment anytime within the assessment period. 3. Record review revealed Resident #161 was admitted to the facility on [DATE] with diagnoses including dementia with behavioral disturbance, Parkinson's disease, and acute myeloblastic leukemia. Review of the 5-day MDS 3.0 assessment, dated 04/22/23, revealed Resident #161 was assessed in section E0200(A) for physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, and grabbing) as behavior exhibited one to three days and the response was locked on 04/24/23. Review of the psychosocial assessment dated [DATE] for Resident #161 revealed E0200(A) for physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, and grabbing) was answered as behavior exhibited one to three days. Review of the behavior documentation report and progress notes for April 2023 revealed Resident #161 did not demonstrate any physical behavior directed toward others. Interview on 05/03/23 at 10:01 A.M. with SSD #608 and MDS Registered Nurse (RN) #583 confirmed Resident #161's 5-day MDS assessment dated [DATE] was incorrect. Resident #161 did not exhibit any physical behavioral symptoms. SSD #608 indicated selecting the wrong response when completing the assessment. MDS RN #608 stated Resident #161's MDS assessment would be corrected. Review of Resident #161's 5-day MDS assessment dated [DATE] revealed section E0200(A) for physical behavioral symptoms directed toward others was modified to behavior not exhibited and was locked on 05/03/23.

Based on observation and interview, the facility failed to maintain the kitchen in a sanitary manor. This had the potential to affect the 167 residents receiving food prepared in the kitchen. Three residents did not receive food from the kitchen (Resident #114, Resident #122 and Resident #45). The census was 170. Findings include: On 09/16/19 at 9:41 [NAME]M., during the initial tour of the kitchen, observation of the shelf over the stove revealed it was greasy and dusty. There were two pans, open side facing upward, set on top of the dirty surface. On 09/16/19 at 9:52 [NAME]M this was verified by Dietary Manager #444. The pans were removed and rewashed, and the shelf was washed. On 09/18/19 at 4:40 P.M. observation of the kitchen ceiling directly over tray line revealed there were three air vents on the ceiling measuring approximately two feet by two feet surrounded by rectangular ceiling tiles measuring approximately 16 inches by 36 inches in size. Three of those ceiling tiles hung directly over tray line holding open pans of food, and the tiles were heavily covered in black dust. Some of the dust was blowing in the air [MEDICATION NAME] coming from the vents. On 09/18/19 at 4:45 P.M. this was reviewed with and verified by Dietary Manager #444.

Based on observation, interview and record review, the facility failed to adequately and promptly resolve Resident Council grievances regarding late meal trays. This affected seven residents (Residents #64, #75, #80, #103, #134, #147 and #150) of seven residents who attended the Resident Council meeting during the survey. This had the potential to affect all 167 of 170 residents residing at the facility. The facility identified three (Residents #45, #114 and #122) who did not receive a meal tray from the kitchen. Findings include: Review of Resident Council Meeting minutes dated 06/05/19 revealed a grievance regarding meal trays being served late. Resident #5 had revealed she was not getting her lunch tray until 2:30 P.M. Review of form titled, Response to Resident Council dated 06/05/19 revealed Dietary Manager #443's response regarding the Resident Council grievance of late meal trays revealed she was in the process of training new cooks and timing would continue to improve. No other plan for improvement of late trays was documented. Review of Resident Council Meeting minutes dated 08/07/19 revealed the residents had a grievance regarding meals being late. Review of form titled, Response to Resident Council dated 08/07/19 revealed Dietary Manager #443's response regarding the Resident Council grievance of late meal trays revealed meals were a little behind due to training and times would improve. No other plan for improvement of late trays was documented. Interview on 09/16/19 at 1:16 P.M. with Resident #161 revealed lunch was always late, and it had been coming later and later over the last two weeks. Resident #161 revealed he usually received his lunch tray at approximately 1:45 P.M., and it was about 45 minutes after it should have arrived. Interview on 09/16/19 at 1:28 with State tested Nursing Assistant (STNA) #951 revealed she was supposed to get the trays on the A unit between 12:30 P.M. and 12:45 P.M., but the trays had been late recently. Observation on 09/16/19 at 1:38 P.M. revealed Resident #161 received his lunch tray at 1:38 P.M., and STNA #951 verified the time he received his tray. Resident Council Meeting was held with the surveyor on 09/17/19 at 3:00 P.M. with Residents #64, #75, #80, #103, #134, #147 and #150, and all residents present at the meeting brought up the concern of late meal trays. They revealed they had brought up the concern previously in Resident Council meetings, and the concern had not been resolved. They revealed they wait for extended periods of time for their trays as they have no idea when the trays will arrive. Resident #103 revealed there had been someday's she had not received her lunch tray until 2:30 P.M. Resident #80, who was the Resident Council President, revealed she did not feel the facility provided the Resident Council with an effective action plan of how they were addressing the late meal trays as the concern continued. Interview on 09/17/19 at 3:50 P.M. with Activities Director #602 verified the residents had voiced complaints at a few of the Resident Council meetings regarding their meal trays being late. He revealed Dietitian #442 and/ or Dietary Manager #443 had been present at the meetings and were aware of the continued complaints. Interview on 09/18/19 at 5:50 P.M. with Licensed Practical Nurse (LPN) #600 revealed there had been a concern with late trays. She revealed she never knew when the dinner trays would arrive to the B unit as the time always varied. She revealed she had orders for residents to receive their glucometer checks and insulin sliding scale coverage at 4:00 P.M. She revealed she administered Resident #56, #92 and #110 their insulin sliding scale coverage at approximately 4:00 P.M. She revealed she sometimes called the kitchen to see if the trays were running late but did not today. The dinner trays arrived on the B unit at 5:56 P.M. Interview on 09/19/19 at 10:29 [NAME]M. with Dietitian #443 revealed he had been aware of the resident complaints regarding their meal trays being late. He revealed they had been having issues with late meals because of staffing and dietary turnover being the contributing factors. He revealed they had hired and were in the continued process of training. He was not aware of any other action plan currently regarding the concern of late meal trays. Interview on 09/19/19 at 10:45 [NAME]M. with Dietary Manager #443 revealed she was aware of the residents' concerns of late meal trays. She verified she was aware the residents voiced their concern at the (MONTH) 2019 and (MONTH) 2019 Resident Council meetings regarding late meal trays, and it remained a concern of the residents. She revealed she was attempting to prep more at night, hire more dietary staff, and train the staff hired. She verified there was a few days lunch trays were not served until after 2:00 P.M. Review of facility policy titled, Resident Council dated 10/18/01 revealed the Resident Council was intended to promote resident interest and provide a forum for residents to voice their opinions, concerns, suggestions for change in day to day operation of the facility. The council was to meet monthly to discuss issues and seek resolution of concerns of residents. The facility would investigate Resident Council concerns as the activity director or designee would submit the expressed concern to the appropriate facility department or administrator on a Resident Council concern form. The facility would, before the next meeting, return the form and an action plan of how they will resolve the concern.

Based on observation, interview, record review and policy review, the facility failed to complete accu checks (use of a glucometer to test a resident's blood sugar level) and sliding scale insulin coverage before they received their meal in a timely fashion affecting four residents (Resident #56, #72, #92, and #100) of 19 residents receiving accu checks with insulin sliding scale coverage. This had the potential to affect 56 residents at the facility with a [DIAGNOSES REDACTED]. Findings include: 1. Record review for Resident #56 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of care plan dated 08/15/17 revealed Resident #56 was at risk for [DIAGNOSES REDACTED] and [MEDICAL CONDITION] episodes and required daily insulin related to diabetes. Interventions included for staff to be alert to medications that caused changes in blood sugar levels, diet as ordered, insulin as ordered, monitor blood sugar levels as ordered, and monitor for signs and symptoms of [MEDICAL CONDITION] and [DIAGNOSES REDACTED]. Review of Resident #56's (MONTH) 2019 physician orders [REDACTED]. Review of Medication Administration Record [REDACTED].M. Interview on 09/18/19 at 5:50 P.M. with Licensed Practical Nurse (LPN) #600 revealed there had been an issue with late trays. She revealed she never knew when the dinner trays would arrive to the B unit as the time always varied. She revealed she had orders for residents to receive their glucometer checks and sliding scale at 4:00 P.M. She revealed she obtained Resident #56's accu check and administered her sliding scale insulin coverage at 3:45 P.M. She revealed she sometimes called the kitchen to see if the trays were running late but did not today. LPN #600 verified the dinner trays arrived at the B unit at 5:56 P.M., and she verified it was over two hours from the time Resident #56 received her sliding scale insulin coverage until the time she received her meal tray. Interview on 09/19/19 at 8:01 P.M. with the Director of Nursing verified LPN #600 obtained Resident #56's accu check and administered her insulin sliding scale coverage over two hours before Resident #56 received her tray. She revealed she was aware of residents' complaints over the last few months of receiving their meal trays late. She verified accu checks with sliding scale coverage should be within a half hour of a resident receiving their tray. Interview on 09/19/19 at 12:23 P.M. with Facility Pharmacy Consultant #601 revealed [MEDICATION NAME] needed to be given within a half hour of Resident #56 receiving her meal as any longer could have the potential to cause a hypoglycemic reaction as [MEDICATION NAME] was a fast-acting insulin. 2. Record review for Resident #110 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of care plan dated 03/04/14 revealed Resident #110 was at risk for [DIAGNOSES REDACTED] and [MEDICAL CONDITION] episodes and required daily insulin related to diabetes. Interventions included for staff to be alert to medications that caused changes in blood sugar levels, diet as ordered, insulin as ordered, monitor blood sugar levels as ordered, and monitor for signs and symptoms of [MEDICAL CONDITION] and [DIAGNOSES REDACTED]. Review of quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #110 had intact cognition and received insulin. Review of physician orders [REDACTED].#110 had an order for [REDACTED]. Review of MAR for (MONTH) 2019 revealed Resident #110 on 09/18/19 at 4:16 P.M. received her accu check which was 188 mg/dL, and she was administered two units of [MEDICATION NAME] R insulin per her sliding scale subcutaneously per LPN #600. Interview on 09/18/19 at 5:50 P.M. with LPN #600 revealed there had been an issue with late trays. She revealed she never knew when the dinner trays would arrive to the B unit as the time always varied. She revealed she had orders for residents to receive their accu checks and sliding scale at 4:00 P.M. She revealed she obtained Resident #110's accu check and administered her sliding scale insulin coverage at 4:16 P.M. She revealed she sometimes called the kitchen to see if the trays were running late but did not today. LPN #600 verified the dinner trays arrived at the B unit at 5:56 P.M., and she verified it was over an hour from the time Resident #110 received her sliding scale insulin coverage until the time she received her meal tray. Interview on 09/19/19 at 8:01 P.M. with the Director of Nursing verified LPN #600 obtained Resident #110's accu check and administered her sliding scale coverage over an hour before Resident #110 received her meal tray. She revealed she was aware of residents' complaints over the last few months of receiving their meal trays late. She verified accu checks with sliding scale coverage should be within a half hour of a resident receiving their tray. Interview on 09/19/19 at 12:23 P.M. with Facility Pharmacy Consultant #601 revealed [MEDICATION NAME] Regular insulin needed to be given within a half hour of Resident #110 receiving her meal as any longer than a half hour could have the potential to cause a hypoglycemic reaction as [MEDICATION NAME] was a fast-acting insulin. 3. Record review for Resident #92 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of care plan dated 10/25/16 revealed Resident #92 was at risk for [DIAGNOSES REDACTED] and [MEDICAL CONDITION] episodes. Interventions included for staff to be alert to medications that caused changes in blood sugar levels, diet as ordered, insulin as ordered, monitor blood sugar levels as ordered, and monitor for signs and symptoms of [MEDICAL CONDITION] and [DIAGNOSES REDACTED]. Review of quarterly MDS 3.0 assessment dated [DATE] revealed Resident #92 was cognitively intact and received insulin. Review of physician orders [REDACTED].#92 had an order for [REDACTED]. Review of Resident #92's MAR for 09/18/19 at 4:44 P.M. Resident #92's accu check was checked and was 164 mg/dL. She was given [MEDICATION NAME] four units subcutaneously per her sliding scale coverage. Interview on 09/18/19 at 5:50 P.M. with LPN #600 revealed there had been an issue with late trays. She revealed she never knew when the dinner trays would arrive to the B unit as the time always varied. She revealed she had orders for residents to receive their accu checks and insulin sliding scale at 4:00 P.M. She revealed she obtained Resident #92's accu check and administered her sliding scale insulin coverage at 4:44 P.M. She revealed she sometimes called the kitchen to see if the trays were running late but did not today. LPN #600 verified the dinner trays arrived on the B unit at 5:56 P.M., and she verified it was over an hour from the time Resident #92 received her sliding scale insulin coverage until the time Resident #92 received her meal tray. Interview on 09/19/19 at 8:01 P.M. with the Director of Nursing verified LPN #600 obtained Resident #92's accu check and administered her sliding scale coverage over an hour before Resident #92 received her tray. She revealed she was aware of residents' complaints over the last few months of receiving their meal trays late. She verified accu checks with sliding scale coverage should be within a half hour of a resident receiving their tray. Interview on 09/19/19 at 12:23 P.M. with Facility Pharmacy Consultant #601 revealed [MEDICATION NAME] needed to be given within a half hour of Resident #92 receiving her meal tray as any longer than a half hour before eating could have the potential to cause a hypoglycemic reaction as [MEDICATION NAME] was a fast-acting insulin. Review of facility policy labeled, Care of the Adult Diabetes Mellitus Resident dated 02/21/2007 revealed the staff was to assist the resident to establish a balance between diet, exercise and insulin and was to prevent recurrence of [MEDICAL CONDITION] and [DIAGNOSES REDACTED]. The policy did not include timing of the administration of short acting insulin with the timing of when a resident received their meal. . 4. Observation of a medication pass for Resident #72 on 9/17/19 at 8:38 [NAME]M. by LPN #201 revealed the resident received a blood glucose check and sliding-scale insulin administration as part of the pass. Observation at this time revealed a breakfast tray containing no remaining food at the resident's bedside table. Interview with Resident #72 at the time of the above observation revealed he had already received his breakfast and eaten it before the nurse arrived for his blood glucose test. Interview with LPN #201 on 09/17/19 at 9:10 [NAME]M. confirmed she gave Resident #72 his glucose test and insulin after he had already eaten breakfast. Record review of Resident #72 revealed he had a [DIAGNOSES REDACTED]. He had an order dated 01/08/19 for insulin to be administered based on the blood glucose value (sliding scale insulin) four times per day, before each meal and at bedtime.

Based on observation and interviews, the facility did not ensure food was served at palatable temperatures to Residents #75, #149, #161 and #469. This affected four of seven residents reviewed for food. The facility census was 170. Findings included: Interview was conducted on 09/16/19 at 12:07 P.M. with Resident #469 who revealed he ate in his room, and the hot food was never hot. He explained the problem was at lunch and dinner time, any food he was served that should be hot was barely warm in his mouth. Interview was conducted on 09/16/19 at 12:12 P.M. with Resident #75 who revealed he ate in his room and he was almost never served a hot meal. He gave examples of hamburgers, casseroles, soups and hot sandwiches were barely warm by the time he was served in his room. Interview was conducted on 09/16/19 at 12:22 P.M. with Resident #149 who stressed he would be happy if he could get a hot meal once in a while. Resident #149 shared he preferred to eat in his room, and he would have to ask for his meal to be reheated if he wanted to eat hot food. Interview was conducted on 09/16/19 at 12:44 P.M. with Resident #161 who revealed the food was not served hot, and he preferred to eat in his room. He gave examples of potato, roasts and sandwiches that should be hot but were served just warm. An observation was conducted on 09/18/19 from 4:20 P.M. to 6:07 P.M. with Dietary Manager (DM) #443 of dinner tray line and a room test tray. At 4:20 P.M., Cook #444 took tray line temperatures as followed: baked potato - 179 degrees Fahrenheit (F), steamed broccoli - 168 degrees F, chili sauce - 171 degrees F, and cheese sauce 163 degrees F. Next to the tray line sat large tub containers filled with ice and contained half pints of white milk and tulip dishes with fresh, green melon. Cook #444 finished the temperatures at 4:24 P.M., and no additional food temperatures were taken during the course of the tray line during the observation. Tray line service started at 4:50 P.M. with Cook #445 serving the meal to the main dining room just off the kitchen. At 5:15 P.M., Cook #445 began serving the trays that were going to be transported to the secured unit dining room. At 5:34 P.M., Cook #445 began serving the room trays for the B unit hallway cart. At 5:55 P.M., a test tray was placed lastly onto the B unit hallway cart. At 5:56 P.M., the cart was on the B unit. All trays were passed by 6:07 P.M., and the test tray was removed from the cart to begin obtaining food temperatures. DM #443 began taking the temperature of the half pint of milk using a calibrated, digital touch-point thermometer. At 6:07 P.M., the milk was 47.8 degrees F. The remaining temperatures were taken as followed: baked potato with chili and cheese sauce - 119.6 degrees F, steamed broccoli - 107.0 degrees F and fresh melon - 50.4 degrees F. The baked potato item and steamed broccoli felt barely warm in the mouth of the surveyor.

Based on record review, observation and interviews, the facility failed to provide adequate activities for Resident #122. This affected one of two residents being reviewed for activities. The facility census was 170. Findings include: Review of the medical record for Resident #122 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. The resident's mother was listed as her legal guardian. The annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was totally dependent for activities of daily living, was not comatose, had adequate hearing, impaired vision and daily physical behaviors directed towards herself. In the section regarding the daily preferences for everyday living, the staff gave input but did not include her guardian. The plan of care with a date initiated of 06/10/11 and authored by Activity Director (AD) #602 indicated Resident #122 had a guardian who did not want Resident #122 to leave her room for any activities. Observations were conducted of Resident #122 on 09/16/19 at 11:11 [NAME]M., 09/16/19 at 3:30 P.M., 09/17/19 at 9:37 [NAME]M., 09/18/19 at 1:33 P.M. and 6:01 P.M. and 09/19/19 at 10:10 [NAME]M. Each time the resident was dressed in a hospital gown. During verbal stimulation she would turn her head and make unintelligible noises. She had a room mate who was alert but disoriented to person, place and time. Resident #122 was never seen out of her room throughout the four day survey. She had a tube feeding and did not eat by mouth. There was a radio and reading materials in her room but no tactile or aroma sensory objects in her room. Interviews were conducted on 09/18/19 from 11:15 [NAME]M. to 11:33 [NAME]M. with AD #602, Activity Aide (AA) #607 and AA #608 regarding Resident #122's participation in activities. AD #602 revealed Resident #122 only left her room to be showered twice a week and had room visits because her guardian/mother did not want the resident to leave her room. AD #602 explained he had never came out and asked the guardian why she could not leave her room because he had worked with her in the past, and he believed the guardian had a stigma about Resident #122 being seen in public and people seeing her due to her condition. AA #607 added when pets visit AA #607 would take the pet into Resident #122 and put her hands on the fur. Resident #122 would respond by making squealing noises like she enjoyed it. AA #608 shared the document Monthly 1:1 Log dated (MONTH) 2019 for Resident #122 and verified she and AA #607 had provided reading magazines, singing songs and playing music to her 16 times for 15 minutes each and rubbed lotion on her hands three times for 15 minutes each during the month of (MONTH) 2019. AD #602 said they did not provide any evening activities after 3:00 P.M. to Resident #122, and there had not been any pet visits for several months. Interview was conducted on 09/18/19 at 1:33 P.M. in Resident #122's room with Licensed Practical Nurse (LPN) #606 who revealed she had been Resident #122's nurse for several years. She said a typical day for Resident #122 was to be dressed in an institutional gown, spend her day in her room and staff would turn the radio on for her to keep her company. LPN #122 said staff do not take her out of her room except for a shower because that was the guardian's wishes to her knowledge. LPN #122 verified the staff only dressed her in an institutional gown and Resident #122 would cry out through the day randomly and scratch at herself for no known reason. LPN #122 verified the only activity materials in the room were a radio and reading materials, and Resident #122 was dependent on staff for all of her activities. Interview was conducted on 09/18/19 at 12:56 P.M. with the Social Services Director (SSD) #603 who revealed she had worked at the facility for about a year, and it was her understanding Resident #122 should not leave her room. When asked if she had ever tried to ask Resident #122's guardian if she would consider permitting her to leave the room for social time. SSD #603 said no. SSD #603 added Resident #122's guardian visited every Sunday and had seen her on Sundays when she worked on the weekend but had not thought to discuss with her liberalizing Resident #122's social opportunities through different activity participation.

Based on observation, interview and record review, the facility failed to provide quarterly care conferences for Resident #122 and Resident #144 according to the regulatory requirements. This affected two residents (Resident #122 and #144) of three residents reviewed for care planning. The facility census was 170. Findings included: 1. Review of the medical record for Resident #122 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. The resident's mother was listed as her legal guardian. The annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was totally dependent for activities of daily living, was not comatose, had adequate hearing, impaired vision and daily physical behaviors directed towards herself. In the section regarding the daily preferences for everyday living, the staff gave input but did not include her guardian. The record did not contain any evidence that interdisciplinary plan of care meetings were held to include a state tested nursing assistant (STNA) familiar with her care or to include the guardian on the days staff knew she regularly visited the facility. Observations were conducted of Resident #122 on 09/16/19 at 11:11 [NAME]M., 09/16/19 at 3:30 P.M., 09/17/19 at 9:37 [NAME]M., 09/18/19 at 1:33 P.M. and 6:01 P.M. and 09/19/19 at 10:10 [NAME]M. Each time the resident was dressed in a hospital gown, appeared to be visually impaired and unable to move herself in her bed. During verbal stimulation she would turn her head and make unintelligible noises. She had a tube feeding and did not eat by mouth. She had a room mate who was alert and disoriented to person, place and time and did not interact with Resident #122. Resident #122 was never seen out of her room throughout the four day survey. Interview was conducted on 09/18/19 at 12:56 P.M. with the Social Services Director (SSD) #603 who verified she had seen the guardian visiting Resident #122 on Sundays and a few times a week in the evenings. She said she had not made any attempts to schedule plan of care meetings when the guardian routinely visited in the facility on Sundays or in the evenings. SSD #603 revealed she had worked at the facility for about a year, and it was her understanding Resident #122 should not leave her room. When asked if she had ever tried to ask Resident #122's guardian if she would consider permitting her to leave the room for social time, SSD #603 said no. SSD #603 added the resident was discussed at weekly risk management meetings, but those meetings did not include a STNA familiar with her care nor was it a plan of care meeting specific to that resident. 2. Review of medical record revealed Resident #140 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of care plan dated 01/31/19 revealed Resident #140 planned to be discharged by the end of (MONTH) 2019, and he needed a new place to live. Interventions included to allow resident choice related to daily care, and the resident was to be offered opportunity to verbalize feeling related to placement. Review of facility form titled, Plan of Care Review Summary dated 03/21/19 revealed SSD #603, Registered Nurse (RN)/ Assistant Director of Nursing (ADON) #605 and Physician #950 by telephone participated in reviewing Resident #140's plan of care. The notes of the care conference revealed Physician #950 restricted leave of absence until care conference for safety as Resident #140's pattern of poor decisions while on leave of absence could potentially cause harm to self and others. The resident agreed to make better decisions and his leave of absence restrictions were lifted. There was no documentation the resident or resident representative attended the meeting. Review of quarterly MDS 3.0 assessment dated [DATE] revealed Resident #140's Brief Interview of Mental Status (BIMS) score was a 13, indicating he was cognitively intact. He required extensive assist of two persons with bed mobility and was totally dependent of two persons with transfers. Interview on 09/16/19 at 3:18 P.M. with Resident #140 and his wife revealed they did not feel the facility was assisting or keeping them informed regarding Resident #140's discharge planning, and they revealed they had not been invited or had participated in any care plan meetings since his admission. Resident #140's wife revealed she comes daily to the facility to visit her husband. They revealed they had not been informed on admission regarding care conferences and had not received a letter or schedule when Resident #140's care conferences were. Interview on 09/19/19 at 09:37 [NAME]M. with SSD #603 and Social Service Designee #604 revealed they send out a letter inviting family quarterly and for a significant change. They revealed if the family returned the call, they set up a care conference with the family. They revealed if the family did not call back, they did not have a care conference. They revealed they only had documentation for Resident #140 having a care conference on 03/21/19 but verified it was not marked on the form if the resident or surrogate was invited, attended, or if they declined. They verified they did not have any other documentation in the medical record regarding any other care conferences held for Resident #140. They verified they did not document the reasons, including the steps the facility took to include the resident and/ or the resident representative in care planning in the medical record. Review of facility policy titled, Resident/ Resident Representative Care Conferences dated 08/08/06 revealed the facility was to provide the resident and/ or resident representative the opportunity to participate in the resident's plan of care. The facility, on admission, was to inform the resident and/ or representative of the facilities' care conference protocols. They were to be offered an initial care conference meeting and informed of a projected schedule for quarterly care conferences for the year. The agenda for care conference meetings included but not limited to customer service queries, discharge planning, advance care planning directives, realistic goal setting and communication structure. The facility would send out routine letters to residents and residents representatives reminding them of the availability of the care conference meeting. If the participation of a resident and/ or resident representative in a care conference was determined not practicable an explanation would be documented in the resident's medical record.

Based on observation, record review and interviews, the facility did not provide a timely weight assessment and/or nutritional interventions for Resident #71 and Resident #119. This affected two (Resident #71 and Resident #119) of six residents reviewed for nutrition. The facility census was 170. Findings include: 1. Review of the medical record for Resident #119 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/10/19, revealed the resident had impaired cognition. The resident had delusions and physical behavior directed at others. Resident #119 required limited assistance for eating. The resident was on hospice. Review of physician orders [REDACTED]. Review of the dietary progress note dated 08/07/19 at 9:04 [NAME]M. revealed Resident #119 was receiving hospice services. On 07/04/19, the resident weighed 142.2 pounds and had a Body Mass Index (BMI) of 19.8 indicating underweight status for age and a height of 71 inches. There were no significant weight changes at one, three or six months; however, a gradual weight loss of 11.4 pounds was noted. The resident received assistance with feeding in the dining room and consumed 25 to 75 percent of meals on the pureed diet with nectar thickened liquids. Meal intakes were not meeting estimated daily nutrient needs. The resident was at high risk for nutritional decline per the nutrition risk tool. No new recommendations were made. The plan was to continue with current diet regimen. Review of the dietary progress note dated 09/06/19 at 10:20 [NAME]M. revealed Resident #119 was no longer receiving hospice services. No new weight had been obtained from the previous dietary progress note. The resident was assisted with feeding and was consuming 25 to 100 percent of meals on the pureed diet with nectar thickened liquids and tolerating well. The plan was to continue with the current diet regimen. Review of supplement documentation revealed no supplements were provided. Review of weights revealed on 09/10/19 Resident #119 weighed 138 pounds. On 06/21/19, the resident weighed 141.8 pounds. On 01/08/19, the resident weighed 153.6 pounds. Resident #119 had a weight loss of 2.75 percent in three months, 4.35 percent in six months and 11.3 percent in eight months. Interviews on 09/18/19 at 10:41 [NAME]M. Registered Dietetic Technician (RDT) #442 verified Resident #119 was not receiving a supplement, and no interventions had been made even though the dietary progress notes indicated meal intakes were not meeting estimated daily nutrient needs, the resident was at high risk for nutritional decline per the nutrition risk tool, and there had been a gradual weight loss. 2. Record review was conducted for Resident #71 who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS 3.0 assessment dated [DATE] indicated he was cognitively intact and required set up assistance by staff for meals. The Plan of Care with an initial date of 12/24/15 indicated he was at nutritional risk due to [MEDICAL CONDITION] and swallowing problems. The interventions included monitoring weights and notifying the physician of any significant weight changes. The weights documented in the record were as followed: 02/12/19 - 162.0 pounds, 03/26/19 - 158.0 pounds, 04/16/19 - 155.8 pounds, 05/04/19 - 153.0 pounds, 06/10/19 -152.0 pounds, 07/04/19 - 151.0 pounds, 08/20/19 - 145.8 pounds and 09/07/19 143.4 pounds for a 10.0 percent significant weight loss from 02/12/19 to 08/20/19. On 12/19/15, a physician's orders [REDACTED]. Record review was conducted of the Dietary Assessment Narratives and Nutrition Assessments authored by RDT #442 from 04/01/19 to 07/19/19. The Dietary Assessment Narrative from 04/01/19 revealed staff assisted Resident #71 with feeding due to tremors from [MEDICAL CONDITION], he was at no risk for altered hydration status, meal intakes were meeting his needs. The goal was to maintain his weight within one to three pounds of 158 pounds and continue his regular diet. The next entry by RDT #442 was another Dietary Assessment Narrative from 07/11/19 noting a gradual weight loss of 13.4 pounds over six months with a current body weight of 151 pounds. The goal was to maintain his weight within one to three pounds of 151 pounds, and RDT #442 had no new recommendations. The Dietary Narrative on 07/18/19 by RDT #442 revealed Resident #71 was placed on dehydration alert protocol on 07/18/19, and RDT#442 wrote he would continue to monitor the resident. The were no further entries by RDT #442 addressing the dehydration risk or the documented weight of 145.8 pounds with a significant weight change on 08/20/19. An interview and observation was conducted on 09/17/19 at 2:21 P.M. with Resident #71 in his room. He was left side lying across his bed with his lunch tray sitting on his bed side table next to his bed. When asked if he was having any problems eating, he reported his right hand (dominant hand) was hard to close, and that made it difficult to hold the utensils on his meal tray. He demonstrated trying to close his hand, and his fingers were not able to close enough to touch his palm. Resident #71 said he preferred to eat in his room and had just consumed all of his lunch. He appeared thin for his frame, spoke in a soft voice with somewhat garbled speech but was able to get his meaning and points across to the listener. An interview was conducted on 09/18/19 at 11:55 [NAME]M. with RDT #442 with the Director of Nursing (DON) present during the interview. RDT #442 stated he knew the resident was having what he referred to as an insidious weight loss most likely related to his [MEDICAL CONDITION]. RDT #442 verified he had not addressed Resident #71's significant weight change, did not put any interventions in place to address the weight change nor was the physician notified of the weight change. RDT #442 verified Resident #71 had lost an additional 2.4 pounds from 08/20/19 to 09/07/19, and he had not made any entries in the medical record since 07/18/19. Record review was conducted of the facility document titled Weight Change Protocol, dated 07/01/04. The document stated resident weights would be reviewed weekly to identify those residents who were experiencing weight changes and appropriate interventions would be put into place.

Based on observation, record review and interviews, the facility did not provide an adequate number of clinical nutrition staffing hours to address weight loss and implement nutritional interventions in a timely manner. This affected two (Resident #71 and Resident #119) of six residents reviewed for nutrition and had the potential to affect all residents in the facility. The facility census was 170. Findings include: 1. Record review was conducted for Resident #71 who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated he was cognitively intact and required set up assistance by staff for meals. The Plan of Care with an initial date of 12/24/15 indicated he was at nutritional risk due to [MEDICAL CONDITION] and swallowing problems. The interventions included monitoring weights and notifying the physician of any significant weight changes. The weights documented in the record were as followed: 02/12/19 - 162.0 pounds, 03/26/19 - 158.0 pounds, 04/16/19 - 155.8 pounds, 05/04/19 - 153.0 pounds, 06/10/19 -152.0 pounds, 07/04/19 - 151.0 pounds, 08/20/19 - 145.8 pounds and 09/07/19 143.4 pounds for a 10.0 percent significant weight loss from 02/12/19 to 08/20/19. On 12/19/15, a physician's orders [REDACTED]. An interview and observation was conducted on 09/17/19 at 2:21 P.M. with Resident #71 in his room. He was left side lying across his bed with his lunch tray sitting on his bed side table next to his bed. When asked if he was having any problems eating, he reported his right hand (dominant hand) was hard to close, and that made it difficult to hold the utensils on his meal tray. He demonstrated trying to close his hand, and his fingers were not able to close enough to touch his palm. Resident #71 said he preferred to eat in his room and had just consumed most of his lunch with difficulty holding the fork. He appeared thin for his frame, spoke in a soft voice with somewhat garbled speech but was able to get his meaning and points across to the listener. Record review was conducted of the Dietary Assessment Narratives and Nutrition Assessments authored by Registered Dietetic Technician (RDT) #442 from 04/01/19 to 07/19/19. There were no further entries by RDT #442 after 07/19/19 addressing the dehydration risk or the documented weight declines recorded in the medical record through 09/07/19. The next entry by RDT #442 was after speaking to the state surveyor on 09/18/19. An interview was conducted with Dietary Manager (DM) #443 on 09/18/19 at 9:40 [NAME]M. regarding who was responsible for addressing the nutritional needs and weights of the residents. DM #443 shared she obtained diet histories on the residents, and RDT #442 did all the nutritional assessments and follow up on the resident nutritional needs. DM #443 added Registered Dietitian (RD) #700 visited one to two days a month and would complete sanitation rounds in the kitchen on one of those days. Record review was conducted of the facility document titled Facility Assessment, dated 2019 to 2020. The document failed to identify the staffing needs for dietary and clinical nutrition services personnel in the facility to meet the acuity needs of the residents. An interview was conducted on 09/18/19 at 10:37 [NAME]M. with the Administrator who verified there was no staffing plan on the current facility assessment to identify the number of dietary staff needed to carry out the daily function of kitchen services and clinical nutrition assessments and follow-up on the residents needs. An interview was conducted on 09/18/19 at 11:55 [NAME]M. with RDT #442 with the Director of Nursing (DON) present during the interview. RDT #442 verified he had not addressed Resident #71's significant weight change, did not put any interventions in place to address the weight change nor was the physician notified of the weight change. He verified he had a case load of 170 residents and was the only clinical nutritionist for the facility and must have somehow missed addressing the weight on 08/20/19. When asked if he had any Registered Dietitian (RD) oversight, he shared a corporate RD comes to the facility on e to two times a month or to cover his vacations, but besides that he is responsible for the case load of 170 residents on his own. The DON also verified the physician was not notified of the weight change, and she was working on a better system to keep track of the weight changes in the facility. Record review was conducted of the facility document titled Weight Change Protocol, dated 07/01/2004. The document stated resident weights would be reviewed weekly to identify those residents who were experiencing weight changes. 2. Review of the medical record for Resident #119 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly MDS 3.0 assessment, dated 08/10/2019, revealed the resident had impaired cognition. The resident had delusions and physical behavior directed at others. Resident #119 required limited assistance for eating. The resident was on hospice. Review of physician orders [REDACTED]. Review of the dietary progress note dated 08/07/19 at 9:04 [NAME]M. revealed Resident #119 was receiving hospice services. On 07/04/19, the resident weighed 142.2 pounds and had a Body Mass Index (BMI) of 19.8 indicating underweight status for age and a height of 71 inches. There were no significant weight changes at one, three or six months; however, a gradual weight loss of 11.4 pounds was noted. Resident received assistance with feeding in the dining room and consumed 25 to 75 percent of meals on the pureed diet with nectar thickened liquids. Meal intakes were not meeting estimated daily nutrient needs. The resident was at high risk for nutritional decline per the nutrition risk tool. No new recommendations were made. The plan was to continue with current diet regimen. Review of the dietary progress note dated 09/06/19 at 10:20 [NAME]M. revealed Resident #119 was no longer receiving hospice services. No new weight had been obtained from the previous dietary progress note. The resident was assisted with feeding and was consuming 25 to 100 percent of meals on the pureed diet with nectar thickened liquids and tolerating well. The plan was to continue with the current diet regimen. Review of supplement documentation revealed no supplements were provided. Review of weights revealed on 09/10/19 Resident #119 weighed 138 pounds. On 06/21/19 the resident weighed 141.8 pounds. On 01/08/19 the resident weighed 153.6 pounds. Resident #119 had a weight loss of 2.75 percent in three months, 4.35 percent in six months and 11.3 percent in eight months. Interviews on 09/18/19 at 10:41 [NAME]M. RDT #442 verified Resident #119 was not receiving a supplement, and no interventions had been made even though the dietary progress notes indicated meal intakes were not meeting estimated daily nutrient needs, the resident was at high risk for nutritional decline per the nutrition risk tool and there had been a gradual weight loss.

Based on observation, interview and record review, the facility failed to have accurate pain assessments for Resident #48. This affected one resident (Resident #48) of one resident reviewed for pain. The facility census was 170. Findings include: Record review for Resident #48 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] for Resident #48 revealed he was cognitively intact. He required limited assist of one person with bed mobility and extensive assist of one person with transfers. He had pain present with a pain intensity of a three out of ten and was on a pain medication regimen. Review of pain assessment for Resident #48 titled, Pain Assessment- V7 dated 08/08/19 completed by Licensed Practical Nurse (LPN) #900 revealed Resident #48's pain was assessed for the last five days (from 08/03/19 to 08/08/19). LPN #900 documented on the assessment Resident #48 did not receive any as needed pain medications, he did not receive any non-medication interventions for pain. Resident #48 was asked if he had any pain or hurting in the last five days, and she documented no pain. Review of (MONTH) 2019 Medication Administration Record [REDACTED].M. as his pain was a four out of ten, on 08/04/19 at 6:41 P.M. as his pain was a seven out of ten, on 08/06/19 at 5:17 P.M. as his pain was a five out of ten, and on 08/07/19 at 6:37 P.M. his pain was a four out of ten. Review of pain assessment for Resident #48 titled, Pain Assessment- V7 dated 08/16/19 completed by LPN #900 revealed Resident #48's pain was assessed for the last five days (from 08/11/19 to 08/16/19). LPN #900 documented on the assessment Resident #48 did not receive any as needed pain medications, he did not receive any non-medication interventions for pain. Resident #48 was asked if he had any pain or hurting in the last five days, and she documented no pain. Review of (MONTH) 2019 MAR for Resident #48 revealed he had received [MEDICATION NAME] tablet 5-325 milligrams (mg) one tablet by mouth every 24 hours as needed for severe pain on 08/11/19 at 1:01 P.M. as his pain was a eight out of ten, on 08/12/19 at 4:15 P.M. as his pain was a eight out of ten, on 08/14/19 at 1:13 P.M. as his pain was a six out of ten, and on 08/15/19 at 3:13 P.M. his pain was a three out of ten. Review of care plan last reviewed 08/28/19 revealed Resident #48 had pain related to low back pain, foot drop pain, discomfort associated with activities of daily living and neuropathic pain. Interventions included one on one sessions to allow resident to express his feelings, provide rest periods, administer pain medication as per physician and monitor effectiveness, acknowledge presence of pain and discomfort and listen to his concerns, and document complaints and non-verbal signs of pain. Review of pain assessment for Resident #48 titled, Pain Assessment- V7 dated 09/06/19 completed by LPN #900 revealed Resident #48's pain was assessed for the last five days (from 09/01/19 to 09/06/19). LPN #900 documented on the assessment Resident #48 did not receive any as needed pain medications, he did not receive any non-medication interventions for pain. Resident #48 was asked if he had any pain or hurting in the last five days, and she documented no pain. Review of (MONTH) 2019 MAR for Resident #48 revealed he had received [MEDICATION NAME] tablet 5-325 milligrams (mg) one tablet by mouth every 24 hours as needed for severe pain on 09/01/19 at 4:33 P.M. as his pain was a four out of ten, on 09/02/19 at 5:47 P.M. as his pain was a seven out of ten, and on 09/04/19 at 3:49 P.M. as his pain was a six out of ten. Interview and observation on 09/16/19 at 9:55 [NAME]M. with Resident #48 revealed he had severe pain in his back for the last two months, and he stated he felt the facility does not know how to treat his pain as some days it really hurts bad. Resident #48 was sitting on the side of his bed holding his lower back with a facial grimace when he went to lay back down. Interview on 09/18/19 at 9:53 [NAME]M. with Registered Nurse/ Assistant Director of Nursing #605 revealed they completed pain assessments weekly to monitor a resident's pain and to ensure pain management was effective. She revealed the pain assessments were to look at interventions used and see if the interventions were effective. She verified the pain assessments completed for Resident #48 on 08/08/19, 08/16/19 and on 09/16/19 were not accurate as Resident #48 did receive as needed pain medication, he did receive non-medication interventions, and he did have pain. She revealed he complained almost daily of pain and received routine medication as well as needed pain medication almost daily due to pain. She verified his pain appeared to have increased since the last MDS dated [DATE] as his highest pain intensity recorded was a three on the MDS, and in (MONTH) 2019 he had pain intensity levels of an eight out of ten, and (MONTH) 2019 he had pain intensity levels of a seven out of ten. Review of the facility policy labeled, Pain Assessment and Management dated 03/31/16 revealed pain assessment and adequate treatment of [REDACTED]. The resident's pain was to be assessed with [REDACTED]. If a resident was alert and oriented, he was asked to describe his pain and obtain pertinent information regarding the pain. The resident's response to interventions was to be evaluated.

Based on record review and interview the facility failed to ensure Resident #88 received medications as ordered when out of the facility for [MEDICAL TREATMENT] treatments. This effected one (Resident #88) of one resident reviewed for [MEDICAL TREATMENT]. The facility census was 165. Findings included: Resident #88 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The plan of care initiated on 08/29/17 indicated Resident #88 would leave for [MEDICAL TREATMENT] at approximately 5:30 A.M. and return to the facility prior to lunch. Review of physician's orders [REDACTED].M. Additionally, beginning on 11/11/17 the resident was to receive Sevelamer HCL (for control of [MEDICATION NAME] levels) 800 milligrams (mg) with meals; beginning on 03/07/18 Artificial Tears one drop per eye, were ordered four times per day; on 04/09/18 Pro-Stat sugar-free (a protein supplement) was ordered to be given three times a day at 9:00 A.M., 2:00 P.M. and 9:00 P.M.; on 07/19/18 [MEDICATION NAME] 70/30 insulin, ten units was ordered to be given daily at 8:00 A.M.; and on 07/21/18 [MEDICATION NAME] (an antibiotic) was ordered to be given, one drop in each eye, four times a day at 9:00 A.M., 1:00 P.M., 5:00 P.M. and 9:00 P.M. Review of the Medication Administration Records (MAR) for (MONTH) (YEAR) through (MONTH) (YEAR) revealed nine 8:00 A.M. doses of Sevelamer, 35 doses of Artificial tears, 34 of the 9:00 A.M. doses of Pro-stat, three doses of [MEDICATION NAME] insulin, and two doses of [MEDICATION NAME] eye drops were omitted. On 07/26/18 at 11:59 A.M. interview with Resident #88 revealed he did not receive his 8:00 A.M. and 9:00 A.M. medications when he went to [MEDICAL TREATMENT]. Resident #88 knew he needed the Pro-stat for low protein levels, the eye drops and insulin, but did not get those or any of his other morning medications either at the facility or at the [MEDICAL TREATMENT] center on Mondays, Wednesdays or Fridays. Review of laboratory test results revealed dated 06/08/18 revealed Resident #88 had a blood [MEDICATION NAME] level (indicator of protein stores) of 2.9 and the recommended level was 4.0. The report recommended that protein be increased in the diet. On 07/26/18 at 12:09 P.M. Registered Nurse (RN) #20 verified Resident #88 had not been receiving medications doses ordered to be given at 8:00 A.M. and 9:00 A.M. on the days he went for [MEDICAL TREATMENT]. On 07/26/18 at 12:43 P.M. the Director of Nursing verified the physician and [MEDICAL TREATMENT] center should have been contacted to modify orders to ensure Resident #88 received all medications.

Based on record review and interview the facility failed to ensure medication ordered for Resident #42 contained a prescribed dosage for administration. This affected one resident (Resident #42) of five residents reviewed for unnecessary medication use. Findings include: Record review revealed Resident #42 had [DIAGNOSES REDACTED]. Record review revealed a physician order, dated 01/20/17 for a stool softening medication, [MEDICATION NAME] one capsule by mouth daily. [MEDICATION NAME] is an over the counter medication available in both 50 milligram (mg) and 100 mg capsules. Record review revealed the [MEDICATION NAME] order did not identify the strength for the medication dose to be administered. Review of the physician's summary of orders and medication administration records (MARs) for February, March, April and May 2017 revealed the strength of the dose of [MEDICATION NAME] ordered was not noted nor was it documented as administered. On 05/09/17 at 4:30 P.M. interview with the director of nursing (DON) verified the [MEDICATION NAME] ordered for Resident #42 did not contain a dosage.

Based on record review and interview the facility failed to assess Resident #103 upon return from [MEDICAL TREATMENT] and failed to provide consistent pre-[MEDICAL TREATMENT] communication with the [MEDICAL TREATMENT] center. This affected one resident (Resident #103) of one resident reviewed receiving [MEDICAL TREATMENT] services. Findings Include: Record review revealed Resident #103 was admitted [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had no cognitive deficits, required extensive assistance to meet his daily needs and received [MEDICAL TREATMENT] services. Review of July 2016 physician orders [REDACTED].M. to 9:45 A.M., with a pick-up at 5:15 A.M. for transport to the [MEDICAL TREATMENT] center. Review of the June and July 2016 Treatment Administration Record (TAR) revealed the resident received [MEDICAL TREATMENT] on 06/01/16, 06/03/16, 06/06/16, 06/10/16, 06/13/16, 06/15/16, 06/17/16, 06/20/16, 06/22/16, 06/24/16, 06/27/16, 06/29/16, 07/01/16, 07/04/16, 07/06/16, 07/11/16, 07/15/16, and 07/15/16. Record review of progress notes and treatment administration records from 06/01/16 through 07/15/16 revealed the resident's [MEDICAL TREATMENT] was not assessed upon return to the facility from [MEDICAL TREATMENT] treatments. During an interview with Licensed Practical Nurse (LPN) #25 and LPN #26 on 07/13/16 at 4:03 P.M. they stated they assessed residents when they got back from [MEDICAL TREATMENT]. However, they both verified there was no documenting of the assessments including assessment of the [MEDICAL TREATMENT] for bleeding. Review of the [MEDICAL TREATMENT] Communication Forms revealed the form was divided into two sections, an area for the facility to document pre-[MEDICAL TREATMENT] information and an area for [MEDICAL TREATMENT] to complete. An interview with LPN #25 and LPN #26 on 07/13/16 at 4:03 P.M. verified that some of the forms were incomplete. The facility was to note on the form any changes in the resident's medical status or to note if the resident's had no complaints since the previous [MEDICAL TREATMENT] session. Review of the [MEDICAL TREATMENT] Communication Forms from June and July 2016 revealed the facility did not thoroughly complete the form prior to [MEDICAL TREATMENT] on the following days: 06/06/16, 06/08/16, 06/10/16, 06/15/16, 06/24/16, 06/27/16, 07/04/16, 07/11/16, 07/06/16, 07/09/16 and 07/13/16. Interview with Assistant Director of Nursing (ADON) #20 on 07/13/16 at 4:46 P.M. revealed the [MEDICAL TREATMENT] Nursing Policy and Procedure was not specific to post-[MEDICAL TREATMENT] assessment nursing requirements. ADON #20 stated the vital signs were taken every shift, but verified they were not always taken upon return from [MEDICAL TREATMENT].

Based on observation, record review and interview the facility failed to ensure personal protective equipment was readily available for Resident #197 who was in contact isolation. The facility also failed to ensure all staff were knowledgeable of the location of the infection to ensure contact isolation was maintained for Resident #197 to prevent the spread of infection. This affected one resident (Resident #197) of one resident identified to be in isolation. Findings include: Record review revealed Resident #197 was admitted on [DATE] with diagnoses that included sacral pressure ulcer, methicillin-resistant Staphylococcus aureus (MRSA) located in a sacral pressure ulcer and nares, diabetes, amputation third digit right foot and rheumatoid arthritis. Record review of the 07/12/16 nursing assessment revealed the resident had no cognitive deficits, transferred via a mechanical lift and required assistance to meet his daily needs. Record review of the Nurse to Nurse report dated 07/08/16 revealed the resident's diagnoses included positive MRSA in his nares and in his sacral pressure ulcer. Review of the accumulative diagnosis list dated 07/08/16 revealed the resident had MRSA in his nares and MRSA in his Stage IV sacral pressure ulcer. (A Stage IV pressure ulcer presents with full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed and often included undermining and tunneling). Review of the July, 2016 monthly physician orders [REDACTED]. Review of the wound assessments dated 07/09/16 revealed the resident was admitted with the Stage IV sacral pressure ulcer, a surgical wound to the third toe of his right foot and bilateral extremity cellulitis. Interviewed the unit nurse, Licensed Practical Nurse (LPN) #23 on 07/11/16 at 12:45 P.M. LPN #23 stated Resident #197 was in contact isolation due to the presence of MRSA in his foot and nares. She stated all visitors and staff should wear a gown, mask and gloves when entering his room. She stated that you cannot be too careful, if he sneezed, you needed to be protected. She stated the resident might also inadvertently touch his nose, and then his clothing, and possibly contaminate his clothing. On 07/11/16 at 2:37 P.M. the surveyor knocked on Resident #197's door. The resident's bed was located by the window and the privacy curtain was pulled between the beds. Outside of the room was a three drawer plastic cabinet and on the door a sign that noted that visitors were to report to the nurses's station before entering the room. Resident #197 stated he was using the urinal and the surveyor stated she would return in a few minutes. At 2:39 P.M. State tested nursing assistant (STNA) #21 was observed entering Resident #197's room and exited shortly afterward. Interviewed STNA #21 when she exited the room. She stated she asked the resident about a snack, but had no contact with the resident, and would not need to wear any personal protective equipment (PE) nor need to wash her hands. At 2:42 P.M. the Social Service Designee (SSD) #22 was observed entering the room. She had a notebook in her hand and walked into the room without applying any personal protective equipment (PPE). She walked over to speak to Resident #197. She exited the room without washing her hands. Interviewed SSD #22 when she exited the room and she stated that she usually wore PPE if a resident was in isolation. On 07/11/16 at 3:12 P.M. the surveyor received permission from Resident #197 to enter room for interview and prepared to enter the room wearing PPE of gown, mask and gloves. While standing outside the door of the resident's room, interviewed STNA #21 regarding the PPE availability. She stated all PPE was in the three drawer container outside the resident's doorway and opened the top drawer. She then opened the other two drawers and verified there were no gowns in the container. She stated someone must have used the last gown and they should have replaced the stock. STNA #21 stated she would find some gowns and stock the container. She returned at 3:17 P.M. with the disposable gowns. On 07/14/16 at 10:52 A.M. the wound nurse, LPN #24 was observed completing the wound treatment to the Stage IV pressure ulcer. LPN #30 was also in the room assisting LPN #24 during the treatment. Both LPN #24 and LPN #30 applied gowns, masks and gloves before approaching Resident #197. Interviewed LPN #24 regarding the contact isolation and PPE. She stated the resident had MRSA in his sacral pressure ulcer, but was not aware of MRSA in his nares. She stated she was just focused on the wound. She did not state the resident had MRSA in his foot. Record review of the pressure ulcer care plan interventions, revealed an intervention for Contact precautions as specified. No specifications were noted, regarding PPE to be utilized. There was no care plan regarding the MRSA in his nares or surgical amputation site. Interviewed the Director of Nursing on 07/14/16 at 12:13 P.M. She verified she was not aware of the [DIAGNOSES REDACTED]. Reviewed the 07/08/16 Nurse to Nurse report with the DON and the accumulative diagnoses list dated 07/08/16 which both indicated the resident had MRSA of his sacral wound and nares. Also, reviewed with the DON the interview with LPN #23 who had stated she notified the family members they had to wear gowns, gloves and masks due to the MRSA in his nares and pressure ulcer. Verified there was no diagnoses on the accumulative diagnosis list regarding MRSA in the resident's foot. The DON stated staff would only need to gown, glove, wear a mask and wash their hands if they had direct contact with the resident. Review of the Isolation Policy revised August, 2012, revealed Contact precautions were implemented for residents known or suspected to be infected or colonized with microorganisms that could be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident care items in the resident's environment.

Based on interview and record review, the facility failed to monitor medication-related laboratory values as ordered by the physician. This affected one resident (Resident #70) of five residents reviewed for unnecessary medication use. Findings include: Record review revealed Resident #70 was admitted on [DATE] with a [DIAGNOSES REDACTED].#70 was ordered [MEDICATION NAME] (a lipid-lowering medication commonly called [MEDICATION NAME]) 40 milligrams (mg) once per day. Orders also included a fasting lipid panel to be obtained every six months, with an original start date of 12/10/15. Review of the lab results in the chart revealed no evidence the lab test was completed as ordered. On 07/14/16 at 4:30 P.M., surveyor notified Registered Nurse Assistant Director of Nursing (ADON) #20 the lipid panel results were not located in the chart. Following surveyor intervention, the facility contacted Resident #70's physician regarding the missing lab draw. The order was revised on 07/14/16 to a lipid fasting panel to be drawn every twelve months, with the first draw to be done on 07/15/16. ADON #20 was interviewed on 07/15/16 at 9:30 A.M. She stated that when a physician ordered the lab, the nurse was to place the order in the computer system. The order was then to be printed and faxed to their laboratory. It was the ward clerk's (unit secretary's) responsibility to track the order. Interview with ADON #20 on 07/15/16 at 11:00 A.M. revealed they had no documentation indicating the ordered lab draw was completed. Review of nursing notes revealed no documentation indicating resident had refused a lab draw. The facility did not provide a written copy of the policy for their laboratory work.

Based on observation and interview the facility failed to ensure each bed had a ceiling suspended curtain which extended around the bed to provide full visual privacy in combination with adjacent walls and curtains. This affected the following resident rooms: Room B169-2, B170-2, B171-2, B172-2, B173-2, B180-2, B186-2, C 101-2, C102-2, C105-2, C106-2, C131-2, C126-2, C127-2, C135-2, D106-2, D160-2, D160-2,D174-2, and D179-2. The facility census was 165 at the time of the survey. Findings include: On 03/23/15 during the initial tour and on 03/26/15 during the environmental tour conducted between 10:30 A.M. and 11:15 A.M., with the administrator, director of maintenance, and the administrator in training (AIT) revealed the second bed in the following rooms did not have a curtain suspended from the ceiling to provide full visual privacy for the resident: Room B169 -2, B170-2, B171-2, B172-2, B173-2, B180-2, B186-2, C 101-2, C102-2, C105-2, C106-2, C131-2, C126-2, C127-2, C135-2, D106-2, D160-2, D160-2, D174-2, and D179-2. The administrative staff present revealed they thought the curtains from the other bed in the room (bed 1) would "count" for the privacy. However, the second bed in each of the above rooms did not have a curtain that would surround the foot of the bed and extended to the side wall, that area was open. If the roommate of the residents in those rooms, staff and/or visitors would walk to the side of the room where bed two (2) was located, they would be able to see what the resident in bed two was doing.