Every finding on record at Cottonwood Rehabilitation and Healthcare Center

Based on record review and interviews, the facility failed to provide services to ensure the residents highest practical physical wellbeing for two (#2 and #3) of four residents reviewed out of four sample residents. Specifically, the facility failed to ensure Resident #2 and Resident #3 had a physician's order to consume alcoholic beverages.Findings include:I. Facility policy and procedure The Alcoholic Beverages Policy, revised February 2023 was provided by the director of clinical services on 4/1/26 at 1:19 p.m. The policy read, The purpose of this procedure is to establish uniform guidelines concerning the administration of alcoholic beverages. A physician's order must be received before any alcoholic beverage may be administered to a resident. Should such an order be received, the nurse supervisor receiving the order must contact the pharmacist to determine if any of the residents' current medications would interact with alcohol. Should there be a medication that would interact with the alcohol, the nurse manager must inform the physician of such medications. Record and follow the physician's instructions.The Physician Orders Related to Activities policy, revised June 2018, was provided by the director of clinical services on 4/1/26 at 1:19 p.m. The policy read, The facility obtains activities related to physician orders in a timely manner. The activity director/coordinator reviews the physician's orders upon admission during the activity assessment period, and within 'progress' or 'change of condition' reviews for the following areas which may impact activities such as: Consumption of alcohol (if alcohol was served or requested by a resident).II. Resident #2A. Resident statusResident #2, age [AGE], was admitted on [DATE]. According to the March 2026 computerized physician orders (CPO), diagnoses included multiple sclerosis, hypertension, osteoarthritis and depression.The 2/5/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. He required maximum assistance with activities of daily living (ADL). B. Resident interview Resident #2 was interviewed on 4/1/26 at 10:30 a.m. Resident #2 said he attended happy hour at the facility and he drank alcoholic beverages on occasion when offered. He said residents had the right to make their own decisions to consume alcohol or have non-alcoholic beverages. C. Record reviewReview of Resident #2's confidentiality, privacy and activities form, dated 9/25/24, revealed Resident #2 circled yes and gave permission to the facility staff to allow alcoholic beverages to be served to him during the facility's Happy Hour activity if the physician agreed. The form documented a maximum of two alcoholic drinks would be allowed, per the physician's order. Review of Resident #2's comprehensive care plan, initiated 3/10/25, revealed there was no care plan focus for Resident #2's alcohol consumption. Review of Resident #2's March 2026 CPO revealed no physician's order that indicated Resident #2 was able to consume alcohol.III. Resident #3 A. Resident statusResident #3, age [AGE], was admitted on [DATE]. According to the March 2026 CPO, diagnoses included chronic respiratory failure, hypertension, dementia, mild with anxiety disorder and depression.The 1/26/26 MDS assessment revealed the resident was moderately cognitively impaired with a BIMS score of 11 out of 15. She required substantial maximum assistance with ADLs. B. Resident interviewResident #3 was interviewed on 4/1/26 at 11:35 a.m. Resident #3 said she attended happy hour weekly and enjoyed going to have alcoholic beverages and to socialize with others. She said not all residents had alcoholic beverages, but she preferred to. C. Record reviewReview of Resident #3's confidentiality, privacy and activities form, dated 9/25/24, revealed Resident #3 circled yes and gave permission to the facility staff to allow alcoholic beverages to be served to her during the facility's Happy Hour activity if the physician agreed. A maximum of two alcoholic drinks would be allowed, per the physician's order. The psychosocial care plan, initiated 3/11/25 and revised 3/24/26, revealed Resident #3 had a history of alcohol abuse and dependency and the resident was in remission from alcoholism. The care plan revealed Resident #3 was at risk of an impaired psychiatric mood related to the diagnosis of depression, history of alcohol dependency and anxiety. Review of Resident #3's March 2026 CPO revealed no physician's order that indicated Resident #3 was able to consume alcoholic beverages. IV. Staff interviews The activities director (AD) was interviewed on 4/1/26 at 11:00 a.m. The AD said the facility's happy hour activity took place every Thursday. She said alcoholic beverages and non-alcoholic beverages were served to the residents. The AD said residents were offered whatever they preferred to drink. She said a variety of alcoholic drinks were served, with a maximum of two drinks for each resident. The AD said upon admission to the facility, residents were asked about their preference to consume alcoholic beverages or not. She said the social services director (SSD) assisted residents to complete the alcoholic beverages preference form and the information was shared with activities if a resident was not allowed to consume alcohol. The AD said she did not have a list of residents who could or could not have alcohol. She said it was up to the residents to decide if they wanted alcohol or not. The interim SSD was interviewed on 4/1/26 at 12:02 p.m. The interim SSD said an evaluation for the consumption of alcoholic beverages was completed with residents as part of the admission packet when they were admitted to the facility. He said a care plan was completed if a resident had a history of alcohol abuse and the information was shared with the activities director and management. The interim SSD said residents had the right to consume alcohol. He said the physician was made aware if a resident had a history of alcohol abuse, in case the alcohol could interfere with certain medications or in case staff needed to be monitoring residents for any alcoholic withdrawal concerns. The interim SSD said the facility did not track residents' intake of alcoholic beverages because consumption happened one time a week at happy hour and not on a daily basis. Registered nurse (RN) #1 was interviewed on 4/1/26 at 12:45 p.m. RN #1 said the physician gave orders when a resident wanted to consume alcoholic beverages. The director of clinical service nurse was interviewed on 4/1/26 at 12:15p.m. The director of clinical services said residents should have a physician's order to consume alcoholic beverages. She said the physician's order should include parameters for the amount of alcohol and risks with any medications the resident took. She said she was not part of the evaluations for residents to have alcohol, but she said had started an audit to identify which residents consumed alcoholic beverages (during the survey). She said she would look at the residents' physician's orders and would discuss it in the interdisciplinary team (IDT )meeting. The interim nursing home administrator (NHA) was interviewed on 4/1/26 at 12:30p.m. The interim NHA said there was no documentation revealing education was completed on the effects of consuming alcoholic beverages for Resident #2 and Resident #3. The medical director (MD) was interviewed on 4/1/26 at 4:15 p.m. The MD said he would prefer for no residents to consume alcoholic beverages, but as a physician, he respected the autonomy of the residents' choice to consume alcohol if they chose to do so. He said when the resident had red flags or big issues, such as they were a fall risk, had dementia or was a known alcoholic, he would not give orders for those residents to consume alcoholic beverages. He said the facility had a physician's order set in the facility's electronic charting system which allowed nursing staff to add the physician's order to consume alcohol into a resident's electronic medical record (EMR), when appropriate. He said it was up to the facility to alert him when a physician's order was needed for the resident. He said he had discussed with residents before why drinking alcohol was a bad decision but he said he had not discussed this with any current residents at the facility that he could recall. He said he relied on the director of nursing (DON) to notify him with any resident alcohol consumption concerns.

Based on interviews and record review, the facility failed to employ an infection preventionist (IP) who had completed specialized training in infection prevention and control which had the potential to affect all residents residing in the facility at the time of the survey. Specifically, the facility failed to have a qualified IP involved with the facility's infection prevention and control program. Findings include: I. Facility policy and procedure The Infection Preventionist policy, revised September 2022, was provided by the nursing home administrator (NHA) on 11/21/24 at 8:25 a.m. The policy read in pertinent part, The IP is professionally trained in nursing, medical technology, microbiology, epidemiology, or other related field with at least the following professional training: -A nurse must have earned a certificate/diploma in nursing; and, -A medical technologist must have earned at least an associate's degree in medical technology or clinical laboratory science. The IP is employed on site and at least part time; and, -The IP is scheduled with enough time to properly assess, develop, implement, monitor, and manage the infection control program, address the training requirements, and participate in required committees. II. Record review A request was made for the IP's infection control certificate on 11/20/24 at 2:30 p.m. The director of nursing (DON) was unable to locate the IP certificate of completion. III. Staff interviews The DON was interviewed on 11/20/24 at 2:10 p.m. The DON said she had worked at the facility as a full time DON. She said she completed the required education in 2024 to obtain the infection control certificate but was unable to locate the certificate of completion. The DON said she worked in the facility as a full time DON but also functioned as the facility IP. The DON said she collected infection statistics but had not analyzed the information to ensure the infection control program was effective. The DON said she was unaware of the requirement for the facility to have a qualified infection preventionist that worked as an IP at least half time. The DON said the facility will review the requirement for the IP position and discuss the requirement with the NHA.

Based on record review and interviews, the facility failed to provide the necessary behavioral health care and services to attain and maintain the highest practicable physical, mental, and psychosocial well-being for one (#14) of three residents reviewed for behavioral and emotional status out of 22 sample residents. Specifically, the facility failed to coordinate timely necessary behavioral, mental and emotional health care and services for Resident #14. Findings include: I. Resident #14 A. Resident status Resident #14, age 65, was admitted on [DATE]. According to the November 2024 computerized physician orders (CPO), diagnoses included Arnold Chiari Syndrome with hydrocephalus (a condition where the lower part of the brain protrudes into the spinal canal causing a blockage in the flow of cerebrospinal fluid and leading to a buildup of fluid in the brain), anxiety disorder, depression, insomnia, other complicated headache syndrome, cognitive communication deficit, unspecified dementia, severe, with mood disturbance and malignant neoplasm of prostate. The 9/17/24 minimum data set (MDS) assessment revealed the resident's cognition was severely impaired with a brief interview for mental status (BIMS) score of four out of 15. Verbal behavioral symptoms directed towards others were present during the assessment. He used a wheelchair for mobility and required partial moderate assistance with toileting hygiene, substantial/maximal assist with bathing and partial/moderate assist with transfers. He was prescribed antianxiety and antidepressant medications. B. Record review A review of the comprehensive care plan, initiated on 11/14/23 and revised on 11/20/24, revealed Resident #14 had a history of depression and insomnia and was taking two antidepressant medications (Trazodone and Lexapro) due to sleep disturbances, withdrawal from activities and refusals of care. He received Ativan for anxiety as evidenced by restlessness and leg movements, pacing, increases in complaints, agitation, obsession about clothing and temperature changes, false accusations against staff, and playing with a suprapubic urinary catheter. Resident #14 was prescribed and administered an antipsychotic medication (Seroquel) related to auditory hallucinations, increased agitation and anxiety. Interventions included referral to a psychologist/psychiatrist as needed. Review of Resident #14's behavior care plan, initiated on 5/16/24 and revised on 11/18/24, revealed the resident had behaviors related to his dementia diagnosis and often made false allegations and statements. The resident yelled and cussed at staff, residents and imaginary individuals and often had auditory hallucinations. He was withdrawn from group activities and stayed in his room most of the day. He had depression at times that caused him to have difficulty sleeping as evidenced by sleep disturbances and restless leg movements. Interventions included administering medications per the physician's order, approaching the resident in a calm manner to avoid frustration and behavior escalation, attempting to redirect the resident when he was exhibiting behaviors, monitoring and documenting episodes of inappropriate behaviors, monitoring the resident's behavior episodes and attempting to determine the underlying cause of the behavior, including considering location, time of day, persons involved and situations, observing and reporting any changes in mental status caused by situational stressors and offering psychologist/psychiatrist services as needed. Review of Resident #14's November 2024 CPO revealed the following physician's orders: Trazodone HCl oral tablet 50 milligrams (mg). Give 25 mg by mouth at bedtime for insomnia and depression, ordered 11/23/23. Cymbalta oral capsule delayed release particles 20 mg (Duloxetine HCl). Give one capsule by mouth one time a day for depression, ordered 11/4/23 and discontinued on 10/31/24. Escitalopram Oxalate (Lexapro tablet 20 mg). Give one tablet by mouth one time a day for depression, ordered 11/1/24. Ativan (Lorazepam) oral tablet 1 mg. Give one tablet by mouth at bedtime related to generalized anxiety, ordered 5/7/24. Quetiapine Fumarate Oral Tablet 25 mg. Give one tablet by mouth three times a day for unspecified dementia, severe, with mood disturbance, ordered 11/14/24. A nurse progress note dated 4/7/24 documented Resident #14 had been angry that he was not served breakfast immediately when entering the dining room. The resident was reminded that the cooking staff did not arrive to work until 6:00 a.m., therefore they were unable to serve him at 5:00 a.m The resident was yelling at his neighbor to 'shut-up', because his neighbor was whistling songs while getting ready for the day. A nurse progress note dated 4/9/24 documented the interdisciplinary team (IDT) met to review resident's psychotropic medication usage. The resident had no adverse side effects to the medications and no changes were made to the current medications per the power of attorney's (POA) and the resident's request. A risk versus benefit form was completed and the IDT would continue to review quarterly or PRN (as needed). A nurse progress note dated 4/16/24 documented Resident #14 had repeatedly set his call light off while laying in bed. When asked upon entering each time, what the nurse could do to assist him, he said his neighbor slammed the bathroom door, his sheet was coming off or he did not call. Upon the nurse entering his room the last time, the resident had thrown a dish from the kitchen on the floor and it shattered. Resident #14 had changed his shirt at least six times this morning (4/16/24). A nurse progress note dated 5/9/24 documented Resident #14 was upset that his neighbor shut his bathroom door loudly. The resident attempted twice to throw ice water into his neighbor's room and was very angry and difficult to redirect. A nurse progress note dated 5/13/24 documented Resident #14 said he was going to throw water at another resident's face. He was asked what made him so upset and he reported his neighbor was in the bathroom, slammed the doors and woke him up. The CNA (certified nurse aide) informed the resident it was his neighbor's shower and he was not creating excess noise on purpose. The resident said he was still going to throw water in his face. The CNA then asked the resident to give them 20 minutes, which he agreed to. No more threats had been made since and he was now in a pleasant mood. A nurse progress note dated 7/24/24 documented the IDT met to review Resident #14's psychotropic medication usage. The resident had had no adverse side effects to the medications and no changes were being made to the resident's current medications. The IDT would continue to review quarterly at the psychotropic committee meeting or PRN and plan GDRs (gradual dose reduction) as appropriate. Resident #14 and his POA requested that no changes be made to his medications because the medications were working for the resident. -The progress note did not indicate the facility offered a psychologist or psychiatrist consultation to the resident to help with the resident's behaviors. A nurse progress note dated 10/6/24 documented the staff was to monitor the resident for the following behaviors related to the use of Ativan as evidenced by an increase in complaints, obsession about clothing and temperature changes, false accusations against staff, playing with his catheter and refusals of care. -The progress note failed to identify interventions that were to be used with the resident to help the resident with the distressing behaviors. A progress note documented by the DON on 10/23/24 DON revealed Resident #14 pressed his call light five times in one minute. The resident was complaining his ears were ringing and he was not able to hear. He was given some eardrops but persisted in fixating on the concern and pressed his call light repeatedly for the same reason. He was requesting to have the physician come in and look in his ears. The note documented the resident had his television (TV) volume extremely loud and, though he claimed he could not hear, he was able to understand everything the DON and the CNAs were saying to him. The DON suggested he turn his TV volume down which could potentially help with his complaint of not being able to hear but the resident refused. Redirection continued without success and the DON notified the physician of the resident's request to look in his ears. A nurse progress note dated 10/24/24 documented Resident # 14 was agitated during the shift and asked to use the bathroom four times in 30 minutes. Staff would assist him to the bathroom every time, for him to sit down, stand right back up and say he was done. The resident was fixating on certain other residents being in the dining room and refusing to eat because they were in there. The resident had to be redirected to the dining room five times during the shift, after being placed at a table per his request, then stating 'that resident is down here' and turning around and leaving the dining room. The resident was difficult to redirect. A nurse progress note dated 10/28/24 documented the resident was yelling out at neighbors and staff to stop slamming the doors. Staff were mindful about closing the doors softly and he continued to yell when doors around him were shut as quietly as possible. Resident #14 was assured everyone was trying to keep the environment quiet, he was given fresh water and his medications at his preferred time. He continued to yell out after any sounds were made in the hall or neighboring rooms until he fell asleep. A nurse progress note dated 10/30/24 documented the resident was yelling loudly about people slamming doors. The nurse watched the resident's neighbor's door be shut with no slamming. The resident had continually used his call light when he was upset about loud noises and cold coffee. A nurse progress note dated 11/1/24 documented Resident #14 was repeatedly screaming 'be quiet' at the top of his lungs, as well as putting his call light on. The nurse informed the resident they would be as quiet as they could and he verbalized understanding. A nurse progress note dated 11/12/24 documented the resident had been yelling over any noise throughout the night. He yelled at another resident to shut up who was talking in the hallway on the way back to their room. Resident #14 was offered food and drink, efforts to keep his environment quiet and reassurance that no one was being noisy on purpose. The resident voiced his understanding, however the resident continued to yell at neighboring residents and staff from his room. A progress note documented by the DON on 11/14/24 documented Resident #14 had been extremely agitated, more so than his normal. He was yelling at his next door neighbor even though the resident was not in his room next door. Resident #14 had pushed his call light three times in five minutes and was yelling and agitated. He then pressed his call light another two times and when the CNA entered the room, he was yelling that the lady next door kept slamming the door, however, there was no lady next door. The physician was notified. A progress note documented by the DON on 11/15/24 documented the DON called the resident's family member to let her know the physician ordered Seroquel for the resident and to obtain consent for the medication. The family member gave consent for the medication. A nurse progress note dated 11/15/24 documented the resident was agitated, yelling, and cursing during the shift and refused a catheter change. The note documented the resident had begun taking Seroquel and was offered a quiet environment, food and drink and lotion was applied to his abdomen as requested for itchiness. A nurse progress note dated 11/19/24 documented the resident was yelling profanities from his room regarding another resident slamming her door, however, there were no residents slamming their doors. A nurse progress note dated 11/20/24 documented Resident #14 was again yelling and screaming about a resident slamming her door. There were no noises heard by staff who were outside his door being mindful of providing a quiet environment for the resident. The nurse apologized and told the resident the staff did not hear any loud noises or door slamming, but they would be more cautious of making noise. Resident #14 indicated the unoccupied room next to him was where the noise was coming from. A progress note documented by the social services director (SSD) on 11/21/24 (during the survey) documented a physician's order for a referral to behavioral psychiatric services for Resident #14 had been obtained. The resident's POA was contacted and agreed with the referral. The SSD attempted to schedule an appointment with a behavioral health services provider. -The progress note failed to indicate if the SSD was able to schedule a behavioral health services appointment. -Review of the progress notes from 4/7/24 through 11/21/24 revealed there was no documentation to indicate the facility assessed the underlying causes and potential triggers for Resident #14's expressions of distress. -There was no documentation in the resident's electronic medical record (EMR) to indicate the facility offered a psychologist or psychiatrist consultation for Resident #14 in order to assist the resident with his distressing behaviors until 11/21/24, despite several months of documentation related to the resident's behaviors (see progress notes above). II. Staff interviews Registered nurse (RN) #2 and CNA #1 were interviewed together on 11/18/24 at 2:01 p.m. RN #2 and CNA #1 said Resident #14 had exhibited his agitation and aggressive verbal behaviors towards staff and other residents for the past several months. RN #2 said Resident #14's behaviors were disturbing to other residents who were on the unit for skilled rehabilitation services and were going back to the community. RN #2 and CNA #1 said Resident #14 was not offered and had not received any psychological or psychiatric health care consultation or services. RN#1 was interviewed on 11/21/24 at 8:45 a.m. RN #1 said Resident #14's behaviors were consistent in the past few weeks and very disturbing to him and other residents. She said his behaviors were not specifically directed. She said the staff offered non-pharmacological interventions such as distractions, TV shows/sports, activities and offered to take the resident outside. She said the resident was not receiving any mental health services for his behaviors. The DON was interviewed on 11/21/24 at 11:10 a.m. The DON said Resident #14's behaviors had escalated within the last few weeks and she said the resident did not feel good in his own skin. She said she communicated with the resident's POA, as well as his physician, regarding recent psychotropic medications changes. She said the physician wanted to try medications first. She said the facility did not consider a behavioral health consultation for the resident during the most recent psychotropic medications review with the medical director and the pharmacist. The DON said she would reach out to the resident's POA for an approval for a mental health consultation for the resident.

Based on observation, records review and interviews, the facility failed to adequately monitor the resident for unnecessary psychotropic medications needed to provide effective and person-centered care for three (#15, #89 and #26) of five residents reviewed for use of psychotropic medication out of 18 sample residents. Record review revealed that Resident #15 had exit-seeking behaviors. The facility failed to obtain consent prior to increasing the administration of antipsychotic medication (Seroquel) and failed to ensure the antipsychotic medication administered was given to treat the resident's medical symptoms and not used for discipline or convenience. Additionally, the facility failed to implement effective person-centered behavior management interventions to prevent occasional wandering and exit-seeking behaviors. The resident was initially administered Seroquel 25 milligrams (mg) without any behaviors present and documented which was increased to 50 mg two times a day after displaying aggressive behaviors toward a nurse who woke the resident from his afternoon nap, triggering Resident #15's aggression. Resident #15 became verbally and physically aggressive towards staff after being provoked, at which time Resident #15 was given an antipsychotic medication Seroquel. The facility failed to ensure Resident #15's antipsychotic medication was not used for discipline or staff convenience. In addition, the facility failed to: -Ensure staff identified triggers for Resident #26's depression and anxiety episodes; -Develop a resident-centered plans of care for generalized anxiety disorder for Resident #26; -Develop a resident-centered plans of care for depressive episodes for Resident #89 and #26; -Ensure staff monitored and documented Resident #89 and Resident #26's response to antidepressant medication and its effectiveness; -Ensure staff monitored and documented adverse reactions to antianxiety and antidepressant therapy Resident #89 and #26; -Ensure provided non-pharmacological interventions were implemented with anxiety and depression for Resident #89 and #26; and, -Obtain informed consent from resident/representative for psychotropic medications Resident #89 and #26. Findings include I. Facility policy The Psychotropic Medication Use policy, dated July 2022, was requested received on 7/11/23 from the nursing home administrator (NHA), which read in pertinent part: A psychotropic medication is any medication that affects brain activity associated with mental processes and behavior. Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: antipsychotics, antidepressants, antianxiety, and hypnotics. Residents are involved in the medication management process. Management includes; indications for use, dose, duration, adequate monitoring for efficacy and preventing, identifying, and responding to adverse consequences. Residents who have not used psychotropic medications are not prescribed or given these medications unless the medication is determined to be necessary to treat a specific condition that is diagnosed and documented in the medical record. Use of psychotropic medications are not increased when efforts to decrease antipsychotic medications are being implemented. Non pharmacological approaches are used to minimize the need for medications, permit the lowest possible dose, and allow for discontinuation of medications when possible. Residents receiving psychotropic medications are monitored for adverse consequences including: anticholinergic effects, cardiovascular effects, metabolic effects, psychological effects. II. Resident #15 A. Professional reference The [NAME] Nursing Drug Handbook, 2021, Quetiapine (Seroquel), read in part; Elderly with dementia related psychosis are at increased risk for death. Uses: Treatment of schizophrenia. Treatment of acute manic episodes associated with bipolar disorder . Off-label: psychosis/agitation related to Alzheimer's dementia. B. Resident status Resident #15, age 95, was admitted on [DATE]. According to July 2023 computerized physician orders (CPO), diagnoses included chronic atrial fibrillation, cardiomyopathy, adult failure to thrive, pain, and unspecified dementia, severe, with other behavioral disturbance. The 5/9/23 significant change in status minimum data set assessment (MDS) revealed the resident's cognition was severely impaired with a brief interview for mental status (BIMS) score of three out of 15. No hallucinations, delusions, rejection of care or wandering behaviors were documented. He required limited assistance with bed mobility, dressing and personal hygiene, supervision with transfers, eating and toilet use. Medications included an anticoagulant and antibiotic. There were no physical restraints or alarms used. The 6/20/23 MDS assessment revealed wandering occurred in one to three days during the assessment period. He required supervision with bed mobility, transfers, eating and personal hygiene, and extensive assistance with dressing and toilet use. Medications included an antipsychotic, anticoagulant and antibiotic. No physical restraints and no alarms were noted. C. Resident observations On 7/9/23 at 3:32 p.m. Resident #15 was observed asleep in his room. On 7/10/23 at 10:00 a.m. Resident #15 was observed in the television (TV) room. He was sleeping in his wheelchair. On 7/11/23 at 10:00 a.m. the resident was observed in the dining room at a table, with other residents playing a bingo game. Resident #15 had his game board in front of him and was not paying attention to the numbers called. He was not able to place a checker on a called number on the game board. The activities staff and other residents were assisting the resident through the game. On 7/11/23 at 2:00 p.m. Resident #15 was observed in his room, sleeping in his wheelchair. D. Record review 1. Care plan The comprehensive care plan revealed the following: -Resident is at risk for elopement r/t (related to) exit seeking behavior (dated 5/22/23). Interventions included: Calmly redirect and divert resident's attention. Distract resident when wandering/insistent on leaving facility by offering pleasant diversions, structured activities, food, conversation, television, books. Set up meeting with family/guardian to determine if resident may need a more appropriate facility if elopement attempts continue. -I am at risk for falls r/t (related to) cognition and not knowing my own abilities, dementia, abnormal gait, weakness, difficulty walking, unsteady on feet (dated 4/11/23). Interventions included: Activity Program/Group Program. Apply bed cane for positioning. Bed against the wall. Call before you fall sign, for visual reminder. Low bed. Maintain needed items within reach. -Resident has an ADL (activities of daily living) self-care performance deficit r/t (related to) cognitive impairment, dementia, depression, fluctuating ADLs, generalized weakness, history of falls, impaired mobility, poor balance (dated 4/11/23). Interventions included: Allow time for resident to express feelings of frustration regarding the need for assistance in ADL tasks. -The resident's centered care plan did not address the use of psychotropic medication Seroquel (Quetiapine Fumarate). 2. Physician orders Quetiapine Fumarate oral tablet 25 mg, give 1(one) tablet by mouth one time a day related to unspecified dementia, severe, with other behavioral disturbance. Start date 5/23/23. D/C (discontinued) date 5/26/23. Quetiapine Fumarate oral tablet 25 mg, give 1(one) tablet by mouth two times a day related to unspecified dementia, severe, with other behavioral disturbance. Start date 5/26/23. D/C date 6/3/23. Seroquel oral tablet 50 mg (Quetiapine Fumarate), give 1 (one) tablet by mouth two times a day related to unspecified dementia, severe, with other behavioral disturbance. Start date 6/4/23. 3. Physician notes On 4/5/23 the resident's physician documented: [AGE] year old male with dementia with behaviors. Pt (patient) with recent decline and adult failure to thrive. Have titrated off and stopped Seroquel. On 6/8/23 the resident's physician documented: Recent GDR (gradual dose reduction) failed and pt (patient) had to be restarted on Seroquel due to agitation and exit seeking. Pt (patient) has improved and more focused without exit seeking. -The physician's note did not reveal the resident was sleepy and lethargic. (see staff interviews) The chemical/physical restraint and antidepressant review committee document in the resident's medical record was dated 1/25/23. (see staff interviews) E. Nursing notes On 3/16/23 at 6:47 p.m., a nurse documented: Resident attempted to leave facility three times today. Twice out East door and once out North. Redirected by staff. Daughter aware. On 5/22/23 a director of nursing documented: Spoke with (physician's name) regarding resident's increased behaviors and exit seeking. Per (physician's name), resident may resume Quetiapine 25mg by mouth daily. Order updated to reflect changes. -There was no documentation in the medical record related to resident's exit seeking or any behaviors from 3/16/23 until 5/25/23 (see below), three days after the psychotropic medication Seroquel was started. On 5/25/23 at 5:20 a.m., a nurse documented: Resident was found by RN (registered nurse) on A wing wheeling out the main door to facility. RN caught him before he made it to the second door. Resident stated he was going to work and was redirected by RN telling him he needed coffee first. On 6/3/23 at 2:40 p.m., a nurse documented: Resident was heading towards the front doors stating that he needed to get out of here and go home. This nurse was able to redirect the resident back to his room. The resident came back to the nurses' station 15-20 minutes later stating that he needed to leave and go home. This nurse was able to redirect the resident to the kitchen for a snack and a cup of coffee. On 6/3/23 at 4:11 p.m., a nurse documented: This nurse went in to the residents room to give the resident his evening medication. The resident was asleep and this nurse woke him up gently. The resident woke up and swung at this nurse grazing this nurse's chin causing the resident to get two skin tears on his right hand. The resident continued to wing his arms stating that this nurse was trying to fight him. This nurse was able to deescalate the resident and allow this nurse to place two Band-Aids on the resident's top of hand. Resident refused his medication from this nurse. This nurse asked the resident to get up and please have dinner. The resident went down to dinner. This nurse asked the CMA (certified medical assistant) to give medication to the resident. The resident's responsible party is out of town. The resident's second contact is also out of town. Staff will notify when the responsible parties are back in town. This nurse notified the DON (director of nursing), administrator, and (physician's name). This CMA was able to administer medication after encouraging and reassuring resident that no one was trying to trick him. On 6/3/23 at 5:45 p.m., a nurse documented: (physician's name) increased the resident Quetiapine to 50 mg PO (orally) BID (two times a day). This nurse notified the resident daughter (name) of the changes in medication. On 6/10/23 at 2:27 p.m., a nurse documented: Res (resident) went out the east door by kitchen, door alarm sounded, res (resident) was able to make it out the door. Housekeeping assisted res (resident) around the building and back into facility through the front entrance with redirection. Res (resident) in his room currently in recliner, continue to check on resident frequently. F. Staff interviews Licensed practical nurse (LPN) #2 was interviewed on 7/11/23 at 9:45 a.m. She said the staff was monitoring the resident every 15 minutes and documented each time on a paper sheet. Every shift the document was turned in to the DON. She said this intervention was initiated by the new director of nursing approximately a month ago. CNA #2 was interviewed on 7/11/23 at 10:05 a.m. She said that in the past couple of months the resident was looking for the facility exit doors four times. She said the resident told the staff he wanted to go home or needed to go to work. She said only one time the resident became aggressive with a nurse who woke him up and tried to give him his medications (Seroquel). She said Resident #15 was very lethargic most of the time, needed more assistance with all activities of daily living. Certified nurse aide (CNA) #1 was interviewed on 7/11/23 at 10:10 a.m. She said she worked with the resident frequently. She said the resident was very sleepy all the time. The social service director (SSD) was interviewed on 7/11/23 at 10:50 a.m. She said she was new to her position. She said she was not aware the resident's care plan did not include the antipsychotic medication Seroquel. She said she added the medication to the resident's care plan today. She said she was unable to find any of the psychotropic medications review notes for Resident #15 and the review dated 1/25/23 was the last one in his medical record. The director of nursing (DON) was interviewed on 7/11/23 at 11:15 a.m. She said she was a new DON in the facility, for about a month. She said there was no care plan for staff monitoring the resident every 15 minutes and there was no care plan for the use of Seroquel. She said the staff who attended the psychotropic committee meeting was not aware the resident was off of Seroquel since March (2023). She said there was no documentation in the resident's medical record to justify initiating the psychotropic medication Seroquel therapy in May (2023). She said at the time Seroquel was started the resident was treated with an antibiotic for urinary tract infection which could trigger an increase in wandering behavior. 47536 III. Resident #89 A. Resident status Resident #89, age 88, was admitted to the facility on [DATE]. According to the July 2023 computerized physician orders (CPO) diagnoses included congestive heart failure, falls, depression, respiratory failure and cataracts. The 4/20/23 minimum data set (MDS) assessment document the resident had moderate cognitive impairment as evidenced by a brief interview for mental status (BIMS) with a score of 10 out of 15. She required one-person assistance for all activities of daily living (ADLs) and had supervision for bed mobility, transfers, walking in the room, locomotion on and off the unit, toilet use, eating and personal hygiene. She required limited assistance for dressing. B. Record review According to the July 2023 medication administration record (MAR) the resident received duloxetine for depression that was ordered on 4/14/23. -The resident's care plan, initiated on 4/20/23, indicated the resident did not have a care plan for care of the resident's depression. -A review of the computerized physician orders (CPO) revealed the facility failed to identify, offer and document effectiveness of non-pharmacological interventions for the resident's depression. The July 2023 MAR was reviewed and revealed the facility failed to effectively monitor the resident for side effects of antidepressant therapy. The physician order directed the nurse to monitor for side effects: drowsiness, blurred vision, dizziness, fatigue, trouble sleeping, dry mouth, hallucination and other unusual changes in mood or behavior every shift. Specifically, if monitoring was performed and none of side effects were observed, the nurse was directed to chart Y; if monitoring was performed and side effects were observed the nurse was directed to chart N and then select chart code other/see nurses notes and progress notes for findings. On 7/1/23, 7/3/23 and 7/8/23 the nurse documented N and information about the side effects the resident experienced and what interventions were taken was not found in the resident's medical record. -The facility failed to identify sources or triggers that manifested the resident's depression and then monitor for effectiveness of antidepressant treatment. C. Resident observation and interview On 7/9/23 at 3:45 p.m., the resident was observed lying in her bed. She said she was tired. She said her mood was not the best. The resident said she knew she had medication for depression and did not remember the name of the medication. She said she did not know why she felt depressed and said maybe it was from her recent illness. D. Staff interview Registered nurse (RN) #1 was interviewed on 7/10/23 at 11:15 a.m. She said the resident took antidepressant medication. She said she was aware the resident took antidepressant medication but was unaware of resident specific needs for the resident's depression. RN #1 said she had not observed the resident acting depressed. IV. Resident #26 A. Resident status Resident #26, age 85, was admitted on [DATE]. According to the July 2023 CPO, diagnoses included depression and anxiety. The 6/24/23 MDS assessment revealed the resident had a moderate cognitive impairment with a BIMS score of seven out of 15. The resident required limited to extensive assistance for most ADLs. The resident received antianxiety and antidepressant medication. No behaviors were indicated. B. Record review A review of the July 2023 medication administration record (MAR) revealed the resident was administered Duloxetine for depression and Buspirone for anxiety that was ordered on 6/12/23. -The care plan, initiated 6/12/23, revealed the facility failed to establish a plan of care for the resident's depression and anxiety. -A review of the resident's record revealed the facility failed to obtain a consent for antianxiety medication and the antidepressant medication consent was unsigned by facility staff or the physician. -The facility failed to identify, offer and document effectiveness of non-pharmacological interventions for the resident's depression and anxiety. -A review of the CPO revealed the facility failed to effectively monitor the resident for side effects from antidepressant and antianxiety medication. The MAR revealed the nurse entered a check mark to indicate monitoring, a check mark was entered every shift every day, but there was no indication what the check mark represented. -A review of the CPO revealed the facility failed to identify triggers for anxiety and to monitor the effectiveness of medication management. C. Resident observation and interview On 7/9/23 at 3:10 p.m., the resident was observed sitting in her room. She said that she frequently felt she had high anxiety related to her health status, felt alone, her stay at the facility and wished to go home. She said she was unaware that she took medication for anxiety and said that if she was ordered medication, it did not help. D. Staff interview RN #1 was interviewed on 7/10/23 at 11:15 a.m. She said the resident was prescribed an antidepressant and antianxiety medication. She said the resident was aware the resident took antianxiety and antidepressant medications but was unaware what specifically the resident needed to manage her depression and anxiety. RN #1 said she had not observed the resident depressed or anxious. The RN said when a nurse monitors medication side effects or effectiveness of medications, the monitoring was documented on the resident's MAR. V. Administrative interview The director of nursing (DON) was interviewed on 7/11/23 at 10:15 a.m. The DON said when a resident was admitted to the facility the interdisciplinary team developed the resident's care plan. She said the residents' care plan should have included care needs and management specific to the resident's depression and anxiety. The DON said a resident taking antipsychotic medication should be monitored for side effects and effectiveness, like a change in resident behavior or mood or adverse outcomes of the medication. The DON was unable to locate care plans specific to managing the residents' depression and anxiety. She said the residents' care plans should have included care needs and management specific to the resident's depression. The DON was interviewed again on 7/12/23 at 10:15 a.m. She said monitoring results were helpful for the physician to determine effectiveness of medication therapy. The DON said that when a resident was admitted , the interdisciplinary team (IDT) determined what monitoring was necessary and then nursing would obtain physician orders for monitoring. The DON said she would review how monitoring orders were entered to make future monitoring complete and effective. The director of nursing (DON) was interviewed on 7/12/23 at 10:15 a.m. She said monitoring results were helpful for the physician to determine effectiveness of medication therapy. The DON said that when a resident was admitted , the interdisciplinary team (IDT) determined what monitoring was necessary and then nursing would obtain physician orders for monitoring. The DON said she would review how monitoring orders were entered to make future monitoring complete and effective.

Based on observations, record review and interviews, the facility failed to implement appropriate nutritional interventions for one (#1) of three residents reviewed for nutrition out of 20 sample residents to maintain acceptable parameters of nutritional status. Resident #1 had diagnoses of Parkinson's disease, protein calorie malnutrition, dysphagia (swallowing difficulty) and dementia, which made her at nutritional risk. She required supervision assistance at meals, which through observations was not provided. The facility failed to implement nutrition interventions when the resident sustained a severe weight loss. Due to the facility's failures, Resident #1 sustained a weight loss of 15.1% (16.8 lbs) from 2/9/23 through 7/6/23, which was considered severe. Findings include: I. Facility policy and procedure The Nutrition at Risk policy, not dated, was provided by the nursing home administrator (NHA) on 7/12/23 at approximately 2:00 p.m. The policy read in pertinent part, Residents with significant weight loss will be submitted to the interdisciplinary nutrition at risk (NAR) committee comprising of the food services, nursing, rehab services, social services, activity and administrator following confirmation by re-weighing. The NAR committee will meet to discuss the resident assessment findings, develop a new MDS (minimum data set) if indicated and plan of care to correct undesirable weight change. Physician will be notified of the plan of care and recommendations. Family members will be encourage to participate and/or will be notified of the recommendations. If despite appropriate interventions by the NAR committee and the staff, the resident is not receiving sufficient nutritional support to meet his/her metabolic needs, physician will be notified. II. Resident #1 Resident #1, age 86, was admitted on [DATE]. According to July 2023 computerized physician orders (CPO), diagnoses included Parkinson's disease, cerebral infarction, unspecified protein calorie malnutrition, aphasia (loss of ability to understand or express speech), dysphasia, dementia and anxiety. The 6/16/23 minimum data set (MDS) assessment revealed severely impaired vision and severely impaired cognition with a brief interview for mental status (BIMS) score three out of 15. She required limited assistance with bed mobility, extensive assistance with transfers, dressing, toilet use and personal hygiene and supervision with eating. Section K (Swallowing Disorders) revealed no difficulty with swallowing, her weight was 96 pounds and no weight loss of 5% or more in the last month or loss of 10% or more in the last six months was documented. She received a mechanically altered diet. Medications received included an antianxiety and anticoagulant. -Section K was incorrectly coded for the resident's weight loss. At the time of the assessment look back period, the resident lost 13.8% weight in three months. III. Resident interview and observations The resident was interviewed on 7/9/23 at 3:41 p.m. She said she did not like the food and had no appetite. The resident was observed on 7/9/23 at 5:10 p.m. in the dining room. She did not eat her supper meal. She was observed drinking a nutritional supplement. The resident was observed on 7/10/23 at 12:20 p.m. in the dining room. There were no staff assisting the resident with her meal. The resident said she had a couple bites of her food. The resident was drinking a nutritional supplement. The resident was observed on 7/11/23 at 5:15 p.m. in the dining room. She did not eat her supper meal. She was drinking a nutritional supplement. The resident was observed on 7/12/23 at 12:10 p.m. There was no staff assisting the resident with her lunch meal and she did not eat any of her food. -The resident was not provided any additional meal options when she did not eat her meal and was only provided a nutritional supplement. IV. Representative interview The representative was interviewed on 7/10/23 at 3:00 p.m. She said she was very disappointed when she learned her mother lost 15 pounds of her weight in a couple months. She said the facility should implement assistance with meals and encourage her mother to eat. She said no staff asked her about her mother's favorite food that she preferred to eat. She said she asked her mother's physician about a hospice care referral so she could get more staff assistance. V. Record review A. Care plan and weights The comprehensive care plan revealed the following: -I am at risk for altered nutritional status r/t (related to): frequently consumes less than 75% meals, low body mass index, refusal of meals, vision problems, dysphagia, malnutrition, potential for dehydration. Regular diet/mechanically soft texture (dated 4/9/23). Interventions included: Administer medication and/or vitamin/mineral supplement per physician order. Encourage/provide intake of fluids throughout the day; if not contraindicated. Monitor meal percentage intake for changes in eating habits. Provide adaptive equipment (likes food in separate bowls as desired, mechanical soft texture) as needed to maintain/promote independence with eating. Provide feeding/dining assistance as needed. If refuses meal offer shake as desired, don't force feed, family will bring in food and snacks at times (dated 6/29/23). Provide nutritional supplement(s) as ordered by physician-Boost. Weekly weights (dated 6/14/23). -I have an ADL (activities of daily living) self-care performance deficit r/t (related to) anxiety, cognitive impairment, fluctuating ADLs, generalized weakness, history of falls, pain, Parkinson's (dated 4/9/23). Interventions included: Eating: Independent to oversight with eating; offer assistance with meal set-up if needed (dated 5/22/23). The resident's weights were: On 1/7/23 the resident weighed 109.6 lbs On 2/9/23 the resident weighed 111 lbs On 3/24/23 resident's weight was 110 lbs On 4/2/23 the resident weighed 109 lbs On 5/1/23 the resident weighed 102.2 lbs (8% weight loss in three months) On 6/6/23 the resident weighed 94.8 lbs (14% weight loss in three months) On 7/6/23 the resident's weight was 94.2 lbs B. Interdisciplinary notes On 5/15/23 a registered dietitian (RD) documented: Resident f/u (follow up). Diet: mechanical soft consuming 25-50% on average. Boost (nutritional supplement) BID (two times a day) taking well. Weights:105.9# (12/30/22) 109.8# (1/7/23) 111# (2/9/23) 110# (3/24/23) 109.6# (4/2/23) 102.2# (5/1/23) BMI:16.5 underweight. Weight loss likely related to previous COVID infection and meal intakes have declined slightly. Resident weight is below RWR (recommended weight range)- 117-143#. Noted all meds (medications). No skin issues noted. Braden-17. Fluid needs: 1393ml/day and resident taking 1610ml/day. No new labs to eval. Continue supplements. Continue to offer snacks. Encourage good meal intakes as resident will accept. Monitor po (oral) intakes, tolerance, labs as available, skin, weights, and care plan. Will follow. -There were no nutritional interventions added when the resident sustained 6.8 lbs weight loss, which was 6.3% (severe). The RD note was written 14 days after the weight loss occurred. The resident weight was not more frequently monitored with her sustaining a significant weight loss. On 6/6/23 a registered dietitian (RD) documented: Resident f/u (follow up). Diet: mechanical soft consuming 25-50% on average. Boost (nutritional supplement) BID (two times a day) taking well with an occasional refusal. Weights: 105.9# (12/30/22) 109.8# (1/7/23) 111# (2/9/23) 110# (3/24/23) 109.6# (4/2/23) 102.2# (5/1/23) 90.3# (6/4/23) Staff getting another body weight today to make sure this is accurate. Meal intakes remain stable at this time. BMI: 14.6 underweight. Resident weight is below RWR - 117-143#. Noted all meds. No skin issues noted. Braden-17. Fluid needs: 1393ml/day and resident taking 1520ml/day. No new labs to eval. Continue supplements. Continue to offer snacks. Please obtain current body weight to confirm accurate weight. Encourage good meal intakes as resident will accept. Monitor po intakes, tolerance, labs as available, skin, weights, and care plan. Will follow. On 6/7/23 the RD documented: Noted current weight of 94.8# (6/6/23) Noted 90.3# was inaccurate. Resident eating breakfast at time of visit and reports appetite 'ok.' Consider increasing boost to TID (three times a day) in between meals. Continue to offer snacks. Encourage good meal intakes. Monitor po (oral) intakes, tolerance, labs as available, skin, weights, and care plan. Will follow. -Even though the weight was 94.8 lbs and not 90.3 lbs as indicated by the RD documentation, the resident still lost an additional 7.4 lbs since her last weight, which was 7.24% in one month (severe). Over two months, she lost 14.2 lbs. On 6/10/23 a nurse documented: Resident's appetite is poor, encouraged resident to eat, supplements offered, resident declined to drink them. Different foods offered to resident, she continues to have poor appetite, Resident's daughters in to visit and discussed resident not wanting to sit and be assisted. Staff will continue to encourage resident to eat and accept assistance. On 6/29/23 the dietary manager (DM) documented: Hospice referral in progress. Family wants comfort measures only. Family states that (Resident) may skip meals if she wishes. On 6/29/23 the DM documented: Meal intake 47%, continue with providing Boost, add ice cream to mighty shake with every meal. On 7/5/23 the RD documented: Resident now admitted to hospice. Diet: mechanical soft consuming 50% on average. Noted that resident is permitted to skip meals as she likes. Boost BID (two times a day) taking well with an occasional refusal. Weights: 95.2# (6/4/23) 95.2# (6/27/23) Meal intakes remain stable at this time. BMI: 15.4 underweight. Resident weight is below RWR - 117-143#. Noted all meds. No skin issues noted. Fluid needs: 1393ml/day and resident taking 1840 ml/day. No new labs to eval. Continue supplements. Continue to offer snacks. Encourage good meal intakes as resident will accept. Monitor po (oral) intakes, tolerance, labs as available, skin, weights, and care plan. Will follow. -Prior to the resident being admitted to hospice care, she had sustained a severe weight loss with limited interventions put in place to address it. C. Physician note On 6/8/23 the physician documented: Pt (patient) continues to lose weight with adult failure to thrive. D/W (discussed with) Pt's (patient's) daughter today and they request comfort measures only for end of life care and no aggressive medical interventions. VI. Staff interviews The director of nursing (DON) was interviewed on 7/10/23 at 2:48 p.m. She said she has been in her position in this facility for three weeks. She said she was aware of Resident #1's weight loss through Nutrition at Risk Review Meetings with the interdisciplinary team (IDT). She said the IDT recommended increasing the Boost supplement to three times a day. She said staff assistance with meals was not considered as the resident was independent. -However, the Boost supplement was not increased and per the MDS assessment the resident minimally required supervision at meals. Certified nurse aide (CNA) #2 was interviewed on 7/11/23 at 10:07 a.m. She said she was not aware Resident #1 required staff assistance during meals. She said she did not see nursing staff helping Resident #1 with meals in the dining room. The resident was seated alone at her table and most of the time she was drinking her supplement. The DM was interviewed on 7/12/23 at 10:28 a.m. He said he was new to this position. He said he did not complete residents' nutritional assessments or food preferences. He said if a newly admitted resident had some kind of diet restrictions, the admitting nurse would send a request to the kitchen. He said he was aware of Resident #1's weight loss and meal refusals. He said he served the resident a milk shake with each meal. He said the dietary aides were recording each resident's meal intakes and took them to the nursing staff. The RD was interviewed on 7/12/23 at 2:45 p.m. She said she did not consider any other protein supplement for the resident as the resident was drinking the prescribed Boost most of the time. She said she was not aware the resident did not receive staff assistance with meals. She said she did not request from the physician any lab work to check on the resident's Albumin (Prealbumin) as she knew it would be low. She said she tried to be in the facility two times a month. She said she did not observe Resident #1 during meals and calculated her meal intakes based on staff recordings. She said she did not provide any education to the dietary staff on how to appropriately document meal intakes.

Based on record review and interviews, the facility failed to develop and implement a discharge planning process that focused on the resident's discharge goals for three (#93, #36 and #138) of four residents out of 20 sample residents. Specifically, the facility failed to for Resident #93, #36 and #138: -Develop and complete a discharge plan of care; -Obtain physician orders for discharge; -Educate and document for discharge instructions; and, -Reconcile medications prescribed for discharge. Findings include I. Facility policy and procedure The Discharge Process policy was requested on 7/12/23 from the nursing home administrator (NHA). The NHA provided the Discharge Protocol, undated, on 7/12/23 and it documented in pertinent part: Three days prior/as soon as notice is given for discharge the following to be initiated. -Discharge Plan of Care; -Social service to fist open; -Nursing, Therapy, MDS, and/or designee will complete their designated sections; -All areas should be completed thoroughly prior to the day of discharge. At the time of discharge: -The in-progress Discharge Plan of Care of Care Evaluation is to have each section completed prior to the resident departing the facility; -The facility to provide the order summary report. The order summary report will include the next time the order is to be administered (handwritten next to each physician order); -Facility Representative to Review/Discuss Reconciliation of Pre and Post discharged medications. II Resident #93 A. Resident status Resident #93, over the age of 65, was admitted on [DATE] and discharged home on 7/3/23. According to the July 2023 computerized physician orders (CPO), diagnoses included femur (hip) fracture, muscle weakness, pulmonary embolism, abnormalities of gait and mobility and heart disease. The 6/15/23 minimum data set (MDS) assessment document the resident had no cognitive impairment as evidenced by a brief interview for mental status (BIMS) with a score of 15 out of 15. He required one-person assistance for all activities of daily living (ADLs) with supervision for dressing, eating, personal hygiene and limited assistance for bed mobility and transfers. B. Record review A review of the July 2023 CPO revealed the facility failed to obtain a physician discharge orders. -The resident's discharge care plan, dated 6/30/23, revealed the care plan was not complete. The discharge care plan was not completed by the therapy department and failed to include information regarding the resident's current abilities, therapy goals, and summary of therapy treatment during the admission. The discharge summary, dated 7/3/23, read the nurse who completed the discharge provided the resident with 46 tablets of five milligram oxycodone. -The record did not include a physician's order to discharge the resident with the opioid medication. The record review failed to indicate the resident or his family member received information on when the next dose of each medication could be administered. III. Resident #36 A. Resident status Resident #36, age 83, was admitted to the facility on [DATE] and discharged home on 5/30/23. According to the May 2023 CPO diagnoses included stroke, respiratory failure, muscle weakness, abnormalities of the gait, metabolic encephalopathy (brain injury) and inflammation of the inside lining of the heart. The 5/30/23 MDS assessment documented the resident had a moderate cognitive impairment as evidenced by a brief interview for mental status BIMS with a score of 11 out of 15. He required one-person assistance for all ADLs and had supervision for bed mobility, locomotion on and off the unit, dressing, eating, personal hygiene and limited assistance for transfers and toileting. The resident participated in goal setting, he expected to transfer to another facility and did not include his family or guardian. B. Record review -A review of the July 2023 CPO revealed the facility obtained a physician's order to discharge the resident home with discharge instructions and medications. -A review of the resident's record indicated the facility failed to initiate and complete a discharge care plan, discharge summary and failed to provide discharge teaching for the resident. IV. Resident #138 A. Resident status Resident #138, age 87, was admitted on [DATE] and discharged home on 6/2/23. According to the June 2023 CPO, diagnoses included respiratory infection, respiratory failure, gait abnormalities, adult failure to thrive, dementia, shortness of breath and urinary tract infection. The 5/14/23 MDS assessment documented the resident had a moderate cognitive impairment as evidenced by a BIMS with a score of nine out of 15. She required one-person assistance for all ADLs with supervision for dressing, eating, personal hygiene and limited assistance for bed mobility and transfers. The resident participated in goal setting, that she expected to transfer to another facility and did not include her family or guardian. B. Record review -A review of the July 2023 CPO revealed the facility obtained a physician order to discharge to another facility with instructions and medication. -The resident's discharge care plan, dated 6/2/23, indicated the care plan was not complete. The discharge care plan was not completed by the therapy department and failed to include information regarding the resident's current abilities, therapy goals, and summary of therapy treatment during the admission. The discharge summary dated 6/2/23, read the nurse who completed the discharge reviewed and provided medications. -The record review failed to reveal the resident, family member or accepting facility received information on when the next dose of each medication could be administered. V. Staff interviews Registered nurse (RN) #2 was interviewed on 7/12/23 at 10:15 a.m. She said when she discharged a resident she was responsible to print the resident's Discharge Plan of Care, review the discharge instructions with the resident and or family member, provide and review medications and document the information on the discharge summary assessment form in the resident's record. She said every resident who was discharged received the controlled prescription medications and other prescription medications were returned to the pharmacy. She said she used nursing judgment when she decided which and how many controlled substance medications she provided to the resident. She said she would give only a few days of narcotic medication, not 30 tablets. The RN said if the resident did not have a discharge order from the physician she would contact a co-worker or the director of nursing (DON) for assistance. The social worker aide (SWA) was interviewed on 7/12/23 at 9:50 a.m. She said the facility had a discharge protocol. She said she coordinated each discharge with the therapy department to determine a discharge date and initiated the Discharge Plan of Care. She said every discipline was responsible to complete the applicable section with resident specific information. She said she did not use the physician discharge order to arrange post discharge care and equipment but referred to the face to face assessment completed by the physician. The SWA said she arranged home health care for every resident because it was a state regulation but she was unsure which regulation. The DON was interviewed on 7/12/23 at 11:15 a.m. She said each nurse discharged a resident to verify the physician had provided a discharge order and to contact the physician if the order was not written. The DON said the physician's order would contain direction to the nurse regarding what medications and amounts should be provided to the resident when discharged and it should not be decided by nursing judgment.

Based on record review, observations and interviews, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with accepted professional standards for one of two medication storage rooms and one of two medication carts. Specifically, the facility failed to label biological supplies and to lock the medication cart when unattended. Findings include: I. Facility policy The Administration of Medication policy, undated, was requested and received on [DATE] from the nursing home administrator (NHA). The policy documented in pertinent part: Never leave medication care open and unattended. The Medication Labeling and Storage policy, undated, was requested and received on [DATE] from the NHA. The policy documented in pertinent part: If the facility has discontinued, outdated or deteriorated medication or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items; Each resident's medications are assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medication of several residents; Multidose vials that have been opened or accessed are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. II. Hall B medication cart On [DATE] at 12:25 p.m., the medication cart was unlocked and unattended. Additionally, medications labeled with resident names were observed on top of the medication cart. The unsecure items were: four boxes of opened eye drops, one box of eye antibiotic drops box opened, two boxes of opened nasal spray and two medication cups that contained miscellaneous tablet medications. Two residents were sitting in wheelchairs adjacent to the medication cart and visitors were in the adjacent lounge area. Licensed practical nurse (LPN) #1 was interviewed on [DATE] at 12:27 p.m., when she returned to the medication cart. She said she was called into a resident's room and left the cart unlocked. She said the medication cart was to be locked and clear of medications whenever it was left unattended. III. Hall A medication room On [DATE] at 9:55 a.m., the medication room was observed with registered nurse (RN) #1. RN #1 verified a multidose vial of tubersol was stored in the supply room refrigerator. and it was opened and undated. RN #1 was interviewed immediately after the observation and said the tuberculin was used for testing residents when they were admitted to the facility to see if they had any exposure to tuberculosis. She said the night shift staff were responsible for identifying and removing expired items from the supply. The RN said the open vials must be dated with an expiration date 30 days after it was opened. The RN replaced the vial in the refrigerator and said she would need the tuberculin for admissions later that day. The director of nursing (DON) was interviewed on [DATE] at 10:15 a.m. She said when a nurse opened a multidose vial the nurse was responsible for dating the vial when opened. She said the multidose vial would expire 28 days after it was opened. The DON said the RN should not have replaced the undated tuberculin back in the refrigerator for use later that day and she removed the undated vial immediately.

Based on observations, record review and staff interviews, the facility failed to ensure two (#8 and #12) of four residents observed for nutrition/hydration maintained acceptable parameters of nutritional status to avoid unintended weight loss out of 20 sample residents. The facility failed to identify and consistently implement timely interventions to maintain residents' weight. The facility failed to timely address Resident #8's significant weight loss and poor intake. Resident #8 lost 17.4 pounds (lbs) between 2/3/22 and 4/3/22, resulting in 11.24% total weight loss in two months. The facility did not identify the weight loss between 2/3/22 and 3/15/22 at 7.11% as a significant loss, delaying interventions to potentially slow the weight loss decline of Resident #8. The resident lost an additional 6.2 lbs from 3/21/22 to 4/3/22 and additional interventions such as speech therapy and an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #8 was diagnosed as having a failure to thrive however, she was not given the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Furthermore, Resident #8 was documented to have a poor appetite and had a current urinary tract infection, potential factors for poor intakes at meals; however, the facility did not review or incorporate all possible and appropriate interventions to increase meal intake during meal service. Resident #8 was observed on two occasions (4/4/22 and 4/5/22) to need additional staff assistance at meals to provide cueing and encouragement. During the observations, the resident continued to show interest in eating but improper set up, lack of supervision and assistance when problems arose, resulted in additional meal challenges for the resident, impairing good meal intake potential. In addition, the facility failed to prevent weight loss and ensure proper nutritional parameters for Resident #12. Findings include: I. Facility policy and procedure The Nutritional Adequacy of Diet policy, undated, was provided by the nursing home administrator (NHA) on 4/12/22 via email. The policy identified the purpose of the nutrition management program included: The nutritional needs of residents are met in response to physician's orders, and to the extent medically possible to meet the dietary allowances of the Food and Nutrition Board of the National Research Council adjusted for age, sex, and activity level . The Nutrition At Risk (NAR) policy, undated, was provided by the NHA on 4/12/22 via email. The policy read: Assessment identification of risk factors will be identified as such for clinical baseline data and/or investigation purposes . The policy outlined a criteria of risk factors to include residents with unplanned weight loss. The policy identified the timelined parameters of weight loss severity. According to the policy, a significant weight loss would be recognised as a 5% loss in one month; a 7.5% loss in three months; and, a 10% loss in six months. A severe weight loss would be recognised as greater than 5% loss in one month; a greater than 7.5% loss in three months; and, a greater than 10% loss in six months. Additional criteria for the identification of risk would include: Residents who leave more than 50% of their meal food and eat at most meals. If the resident's normal intake is only 50% of meals, this should be documented in the plan of care or progress notes. This situation would not indicate nutrition at risk, unless the resident is losing weight. This resident could also be considered a candidate for small portions, which should also be noted in the care plan and in the progress notes. The policy identified the facility's steps to take if the above risk factors for weight loss were present. The policy read in part: If a significant weight loss is determined, the dietary manager will initiate a weight NAR change investigation report .Residents with significant weight loss will be submitted to the interdisciplinary NAR committee comprising of the food services, nursing, rehab services, social services, activity and the administrators, following confirmation by re-weighing. Residents will be referred to the appropriate therapy prn (as needed) or as advisable per nursing/physician. (The) physician will be notified of the plan of care and recommendations. Family members will be encouraged to participate and/or will be notified of the recommendations. These activities will be documented in the progress notes. The NAR committee must review and assess the resident at the minimum of once per month and enter appropriate progress notes. If despite appropriate interventions by the NAR committee and the staff, the resident is not receiving significant nutritional support to meet his/her metabolic needs, the personal physician will be notified. All interdisciplinary team members will be given a copy of all residents on NAR and the trends will likewise be addressed in the NAR committee meeting. Residents addressed by the NAR committee shall be weighed weekly. II. Resident #8 A. Resident status Resident #8, over the age 65, was admitted on [DATE]. According to the April 2022 computerized physician orders (CPO), diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 1/12/22 minimum data set (MDS) assessment revealed the resident's cognition was severely impaired with a brief interview for mental status (BIMS) score of one out of 15. The resident required extensive physical assistance with two or more persons for bed mobility. She needed extensive physical assistance from one person for transfers, dressing, toileting, and personal hygiene. According to the MDS, Resident #8 required supervision with set up for eating and she did not have rejections of care or other identified behaviors. The MDS indicated Resident #8 did not have a weight loss of 5% or more in a month in the MDS look back period and did not have a 10% weight loss or more in the six months prior to 1/12/22. There were no identified concerns with the resident's oral/dental status. B. Observations Resident #8 was observed on 4/4/22 at 5:10 p.m. in the dining room. She was served a sandwich and fries and a glass of fruit juice and water. Resident ate a couple of her fries, sipped her beverage, lightly coughing and then slowly moved away from the dining table. The resident was not: encouraged to eat her food, offered other meal options if she was disinterested in the current meal selection, positioned her closer to the table, and checked if she was swallowing properly. -At 5:38 p.m. the dietary aide (DA) #1 assisted the resident closer to the table. The resident looked down at her food and proceeded to eat her fries and drink her beverage. During the entirety of the meal, DA #1 was the only staff member consistently observed in the dining room. Resident #8 was observed on 4/5/22 at 4:49 p.m. The dietary manager (DM) served the resident a hamburger, sliced carrots, pineapple chunks and tater tots. The resident was properly positioned at the table and proceeded to eat her pineapple and tater tots. The resident began pulling her dentures in and out of her mouth, no longer focusing on her food. She was not observed to be assisted with her dentures, as she held them in her hand. -At 5:08 p.m. the resident was observed with dentures in her mouth, eating more of the pineapple chunks. C. Record review The weight record read as follows: -2/3/22, Resident #8 weighed 154.8 pounds (lbs). -2/7/22, Resident #8 weighed 151 lbs. -3/1/22, Resident #8 weighed 152.1 lbs. -3/7/22, Resident #8 weighed 151 lbs. -3/15/22, Resident #8 weighed 143.8 lbs., the resident lost 11 lbs. since 2/3/22, which was 7.11% considered significant weight loss. -3/21/22, Resident #8 weighed 143.6 lbs. -4/3/22 Resident #8 weighed 137.4 lbs, which was 6.2 lbs in less than two weeks. The resident had weight loss since 3/21/22, which was 14.7 lbs in one month from 3/1/22 to 4/3/22, 9.66% which was considered significant. In addition, she lost 17.4 lbs since 2/3/22, 11.24% which was considered significant. The November 2021 weight was provided on 4/11/22 (after the survey) by the NHA via email. According to the weight record, Resident #8's weight on 11/6/21 was 156.4 lb. Weights for December 2021 and January 2022 were not recorded. Between 3/7/22 and 3/21/22, the resident had a rapid weight loss of 7.6 lbs at 4.9%. According to the NAR statement (as above), the weight loss reported on 3/15/22 was not captured till 3/21/22 and reviewed on 3/23/22 in the NAR meeting. Meanwhile, Resident #8 lost an additional 6.2 lbs at 4.32% between 3/23/22 and 4/3/22. The care plan for nutrition, initiated on 6/29/19, last reviewed on 3/28/22, read Resident #8 was independent and made her own meal and snack choices. Resident #8 did not swallow and chewing concerns and may have weight fluctuation due to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She liked fresh fruit and veggies and gravy. According to the care plan, the resident's food texture had been changed from regular to mechanical soft per speech therapy on 7/21/2020 and returned to regular texture on 3/24/21. Care plan interventions, initiated on 6/26/19, read as the following: (Resident #8) is on regular diet with regular temperature texture; (Resident #8's) intake will be monitored daily; Supplements as ordered; Offer (Resident #8) snacks and fluids between meals; If (Resident #8's) meal intake is 50% or less, offer Boost/Ensure (dietary supplement); (Resident #8) is a big water drinker; (Resident #8) will have weight monitored monthly; and (Resident #8's) big meal is breakfast. She eats the same meal of French toast, bacon and sausage. -The care plan did not address the resident's most recent weight loss of 14.7 lbs and current weight loss interventions. The last intervention under the nutrition care plan addressed the resident's diet texture changes between 7/21/2020 and 3/24/21 as indicated above. The care plan for ADLs, initiated on 9/24/19, identified Resident #8 had dementia and staff may have to anticipate her needs. The ADL care plan related to weight, initiated on 2/4/22, read for staff to encourage and assist the resident with retrieving her weight amount at least monthly. According to the care plan, she would occasionally refuse to have her weight taken. -The care plan did not identify the type of meal assist she may need or how to assist and encourage the resident during meals when her food intake was low. The behavior care plan, initiated on 7/22/19, read Resident #8 exhibited behaviors related to her dementia. According to the care plan, the resident could be uncooperative. -The care plan did not identify the resident exhibited behaviors around meals or was resistant to weight loss prevention and mitigation interventions such as encouragement, proper set up, and cueing as needed during meals. In addition, the 1/12/22 MDS assessment did not identify rejection of care. The 1/6/22 dietary director note read the NAR committee followed Resident #8 for weight changes. According to the note, the resident average intake was 42% to 59%. The resident was above her ideal body weight (IBW). Staff would continue to monitor for additional changes and additional interventions as the resident would accept. The staff would continue to offer snacks, and alternatives. -However, the additional interventions that the resident would accept were not indicated nor was an intervention started for the resident's poor intake. The 1/15/22 resident care conference record indicated Resident #8 was on palliative care per the daughter's request and the resident's weight was stable. According to the care conference record, the facility would offer finger foods and offer milkshakes, noting she liked strawberry milk shakes. -The review of the physician's orders did not identify offering her finger foods or strawberry milkshakes. The 2/10/22 dietary note written by the RD read Resident #8 was on a regular diet, consuming 25% to 50% on average with some meal refusals. The RD noted the resident was on antibiotics which may have contributed to lower meal intakes and slight weight loss. According to the note, the resident's intakes, tolerance, labs as available, skin, weights and care plan would be monitored. -However, there were no additional interventions noted for the resident's poor intake and meal refusal nor review of her dietary preferences. The 3/23/22 NAR meeting minutes, provided by the NHA on 4/8/22 (during the survey) read Resident #8 had a 5% weight change in 30 days. Her average meal intake ranged between 31% to 41%. According to NHA notes after determining Resident #8 had a 5% weight loss in 30 days, staff were to monitor and notify the RD. -No additional interventions were attempted. The NAR minutes identified the weight loss was not triggered in the system. The quarterly nutrition evaluation prepared by the corporate certified dietary manager (CCDM), dated 3/28/22, identified Resident #8's usual weight was between 145 lbs to 160 lbs. Her ideal weight with a height of 5'5, was between 112 lbs and 138 lbs. The assessment indicated the resident weight was 143.6 as of 3/21/22, resulting in recent weight loss. According to the evaluation, the resident was at risk for unplanned weight changes with possible inadequate intake to maintain status. Under anticipated nutrition/hydration approaches, the evaluation read none of the above. An addendum to the evaluation was added by RD on 4/4/22 (which was during the survey) to the 3/28/22 nutrition evaluation. Under monitoring, the evaluation read the resident had a weight loss in the past quarter and was a result from possible poor meal intakes. The RD also noted the resident had dementia and comorbidities that may also have affected the resident's nutritional status. According to the evaluation, the identified weight loss was not significant. The 3/28/22 evaluation read the resident would be monitored for additional nutrition intervention as needed. -However, according to the weight record above, the resident lost 5.59% weight between 3/1/22 and 3/21/22, indicating a significant weight loss in less than a month. The review of the resident's medical record did not indicate additional interventions to prevent further weight loss was added until 4/6/22, which was during the survey. The 3/31/22 nursing note read Resident #8 was diagnosed with a [CONDITION(S)] on 3/29/22 and had a night episode of hallucinations. The 3/31/22 quarterly activity assessment read Resident #8 passively enjoyed exercise, bingo, the outdoors and movie night. According to the note, the resident enjoyed reminiscing and getting milkshakes during one-to-one visits. The April 2022 CPO identified the resident was on a regular diet, with regular texture and thin liquids since 3/25/21. -The April 2022 CPO did not indicate the resident was on a nutritional supplement for weight gain or increased caloric intake. The April 2022 CPO did not identify additional measures to promote weight gain or weight stability. The April 2022 CPO identified Resident #8 had a standing order for Weights per facility policy. The review of the policy (as above) indicated the facility should initiate a NAR committee review and weigh the resident weekly when there was significant weight loss. The annual nutrition evaluation, dated 4/4/22, identified Resident #8's weight was 137.4 as of 4/3/22, resulting in recent weight loss. The resident was not on a physician-prescribed weight-loss regimen. The resident's body mass index (BMI) was 22.8, indicating within a normal range. According to the evaluation, the resident's health condition affected her nutrition. The RD recommended 90 ml Med Pass TID in between meals to help stabilize weights and continue to offer snacks and encourage good meal intake. The RD indicated the resident was on a regular diet and consumed 50% of her meals on average, stating her meal intake was variable. The RD noted the resident sometimes ate well and sometimes did not have an appetite. The RD recommended a reweight related to such a big swing with the last weight. According to the evaluation, the RD would monitor Resident #8's food/liquid intake, tolerance, lab work as available, skin, weights, and care plan. -However, a supplement was added after the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . The nutrition request from the RD to the physician form was provided by the NHA on 4/6/22, which was during the survey. The request read Resident #8 had a weight of 14 lbs since 3/1/22. The RD requested Boost supplement three times a day between meals to stabilize the resident's weight (as indicated above.) According to the NHA, the request to the physician was waiting to be signed. The physician's order, dated 4/6/22 (during the survey), was provided by the NHA on 4/7/22 at 8:25 a.m. According to the 4/6/22 order, the resident had a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The 4/7/22 (during the survey) dietary director note read the NAR committee continues to follow the resident for weight loss and changes. The resident's intake for the past seven days (4/1/22 to 4/7/22) was between 38% to 56%. According to the note, staff would attempt a Med Pass supplement. The note identified the resident had a [CONDITION(S)] without antibiotic treatment per the daughter's request to make comfortable and did not desire additional interventions. The dietary note read staff would monitor for additional nutritional interventions as needed as the resident and family may accept. A nutrition at risk (NAR) review statement was provided by the NHA on 4/7/22 (during the survey) at 1:12 p.m. The statement read Weights are pulled to compile the weekly report on Mondays through very early mornings on Tuesday so the corporate certified dietary manager (CCDM) had time to compile her reports by the Wednesday meeting. Resident #8's 3/15/22 weight was not captured for the report until the following Monday on (3/21/22). This was when the director of nursing (DON) had her re-weighed to ensure it was an accurate weight. We then had NAR on (3/23/22). The registered dietitian (RD) was notified that she needed to do a review during her scheduled visit on 4/4/22. (The RD) then made the recommendation for 90 ml (milliliters) Boost (supplement) TID (three times a day) in between meals to help stabilize weight. According to the statement, the request for the supplement was waiting for the physician's review. -The review of the April 2022 CPO (above) and in an 4/7/22 interview with the RD, the NHA, and the DON, the supplement was not yet implemented as of 4/7/22. An additional quote was added to the NAR statement from the RD. According to the RD: (Resident #8's) weight was not significant until 4/4/22. Overall, she had gained weight since 2019. The RD gave the example of the resident's weight of 138 lb as of 3/21/19. -However, Resident #8's weight as of 11/6/21 was 156.4 lbs. In less than six months, the resident lost a total of 12.15% of her body weight with a 19 lbs weight loss, between 11/6/22 and 4/3/22. D. Staff interview The NHA, the director of nursing (DON) and the MDS coordinator (MDSC) was interviewed on 4/6/22 at approximately 3:30 p.m. The management team said Resident #8 was reviewed in the 4/6/22 NAR committee meeting. The resident had advanced Alzheimers, had a [CONDITION(S)], and did not accept assistance at meals. Staff would encourage snacks. Resident #8 was provided finger food. According to the management team, on 4/6/22, an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . -However, a request for a supplement and the failure to thrive diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident already had significant weight loss and noted poor intakes per previous nutrition notes/assessments. The MDSC was interviewed on 4/7/22 at 10:28 a.m. She said she attended the weekly NAR meeting. She said the NAR meeting was usually where she learned of a resident's weight loss unless she read the registered dietitian (RD) evaluation before the meeting. She said on 4/4/22 the RD identified Resident #8 had weight loss. The MSDC said according to the RAI (resident assessment instrument), a 5% weight loss in 30 days, and/or a 10% weight loss in 180 days was considered to be significant weight loss. She said Resident #8 was determined to have a significant weight loss this week based on the RD assessment and the 4/6/22 NAR committee review. She said the resident lost 10% of her weight so she would initiate a significant change of condition assessment. The MDSC said the director of nursing (DON) collected all the resident weights. The MDSC said the RD would have been notified of the weights on 3/21/22. The MDSC said the RD was then scheduled for a review on 4/4/22. The NHA was interviewed on 4/7/22 at 8:34 a.m. She said weight loss was not immediately identified if the resident was only weighed monthly. The NHA said she was not under the impression Resident #8 was weighed more than monthly. She said any additional weights could have been a result of staff training to determine weight accuracy. The NHA was interviewed again on 4/7/22 at 8:44 a.m. She said Resident #8's weights were reviewed and the weights identified in the weight record were all accurate. -Despite all the weights being accurate in the resident's chart, there was no attempt for a re-weigh to determine if there was an inaccurate weight and no interventions were attempted with her ongoing weight loss identified since 3/15/22 when she lost 11 lbs since 2/3/22. The dietary manager (DM) was interviewed on 4/7/22 at 8:57 a.m. The DM said he was informed anytime a resident had weight loss. Resident #8 was identified for weight loss during the 4/6/22 NAR meeting. He said he was not aware of prior recent weight loss for Resident #8. The DM said she was provided her favorite foods of French toast and sausage in the morning and would sometimes eat eggs. He said staff should be reviewing the menu with Resident #8, offering meal choices. The DM said if Resident #8 said no to a meal offer, staff should reapproach a few moments later. He said most of the time he has found the re-approach to be helpful/successful in her meal acceptance. The DM said the resident received strawberry or vanilla milkshakes and was encouraged to eat. The DM said Resident #8 was not provided meals or beverages that were deemed fortified, to the best of his knowledge. The DM said he would contact the resident's daughter to see if she could help in working out of a weight loss plan for Resident #8. The daughter of Resident #8 was interviewed on 4/7/22 at 9:26 a.m. The daughter was identified as the resident's responsible party. She said Resident #8 had a change in health in the past few months and was tired of the [CONDITION(S)] treatments so the daughter requested the most recent [CONDITION(S)] not to be treated. The daughter said Resident #8 has had weight loss for awhile but was not aware of recent weight loss. The medical director, the NHA, the DON and the MDSC was interviewed on 4/7/22 at 11:32 a.m. The DON said she was the member that collected resident weights. The DON said a 5% weight decline would trigger a weight concern. She said once the weight loss was determined to be accurate, she would inform the interdisciplinary team (IDT), talk with nurses, identify if [CONDITION(S)] was present, and determine if there has been a significant change in weight. The DON confirmed Resident #8 had a significant weight loss and the weights identified were accurate. The DON did not dispute a 9.66% weight loss in a month and a 11.24% loss in 60 days. The NHA confirmed the 4/3/22 weight of 137.4 was the most recent weight gathered. The DON said a reweight was not done after 4/3/22 as identified on the RD note because the weight was accurate and the request was based on potential inaccuracy. The medical director said if someone fell through the cracks, we (the facility) would need to address it. The RD joined the 4/7/22 interview at 12:34 p.m. The RD said once a month she ran a report on resident weights to determine significant weight loss if there has been a 5% weight loss in one month or a 10% weight loss in six months. She said she did not attend the NAR meeting but was aware of the IDT input and would come to the facility twice a month. The RD said when she saw the resident's weight on 4/3/22 at 137.4 lbs. She said her initial thought was it was inaccurate because as of the beginning of March 2022, her weight was fine. She said the facility would usually email her when there was a significant concern. The RD said Resident #8 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The RD said she was not aware of the weight loss concern on 3/15/22 because of the timing of her monthly evaluation forms. She said the weight loss on 3/15/22 was not triggered and prior to 3/15/22, the weight loss had not been significant. The RD said if she was aware of the 3/15/22 weight loss, she would have immediately jumped in, reviewed her meal intake and looked at the potential causations for the loss and implemented interventions. The DON said the facility would offer the resident the supplement and deemed it warranted, but would encourage to eat her food first. The NHA said the resident's family did not want aggressive treatment. The NHA said a supplement would not be considered aggressive treatment. The meal observation of Resident #8 on 4/4/22 (see above) was shared with the RD. The RD said meal assistance was outside of her scope of practice and would fall under occupational therapy. The NHA said the supplement was not yet implemented and they were still waiting on the physician's signature but speech therapy has been referred. The DON confirmed care plans were used as both a staff directive and staff communication on resident's needs. The MDSC said care plans were updated when there were new orders, a change of condition and during routine reviews. She said care plans were person-centered and were considered working care plans, indicating an ever changing based on resident's needs at the time. The NHA said direct care staff also help establish a resident's care plan based on what they observe as a focus or need. The resident's nutrition care plan was reviewed with the MSDC, the DON and the NHA. The NHA said the care plan would be immediately updated with the resident's current nutritional needs and interventions. The NHA said moving forward, the NHA and DON would make routine rounds during meals, identifying a potential need for additional assistance. The identified concerns will be reviewed with staff during the 4/7/22 staff meeting. The RD said she would start a mid month review for all residents instead of only a monthly review. She said the mid month review could identify weight loss concerns allowing for a quicker response to the concern. E. Facility follow-up The 4/7/22 (during the survey) staff meeting agenda was provided by the NHA on 4/11/22 via email. According to the agenda, administration directed staff to review the full meal menu options with residents, offer meal intake encouragement and hydration. The agenda indicated a staff discussion on food temperatures, weight loss and hand hygiene was included in the meeting. III. Resident #12 A. Resident status Resident #12, age 88, was admitted on [DATE]. According to the April 2022 computerized physician orders, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the 1/21/22 significant change minimum data set (MDS) assessment, Resident #12 had severe cognitive impairment, with a brief interview for mental status (BIMS) score of zero out of 15. She had no mood or behavioral symptoms, including care rejection. She needed extensive assistance for most activities of daily living, and was independent with set-up only for eating. She weighed 130 pounds, and her weight loss status was no or unknown. She had no end-of-life prognosis. According to Resident #12's prior MDS assessments: -On 12/20/21 she weighed 130 pounds and had weight loss of 5% or more in the last month, or 10% or more in the last six months; -On 10/6/21 she weighed 134 pounds and had experienced weight loss; -On 7/28/21 she weighed 146 pounds and had no weight loss or weight gain. B. Observations 1. Dinner on 4/4/22 On 4/4/22 at 5:01 p.m. Resident #12 was wheeled into the dining room by a staff person. She played with her napkins while she waited over a half hour, and was served at 5:36 p.m. She had finished her coffee, and continually tried to drink from the empty cup. No other beverages were served to her before she was served her meal of French fries, diced chicken and ice cream. After being served, she was distracted from her food, and took occasional bites. She had difficulty using her fork, and did better with her fingers. 2. Breakfast on 4/6/22 On 4/6/22 at 7:30 a.m. Resident #12 was at the dining room table. She had finished her breakfast, and was looking down at her cereal bowl, which was mostly milk with a few Cheerios floating in it. No staff approached her to see if she would like something else to eat or drink. -At 7:40 a.m. she began to nod off and fell asleep with her face in her cereal bowl, then quickly woke up, wiped her nose and began to eat from her cereal bowl again. -At 7:43 a.m. she fell asleep with her head in her cereal bowl again. At 7:44 a.m., her cereal bowl tipped forward towards her lap, and she woke up and raised her head. -At 7:45 a.m. her head was nodding into her cereal bowl again, her bowl tipped and she raised her head, then lowered her head into her bowl which tipped again, but she did not wake up. The one dietary aide who was serving residents in the dining room did not notice her. -At 7:46 a.m. the dietary staff approached Resident #12, said her name, rubbed her back, and asked her if she was finished. Resident #12 raised her face from her bowl, and staff asked her if she could sit up, and left the dining room as Resident #12's face leaned again toward her bowl. The dietary manager approached Resident #12, gently touched her shoulder, and spoke with her. -At 7:48 a.m. the dietary manager removed Resident #12's bowl and plate from the table. She did not respond, but was more alert and began looking around the dining room. -At 7:49 a.m. Resident #12's head leaned forward, and she rested her forehead on the table and slept. -At 7:50 a.m., she lifted her head, adjusted her glasses, and looked down at the table in front of her, where there was no food or drink. -At 7:51 a.m. her head was resting on the table again. -At 8:06 a.m., she was grimacing, and alternately opening and closing her eyes. No staff brought her more coffee or juice. At 8:11 a.m., she rested her head in her hand. -At 8:15 a.m. a certified nurse aide approached Resident #12, called her by name, put her mask on her face, and wheeled her out of the dining room, without asking her if she wanted anything else to eat or drink. No nursing staff were observed in the dining room during breakfast to encourage, cue or assist any residents to

Based on observation, interviews and record review, the facility failed to ensure safe Hoyer (mechanical) lift transfers for one (#3) of three residents reviewed out of 20 sample residents. Specifically, the facility failed to ensure certified nurse aide (CNA) #1 assisted Resident #3 with Hoyer lift transfers in a safe manner to prevent discomfort and injuries to Resident #3. The facility failed to ensure all nursing staff demonstrated the ability to safely transfer residents with Hoyer lifts to prevent injuries, until after an unsafe transfer was observed during the survey. Findings include: I. Facility policy The Mechanical Lift policy, revised on 11/15/21, documented in pertinent part: -A mechanical lift is used by all nursing personnel; -At least two people are present; -Explain the procedure to the resident; -Using the lever, gently raise and move the resident to the destination; and, -Lower the resident and position comfortably. II. Resident status Resident #3, age 95, was admitted on [DATE]. According to the April 2022 medical record, diagnoses included dementia with behavioral disturbance, chronic [CONDITION(S)] and [CONDITION(S)]. According to the 12/29/21 minimum data set (MDS) assessment, the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of six out of 15. She had hallucinations, but otherwise no mood or behavioral symptoms were documented. The resident did not reject care. She required extensive assistance from two or more persons for transfers and toilet use, and used a wheelchair for ambulation. III. Resident interview Resident #3 was interviewed on 4/4/22 at 2:30 p.m. with her son present in her room. Resident #3 said she had shoulder pain and that staff were safe and gentle with transfers most of the time, but that she had bruises all over from staff who were not as careful during Hoyer transfers. She pointed out some small bruises on her left hand and a larger bluish-colored bruise on her right wrist. The resident's son said she had very fragile skin, and did not like the Hoyer lift that staff had to use to transfer her. He said she needed to be transferred with the Hoyer lift for safety reasons, as she was no longer able to use the sit-to-stand lift because of her shoulder pain and lack of hand/arm strength. He said his sister had observed a Hoyer lift transfer the previous week and had no concerns. IV. Observations On 4/5/22 at 1:45 p.m., a Hoyer transfer was observed conducted by certified nurse aide (CNA) #1, who was training a new CNA, who said she had just started the day before. While CNA #1 was situating the sling under the resident and between her legs, the resident said ouch, and CNA #1 said, That's my watch, but did not apologize or remove her watch. When CNA #1 moved the lift toward the resident, and was not watching the lift bar, which would have hit Resident #3 in the forehead if she had not raised her hand to stop it. You almost hit me, she said. While she was lifting the resident in the sling, CNA #1 repeatedly told the resident to cross her hands over her chest and put your hands down so you don't get hurt, although the resident continued to reach out to hold the bar to steady herself. Once Resident #3 was in bed, CNA #1 moved her to the side, pushing her knees together with the metal sling holder between her knees. The resident said, Ouch, that's my sore knee. CNA #1 then rearranged the sling to a more comfortable position and removed it from under the resident's body. V. Staff interviews CNA #1 was interviewed on 4/5/22 at 2:00 p.m. She said she did her best to be gentle and safe with residents. She said Resident #3 was very fragile and had dementia and said a lot of things during transfers because she did not like the Hoyer lift. She acknowledged there were things that she could have done better during the transfer. She said typically she removed her watch before providing resident care, but she did not think about it until Resident #3 said something. She said she received transfer training and competency assessment when they first started using the Hoyer with Resident #3, but she was trained with a different sling for use with Resident #3 at the time. She acknowledged the metal piece on the sling needed to be more carefully placed, and the resident should be moved more carefully to protect the resident's knees and skin. She said she would welcome additional training regarding safe, careful, gentle Hoyer lift transfers. The nursing home administrator (NHA) and director of nursing (DON) were interviewed on 4/5/22 at 3:45 p.m. They said CNA #1 had reported the incident to them already. They said they would follow up with training for CNA #1 on safe Hoyer transfers and competency by therapy staff and the DON. The NHA provided a document regarding on-the-spot training for CNA #1 (see below). During a follow-up interview on 4/7/22 at 1:15 p.m., the NHA and DON provided the following information regarding their follow-up to ensure Resident #3's Hoyer transfers were safe. The DON started by educating CNA #1 on gentleness, communication and step-by-step technique with Hoyer lift use. Resident #3 was referred to therapy on 4/5/22. They initiated staff in-services on Hoyer lift transfers that evening. A formal training was planned for 3:30 p.m. on 4/7/22. The DON, registered nurses and therapy were in charge of the follow-up training and competency evaluations. VI. Record review and facility follow-up The resident's care plan, revised on 3/28/22, identified activities of daily living goals for optimal levels on a daily basis. Interventions included discontinue use of sit to stand lift, and use Hoyer with two persons for transfers. A Re-Education Hoyer Transfers document, dated 4/5/22, documented CNA #1 was educated in pertinent part as follows: Any time a resident says ouch, you need to stop and attempt to correct what is hurting the resident. If a resident's leg is hitting your watch, you need to remove the watch as this is a hard object that could cause pain or injury. Any object that could cause pain or injury during a transfer needs to be removed prior to transfer. -During the transfer, the Hoyer bar almost hit the resident's head. One employee should be holding the bar and the other employee should be hooking the sling to the bar to prevent this from happening. Please utilize job duties among both staff members to ensure a safe and gentle transfer. -Make sure you are clearing the sling from between their legs before removing the sling completely as it was observed that the piece of metal was between the resident's knees, crunching the knees. -Please always have a welcoming, kind, compassionate approach during transfers and all care. Explain the transfer, talk the resident through the transfer and use reassuring, kind language to the resident. The DON assessed Resident #3's skin on 4/5/22 and documented the following: -Right wrist = 4 cm (centimeter) by 1 cm dark purple bruise to wrist with a red spot in center 1 cm by 1 cm -Left top wrist = 0.5 cm circle dark blue -Abrasion to right knee - .5 cm by .5 cm, described as a chronic wound since admission -Skin tear to upper left shin, 2 cm by 1 cm, first discovered 9/10/21 The NHA documented a progress note on 4/6/22 at 8:34 a.m. which read in part as follows: Late entry for 4/5/22. NHA interviewed resident about transfers and skin issues. Resident stated that her complaints are regarding not being able to use the sit to stand and that she can do it. NHA and staff have previously educated resident on why she was moved to a hoyer lift but at this time due to cognitive status, NHA wanted to talk resident through her feelings about the hoyer vs education. She stated that she doesn't feel staff is doing a 'bad job' and 'No, I don't think anything is on purpose,' she just doesn't want to use the hoyer because she feels the sit to stand is safer. She stated, 'I bruise so easily and feel like I am dangling from a string.' NHA discussed options with her about skin protection barriers (resident initially did not want to try these) but now resident states 'I'll try them.' -Therapy was also notified on 4/5/22 for caregiver education to ensure transfers are safe and gentle, as well as to look at ways to prevent bruising during all activities. The all staff training agenda for 3:30 p.m. on 4/7/22, provided by the NHA, included Hoyer training, bruises, falls, transfers, skin assessments, interventions, resident centered care, and feedback from staff.

Based on record review and interviews the facility failed to ensure residents were as free from accident hazards as possible for one (#1) of three residents reviewed for falls out of four sample residents. Resident #1, a known fall risk, sustained five falls during the course of his stay in the facility (8/26/2020; twice, 10/23/2020, 10/26/2020 and 1/27/21). On 10/26/2020 he was found lying on the floor next to his bed. He was assessed prior to moving and upon getting him up he verbalized pain in his back. On 10/27/2020 he was sent out to an acute care facility to be evaluated as to the cause of continued verbalization of pain. The resident had a spinal X-ray and was found to have a compression fracture to his L2 (lumbar spine) and was sent back to the facility with a back brace. The facility failed to ensure all potential fall interventions were in place and followed, including frequent checks, ensuring his call light was in place at all times and, that he had non-slip socks on, to prevent further falls for Resident #1 who had [DIAGNOSES REDACTED] and was a known fall risk. Findings include: I. Facility policy and procedures The Accident/Incident report policy, with no date when initiated or last updated, was provided on 3/11/21 at 1:30 p.m. by the director of nursing (DON). The policy documented in pertinent part, The accident/incident report is completed for all accidents or incidents where there is injury or the potential to result injury; Class D: an event that has caused or resulted in a serious injury or a significant change in a resident's condition; All accidents/incidents are reported to the physician and family as soon as possible. An investigation will be initiated within 24 hours of the discovery of a resident with an injury. Investigation and findings must be documented and submitted to the long-term care facility's medical staff for review; All residents who fall or are found on the floor must have their vital signs taken as soon as possible. Following an accident that results in head injury, vital signs and neurological checks are monitored every 15 minutes x 4. If the resident is stable, time between may be increased to every 30 minutes for 2 hours, every 60 minutes for two hours, every 4 hours for 24 hours and then once a shift for a minimum of 72 hours; When witnessing resident fall or when a resident is found on the floor and presumed to have fallen, an initial assessment that includes the following will be done: range of motion (ROM), full body assessment, vital signs, the resident should not be moved until the initial assessment is completed, notify physician and family. Documentation in clinical notes should include an accurate description of the accident/incident, result of the ROM, body assessment and vital signs check; notification of physician and family; and remedial measures or treatments and observe resident closely for any change from normal habits that could be an indication that there is an injury not noticed or diagnosed during the initial assessment. II. Resident #1 status Resident #1, age 74, admitted on [DATE] and discharged [DATE]. According to the February 2021 CPO, [DIAGNOSES REDACTED]. According to the MDS dated [DATE], the resident was cognitively intact with a brief interview of mental status (BIMS) of 14 out of 15. He had moods to include trouble falling or staying asleep or sleeping too much and no behaviors during the review period. He required supervision and oversight of one staff person for most activities of daily living. His balance was not steady but he was able to stabilize without staff assistance during transitions and walking. He was mobile per walker and wheelchair. He was coded as having one fall since admission when in fact review of the clinical record revealed he had five falls since his admission documented in his clinical record. The last one occurring on 1/27/21. A. Record review An activity of daily living (ADL) care plan, initiated 8/24/2020 and ongoing, documented in part the resident's ADL status would be maintained at optimal level with all needs met on a daily basis. Interventions included in part to assist the resident with transfers/ambulation with wheelchair or walker, encourage him to use walker and ask for assistance as needed and continue frequent checks. A fall care plan, initiated 8/24/2020, and ongoing, documented the resident and staff would minimize the potential for significant injury from any falls during the quarter. Interventions included in part to encourage him to use the call light, ensure properly fitting non-skid footwear and maintain environment free of clutter. The care plan was revised 8/26/2020 and included to rearrange his room and to have the bed in a low position. The care plan was revised again on 10/27/2020 following his fall with injury to include frequent checks, continue current interventions and encourage back brace. The care plan failed to demonstrate that it was person centered to meet his individual needs and to clearly specify what was meant by frequent checks. An initial fall risk assessment dated [DATE] identified the resident as low risk for falls and standard fall prevention interventions were implemented. A cognition care plan, initiated 8/25/2020, and ongoing, identified the resident with impaired thought process related to metabolic [MEDICAL CONDITION]. Interventions included in part keep call light and frequently used items within an easy reach, encourage/remind him to use call light. On 8/26/2020 the resident had two unwitnessed falls. One occurred at 7:30 a.m. and the second one at 1:00 p.m. He had no injuries with either fall. The follow up investigation revealed the first fall was due to self-transferring to his wheelchair and the second fall he stated he rolled out of bed. A monthly fall risk assessment dated [DATE] documented the resident was not a risk for falls although he had experienced two falls in one day on 8/26/2020. Nurse notes were reviewed from 10/23/2020 through 10/26/2020. The resident had an unwitnessed fall in his room on 10/23/2020 at 5:00 a.m. He was assessed to have no injuries. He stated he had hit his head and neurological checks were started. He continued to work with therapy throughout the day with normal range of motion (ROM) and reported mild low back pain when leaning forward. The entries from 10/23/2020 to 10/26/2020 revealed inconsistent documentation that the resident was educated on call light use and that his call light was checked for proper placement. In addition, documentation from the 10/23/2020 fall until 10/26/2020 when he sustained another unwitnessed fall, revealed he complained of mild low back pain daily. He was given as needed Tylenol and reported it was effective. He was also receiving regular therapy daily up until and after his 10/23/2020 fall and observed walking in his room. The documentation failed to clearly demonstrate if he was using his assistive devices properly when walking and whether or not he had proper foot wear and that his call light was placed within his reach A nurse progress note dated 10/26/2020, time stamped at 10:29 p.m., documented in part the resident was heard calling out and upon entering his room he was found lying on the floor next to his bed. He said he was sitting on the side of the bed and slipped off. The note further revealed the nurse had last been in the resident's room an hour and a half prior and he was sitting in his wheelchair with the brakes locked.The note further documented the nurse had turned down his bed sheets and that his remote and cell phone were placed in the middle of the bed. The CNA had been in his room forty-five minutes before he was found on the floor and he was in his wheelchair on the phone. He was assessed by the RN and then assisted up from the floor and began to verbalize pain by stating my back, my back. He was able to ambulate to the bed without difficulty. The note failed to demonstrate evidence the nurse had ensured the resident's call light was available to him and within his reach per his care plan. An incident report dated 10/26/2020 documented in part the resident was found on the floor in his room at 8:45 p.m. after he was heard yelling out. He was assessed by an RN and then assisted off the floor. While being assisted off the floor he verbalized pain by stating, My back, my back. He was assessed again the following morning and sent to the emergency room to be evaluated and was found to have an L2 (lumbar) compression fracture. He was returned back to the facility with a back brace. The follow up investigation for the 10/26/2020 fall documented he was often noncompliant with asking for assistance and did things independently. He was placed on frequent checks, bed in low position and was reminded to use the call light. No new interventions were implemented after the facility identified in their follow up that he was often noncompliant. The facility conducted a root-cause analysis for the 10/26/2020 fall. They concluded in part the resident was non-compliant with receiving assistance and non-compliant with using his back brace. The root-cause analysis documented the interdisciplinary team (IDT) conducted a huddle and that non-skid socks should be in place, his bed in a low position and his call light and cell phone should be within reach. An X-ray report dated 10/27/2020 conducted at the hospital revealed the resident had an acute or subacute compression fracture of L2. A physician visit note dated 10/28/2020 documented in part the resident reported to him that he lost his balance getting out of bed to go to the bathroom and fell backward. He was sent to the emergency department and found to have an L2 (lumbar) compression fracture. The Plan section of the physician's note did not contain any additional fall prevention interventions except to continue with physical and occupational therapy and nursing to improve strength and balance and to keep pain under control. A monthly fall risk assessment dated [DATE] documented the resident as high risk for falls. B. Neurological assessments The neurological observation record form revealed the following directions: -Fall with head bumping, assess every fifteen minutes times four, every 30 minutes times two, every hour times six, then every 4 hours and then every shift; -Unwitnessed fall, assess every fifteen minutes times two, every 30 minutes times one and then every four hours times two. Neurological assessments revealed that neither the policy nor the neurological record form were accurately followed, to ensure Resident #1 did not have any adverse effects from his unwitnessed falls. The neurological sheet dated 8/26/2020 began with the first fall at 7:30 a.m. and then restarted at 1:00 p.m. after the second fall. There were numerous incomplete entries and the checks were not completed accurately. The neurological sheet dated 10/26/21 had full neuro checks every fifteen minutes times four only. The neurological sheet dated 10/23/2020 were completed per the directions for fall with head bumping, however; there were three missing entries for ability to move and pupil size within the first 30 minutes of the fall. The neurological sheet dated 1/27/21 revealed vital signs were taken eleven times but the resident's sensorium (orientation), speech, tactile stimuli, non-verbal reaction to pain, ability to move and pupil size section were all blank. His vitals were then done every four hours times two with one of the four entries that demonstrated the full neurological assessment was completed. C. Staff interview RN #1 was interviewed on 3/10/21 at 9:10 a.m. she said that Resident #1 was a high fall risk because of his dementia and that he was non-compliant and because of his dementia he had to be reminded to call for assistance. She said because he was a high fall risk they did fifteen minute checks with him. She said he did not like wearing socks and preferred to be barefoot and that he did not like to use his walker. She said he complained of back pain after the 10/26/2020 fall and was sent to the hospital to be evaluated and she remembered he came back with a back brace. She said he did not like to wear his back brace and would take it off. Certified nurse aide (CNA #1) was interviewed on 3/11/21 at 12:12 p.m. He said he remembered taking care of Resident #1 and that he was confused and very independent with his mobilization with a walker. CNA #1 said the resident was also incontinent of his bowels and bladder and would not call for help with the call light. He said he had to check on him frequently, every forty minutes to an hour because he was a high fall risk and did not always use his walker or call on his call light. III. Additional interviews Registered nurse (RN #2) was interviewed on 3/10/21 at 8:37 a.m. She said that every resident that admits to the facility was considered a fall risk and that they were assessed for the level of risk. She said residents were educated on using the call light for assistance and that some residents have memory problems. She said interventions are in place to prevent falls such as non-slip socks and gait belts inside each room. She said they do visual checks on residents every fifteen minutes for those residents that are impulsive. The therapy director (TD) was interviewed on 3/10/21 at 9:41 a.m. she said she remembered resident #1 and that he was on therapy most of the time he was a resident. She said he was a high fall risk and had falls in the facility with associated pain. She said they were working with him for balance and strength and that he participated. She said he was progressing well and then had a set-back due to a fall where he was found to have a fracture. She said he returned from the hospital after the fall with fracture and was prescribed a back brace. She said he was non-compliant with wearing the brace. The DON was interviewed on 3/11/21 at 9:13 a.m. She said that fall risk assessments are done monthly. She said that Resident #1, she thought, had a total of three falls while in the facility. She said he had two falls on one of the days. She said the resident was non-compliant and wanted to be independent. She said the resident was diagnosed with [REDACTED]. She said the resident was considered a fall risk when he was first admitted and a care plan for falls was put into place. She said he fell because he was non-compliant and would get up on his own without using the call light. She said he was educated but his cognition was compromised and he was impulsive. She said that prior to moving any resident an RN had to do a full assessment and then document it. She said the physician and the family are always notified. She said the nurses should fill out an incident report with each fall and then she would document a follow up investigation. She said that neurological assessments are done with each fall and must be complete and that the nurses have been trained. She said it was her expectation neurological assessments are completed to ensure the resident was stable and to catch any abnormal values. She said upon admission residents are educated about using the call light for assistance and to not get up on their own. The nursing home administrator (NHA) was interviewed on 3/17/21 at 9:47 a.m. She said that fall risk assessments are done monthly with the monthly nursing assessment. She said that as a team they discuss any falls the following day in the morning meeting and that they have mini QA (quality assurance) meetings weekly. She said that therapy and housekeeping are involved in the meetings if they identify any fall risks with residents. She said she thought they were doing well with their falls but since the survey they would have to re-think their process and will be implementing a QAPI project going forward.

Based on observation, record review and interviews, the facility failed to maintain acceptable parameters of nutritional status for two (#139 and #6) of five residents reviewed for nutrition out of 22 sample residents. Resident #139 did not receive timely nutiritional assessments, planned weight loss interventions and documentation of weight loss which resulted in the resident experiencing weight loss of 5.66% in less than one month which is a severe weight loss over 21 days, with a total weight loss since admission off 11.32%. (admission date of [DATE]). Specifically, the facility failed to: -Accurately document meal intake and consistently implement interventions to prevent further weight loss for Residents #139 and #6; -Follow physician's orders [REDACTED].#139 and #6; and -Ensure all possible interventions were implemented to prevent weight loss for Resident #139, as she experienced a severe weight loss. Findings include: I. Facility policy and procedure The Nutrition at Risk (NAR) policy and procedure, undated, was provided by the director of nurses (DON) on 1/9/2020 at 11:27 a.m. The policy identified residents with nutritional risk factors and included those who had an unplanned weight loss or gain in the following suggested parameters: In one month, a loss of 5% was significant and greater than five % was severe; over three months, a loss of 7.5% was significant and greater than 7.5% was severe; and over a six month period, a loss of 10% was significant and greater than 10% was a severe loss. Additional residents at nutritional risk included those who were 10% below their ideal body weight, unless determined this was the usual body weight for the resident, those admitted with an admitting [DIAGNOSES REDACTED]. If the resident's normal intake was only 50% of meals, this should be documented on the plan of care or progress notes. This situation would not indicate nutrition at risk, unless the resident was losing weight. This resident could also be considered a candidate for small portions, which should be noted on the care plan or progress notes. All weights would be reviewed by the DON and dietary manager (DM) weekly to determine weight variances. If a significant weight loss was determined, the DM would initiate a weight change investigation report and it would be reviewed by the NAR committee, which included food services staff, nursing, rehabilitation services, social services, activities staff and the administrator. The committee would discuss the resident assessment findings, develop a new minimum data set (MDS) if indicated and plan of care to correct the undesirable weight change. The Administration of Medication policy, undated, provided by the DON on 1/9/2020 at 11:27 a.m., documented the physician orders [REDACTED]. The nurses should check the medication administration record (MAR) and read each order entirely, check the physician orders [REDACTED]. If a scheduled item was not administered as ordered, the nurse should click, Not Administered in the electronic MAR and record the reason in the documentation. II. Resident #139 [NAME] Resident status Resident #139, age 98, was admitted on [DATE]. According to the (MONTH) 2020 computerized physician orders [REDACTED]. The 12/4/19 minimum data set (MDS) assessment revealed the resident required extensive assistance with eating, bathing and dressing, and required total assistance with toileting. She received 13 days of speech-language pathology services. A brief interview for mental status (BIMS) score was not documented and the assessment did not address her cognitive status. No weight changes were documented. B. Initial record review The care plan, initiated 11/22/19, identified inadequate nutritional intake and percutaneous endoscopic gastrostomy (PEG) tube use. The goal was the resident would consistently eat 50% of her meals. The approaches included to weigh weekly, refer to speech therapy as indicated, monitor for signs and symptoms of her condition worsening and notify the provider of changes, check placement of the tube before meals and feedings, check for residual as ordered, and administer tube feedings and flushes as ordered. Mighty Shakes supplements were to be encouraged three times daily. The (MONTH) 2020 CPO included the following orders: -Regular diet with mechanical soft/minced and moist texture, started 12/15/19. -Give Mighty Shakes (nutritional supplement) three times a day between meals, started 12/16/19. -If resident eats less than 50% of meals, give one can bolus of [MEDICATION NAME] tube feeding. Flush with 25 ML free water prior to and after bolus, started 11/15/19. The weights were reviewed since Resident #139's admission and included in total: 11/15/19 = 106 pounds (#) 11/18/19 = 105# 11/22/19 = 105# 11/29/19 = 103# 12/6/19 = 100# (-5.66% in less than one month, which is a severe weight loss over 21 days) 12/12/19 = 97# 12/20/19 = 96# 12/30/19 = 95# 1/3/2020 = 94# 15/19-1/3/2020 C. Observations On 1/7/2020 at 9:29 a.m., Resident #139 was observed quietly lying in bed in her room. Her dentures had white food debris stuck between her teeth, and there was a hand-written note on the white board in the room that read, Reminder: Soak (Resident #139's) dentures one time a day. She was very thin and there was no IV pole or tube-feeding bag observed in the room. On 1/7/2020 at 1:22 p.m., Resident #139 was sitting upright in her bed with a bedside table across her lap. Her lunch of tomato soup, chocolate milk, and mechanical soft grilled cheese sandwich were in front of her and she had eaten approximately 30 percent of the meal. She spilled some of the chocolate milk into the soup bowl and was wiping the tray off with her napkin. She did not receive assistance with the meal. On 1/7/2020 at 2:41 p.m., Resident #139 was walking around in her room, piling up a stack of clothing on top of her walker. She was confused and anxious and walked out of her room with an armload full of personal belongings. A CNA entered her room at that time and began to talk to her in a soothing manner. On 1/8/2020 at 8:35 a.m., Resident #139 was lying in bed asleep, and had not eaten breakfast or gotten up for the day. D. Additional record review The MAR for 12/1/19 through 1/7/2020 was reviewed and compared to the corresponding Meal and Snack (M/S) intake records. If Resident #139 ate less than 50% of meals, she was to receive one can bolus of [MEDICATION NAME] tube feeding, scheduled at 9:00 a.m., 1:00 p.m., and 6:00 p.m. The following discrepancies were identified: On 12/11/19 at breakfast, the M/S documented 0% of the meal was eaten. However, the MAR documented 100% was consumed. On 12/16/19 at breakfast, the M/S documented 0% of the meal was eaten. However, the MAR documented 25% was consumed. There was no documentation that [MEDICATION NAME] had been administered per the order. On 12/19/19 at breakfast, the M/S and MAR documented 0% of the meal was eaten. However, there was no documentation that [MEDICATION NAME] had been administered. On 12/20/19 at lunch, the M/S documented 0% of the meal was eaten. However, the MAR documented 100% was consumed. On 12/21/19 at dinner, the M/S and MAR were void of documentation to indicate how much of the meal was eaten. There was no documentation that [MEDICATION NAME] had been administered. On 12/24/19 at breakfast, the M/S documented 0% of the meal was eaten. However, the MAR documented 25% was consumed. There was no documentation that [MEDICATION NAME] had been administered. On 12/29/19 at lunch, the M/S and MAR were void of documentation to indicate how much of the meal was eaten. There was no documentation that [MEDICATION NAME] had been administered. On 12/31/19 at dinner, the M/S documented 1-25% of the meal was eaten. However, the MAR was void of documentation to indicate how much of the meal was eaten. There was no documentation that [MEDICATION NAME] had been administered. The MAR for 12/12/19 through 1/7/2020 was reviewed and compared to the corresponding Meal and Snack (M/S) intake records. Resident #139 was to receive Mighty Shakes three times a day between meals. The following discrepancies were identified: On 12/21/19 at 7:00 p.m., the Mighty Shake was not administered and no documentation was provided to indicate the reason. On 12/29/19 at 2:00 p.m., the Mighty Shake was not administered and no documentation was provided to indicate the reason. On 12/31/19 at 7:00 p.m., the Mighty Shake was not administered and no documentation was provided to indicate the reason. On 1/6/2020 at 10:00 a.m. and 2:00 p.m., the Mighty Shakes were not administered and no documentation was provided to indicate the reason. No refusals were documented during the 38 day period reviewed. The dietary Initial Assessment, dated 11/18/19, was completed by the dietary assistant (DA). The following was documented: Resident #139 had no weight gain or loss, tube feeding was to be administered if she ate 25% or less and tolerated well. She liked sweets, small portions and disliked spicy foods. She ate in her room or at the nurses' station, and was on a pureed texture diet. Conditions that affected her nutrition included cognition loss, swallowing issues, health conditions that included [MEDICAL CONDITION], and attention deficit. She was unable to make herself understood or make her needs known and was at risk for an unplanned weight loss. RD notified, will monitor intakes and weights, offer supplements. The document was signed off by the RD on 12/4/19. A nutrition note, dated 12/5/19, was written by the RD and included the following: New resident. Diet: mechanical soft and moist, consuming 50%. Resident received [MEDICATION NAME] tube feeding via PEG when oral intakes were less than 50%. Weights: 105.6# (11/22/19) and 103# (11/29/19). BMI 20.6 normal. Monitor oral intakes, tolerance, labs as available, skin, weights and care plan. Will follow. There was a discrepancy between the nutrition note written by the RD and the nutrition note written by the DA as it related to when the tube feeding was to be administered and the type of diet texture the resident received. A second nutrition note, dated 1/8/2020 (during survey), was written by the RD and included the following: Consuming 25-50% on average. One can [MEDICATION NAME] when oral intake was less than 50% but mostly receives TID (three times daily). Noted some refusal. Mighty Shakes TID, consuming 25-50%. Weights: 99.8# (12/6/19) and 94.1# (1/3/20). BMI 18.3 underweight. Plan was to monitor oral intakes and her tolerance to them, labs as available, skin, weights, and care plan. Continue tube feeding and supplements. Encourage good meal intakes as she will accept. Will follow. E. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 1/7/2020 at 9:29 a.m., and she said she routinely cared for Resident #139. She confirmed the resident was supposed to receive tube-feeding boluses if she did not eat very much at her meals and stated, But she eats pretty well at breakfast. The DON was interviewed briefly on 1/8/2020 to clarify the documentation that was hand-written on the (MONTH) 2019 MAR, and difficult to read. She acknowledged there was missing documentation on multiple dates on the MAR and said each nurse was responsible for completing all of their documentation every shift. She stated, The nurses are obviously not filling in the boxes. Certified nurse aide (CNA) #4 was interviewed on 1/8/2020 at 3:58 p.m., and he confirmed he routinely worked with Resident #139. He said she ate most of her meals in her room, but would independently start walking to the dining room at times if she was hungry. He said the CNAs who worked on each hall were responsible for documenting the amount of food the residents ate who received room trays, and that was recorded in a log book located in the dining room. He said the dietary aides were responsible for documenting the meal intakes for residents who ate in the dining room. He said if a resident refused to eat or did not consume very much food at a meal, he would enter zero in the logbook, or RF, which indicated refused. He said he did not routinely inform the resident's nurse. CNA #4 said Resident #139 was not picky at all and would eat all kinds of food. He explained she had dementia so she would forget things easily and was confused. He said the resident was able to feed herself with set up assistance and he would check on her throughout the meals to make sure she was eating. He said she would choose not to eat meals at times, because she just didn't want it. He said it was really hard for Resident #139 to express her needs and he had to kind of guess and work with her to determine what she needed. The DA was interviewed on 1/8/2020 at 10:30 a.m., and she explained she used to be the dietary manager but stepped down and was now responsible for dietary documentation and paperwork. She said a meal intake record was kept in the dining room, and it included the resident's meal intakes by percentages. She said if a resident was just sitting and not eating for a while, they would offer them something different. She said Resident #139 usually ate in her room, but would occasionally wander down to the dining room and they would try to take her order. She explained the resident's speech was garbled and it was hard for them to understand her, so they would ask her yes/no questions a lot. She stated, A lot of times she gets overwhelmed or feels interrogated, but we kind of need to know, 'yes or no.' She explained if a staff member did not enter a meal intake amount, she would have to go find out from the CNAs what the amount consumed was. She said the M/S intake record was completed by both CNAs and dietary staff, which was entered from the hand-written logbook in the dining room. She said if an entry was missed over a weekend, she would go back in and enter it on Monday, but it would not reflect which date was accurate. The DA said she had concerns about Resident #139's nutritional status because she would have moods where she would isolate and not want to eat or drink anything. She stated, I don't think she is dropping a whole lot (of weight) lately, and explained the M/S intake record was not what the facility looked at to identify weight loss, but more the actual weights themselves. She said a resident's weight loss was communicated to the RD by entering the weights into the electronic medical record (EMR) where she could access them. The facility pulled a Weight Change Alert report every Wednesday from the EMR, which would show a list of residents who had lost 5% or more and the details of pounds and percentages lost or gained. Registered nurse (RN) #2 was interviewed on 1/9/2020 at 10:01 a.m., and she confirmed she routinely worked with Resident #139. She said she would ask either the CNAs or dietary staff about the amount of a resident's meal intake, and it depended on if they received a room tray or ate in the dining room. She said the resident refused her Mighty Shakes a lot, and that refusal should be documented on the MAR. She stated, She drinks maybe less than half, which is the norm for me. She doesn't like them. The RN said the PEG tube was present when she was admitted and had been placed because she was not eating. She clarified the [MEDICATION NAME] tube feeding boluses would be administered if Resident #139 ate less than 75% of meals, and needed it every once in a while. She said the resident had lost weight since she was admitted to the facility, but thought her weight was stable now. The DON was interviewed on 1/9/2020 at 10:17 a.m., and she said the nurses in the facility were to follow the physician's orders [REDACTED]. reviewed and discussed, and recommendations were made. She said the residents' preferences should be met, and nutritional supplements, like Mighty Shakes and Med Pass, could be utilized. The DON said she was made aware of residents' weight losses in multiple ways, including verbally from the restorative aide who was responsible for obtaining weights, from the charge nurses, or during the weekly QAPI meetings. She said if a resident continued to lose weight, they could speak to their physician and see if they had any recommendations as well. The DON said she was not aware of the multiple documentations of meal intakes or that there were discrepancies among them. The DON said Resident #139 had the PEG tube and would often refuse to allow nursing staff access to it. However, she said this was not documented. She confirmed that refusals should be documented, and stated, We are trying to find out what she likes more and trying different flavors. She said she was aware of the resident's weight loss and did not know if they had found a flavor she preferred yet. The DON was not aware the physician's orders [REDACTED]. She said the facility had not discussed providing Resident #139 with fortified foods or other methods to prevent her weight loss. III. Resident #6 [NAME] Resident status Resident #6, age 87, was admitted on [DATE]. According to the (MONTH) 2020 CPO, [DIAGNOSES REDACTED]. The 12/16/19 MDS assessment revealed the resident had short and long-term memory problems with severely impaired cognitive skills for daily decision-making. She had [MEDICAL CONDITION] that included inattention and disorganized thinking, and had no rejection of care. She required supervision with eating and had no swallowing difficulties. No weight changes were documented. B. Record review The care plan, initiated 7/23/19 and revised 12/17/19, identified the resident had experienced a weight loss and was taking [MEDICATION NAME] (appetite stimulant). The approaches included monitoring assistance she needed with nutritional intake and notify the physician of changes, weight monthly, provide verbal encouragement and cueing with meals, provide a quiet dining environment, provide between meal snacks, offer food alternatives when appropriate for any meal, maintain a food list of likes and dislikes, assess for serving smaller portions more frequently, and allow her sufficient time to eat. The (MONTH) 2020 CPO included the following orders: -Regular diet, mechanical soft texture, started 12/27/18. -[MEDICATION NAME] 15 mg tablet by mouth every evening with supper, started 5/11/19. -Give one can of health shake three times per day in between meals, started 1/22/19. -Offer nutritional supplement by mouth every six hours as needed for meal intake less than 50% Document amount consumed, started 12/27/18. The weights were reviewed from 9/16/19 through 1/6/2020 and included the following: -9/16/19 = 119# -9/30/19 = 114# -10/28/19 = 115# -11/18/19 = 114# -12/23/19 = 113# -1/6/2020 = 113# Total weight loss was -5.04% over a three-month period. The MAR for 12/1/19 through 1/7/2020 was reviewed and compared to the corresponding M/S intake records. If Resident #6 ate less than 50% of meals, she was to receive a nutritional supplement orally every six hours and staff were to document the amount consumed. In addition, she was to receive one can of health shake three times per day in between meals, scheduled at 10:00 a.m., 2:00 p.m., and 7:00 p.m. The following dates documented less than 50% of a meal was consumed, but the nutritional supplement was not administered: -12/4/19 (breakfast, lunch and dinner) -12/5/19 (dinner) -12/6/19 (lunch and dinner) -12/8/19 (lunch) -12/9/19 (lunch) -12/11/19 (breakfast and lunch) -12/12/19 (breakfast) -12/14/19 (lunch) -12/15/19 (breakfast and lunch) -12/1619 (breakfast and lunch) -12/17/19 (dinner) -12/18/19 (breakfast and dinner) -12/19/19 (lunch) -12/20/19 (breakfast and dinner) -12/21/19 (breakfast, lunch and dinner) -12/22/19 (breakfast and dinner) -12/23/19 (lunch and dinner) -12/25/19 (lunch) -12/26/19 (breakfast, lunch and dinner) -12/27/19 (lunch) -12/30/19 (lunch and dinner) -1/2/2020 (breakfast and lunch) -1/3/2020 (lunch) -1/5/2020 (lunch) -1/6/2020 (breakfast and lunch) A progress note by the RD, dated 1/20/19, documented to consider health shakes three times daily secondary to weight loss. Subsequent RD notes on 2/6/19, 4/4/19, 6/9/19 and 8/8/19, included the recommendation to continue supplements. C. Observations On 1/7/2020 at 12:10 p.m., Resident #6 was lying in bed in the fetal position, under covers. Lunch was being served in the dining room. Her room was dark and there was no food in her room. She remained in bed until 4:29 p.m. On 1/8/2020 at 8:40 a.m., Resident #6 was seated at an assist table in the dining room, waiting for her breakfast to be served. She was awake and alert, and there was juice in a cup on the table in front of her. Her breakfast was served at 8:46 a.m., and the plate had a plate guard around the perimeter. She began to push her food around on her plate and then took bites of food independently. At 9:05 a.m., the resident told a volunteer she was finished eating and pushed her plate to the side. She stood up from the table independently and the nurse assisted her back towards her room. The resident ate approximately 25% of her meal and the volunteer scraped the remainder of the food into the garbage. D. Staff interviews CNA #4 was interviewed on 1/8/2020 at 3:58 p.m., and he confirmed he routinely cared for Resident #6. He said she needed a lot of encouragement to eat her meals and was easily distracted. He explained as soon as the daily newsletter was given to her, it was an immediate distraction and she would start scooping her pancakes into a bowl and take it down the hallway. He said she was highly confused and stated, It is hit or miss with her appetite. He said she liked to eat peanut butter and jelly sandwiches, and cranberry mixed with orange juice. He explained she would eat her meals and stated, You just have to really encourage and cue her. It is a process. You have to work with her. LPN #2 was interviewed on 1/9/2020 at 8:55 a.m., and she confirmed she routinely worked with Resident #6. She said the restorative aide would let her know if a resident's weight was trending downward, and it would pop up on her dashboard in the electronic medical record. She said Resident #6's weight was trending down lately and getting her to eat had been challenging. She explained Resident #6 would get anxious at times, and when that happened, she would not eat. The LPN said Resident #6 received health shakes three times a day that they charted on, but if she had not eaten a meal, she said she would encourage her to eat applesauce or drink another shake. She said the resident did not always consume the whole health shake, but did better if we make it a social thing. The LPN explained if they left her to it and expected her to eat or drink on her own, she was not going to do it, and she required a lot of cueing. LPN #2 explained the nutritional supplement given for meal intakes less than 50% were different from the health shakes three times per day in between meals. She said the nutritional supplement was usually Boost, and the health shake was a Mighty Shake. She said both supplements were documented on the MAR when they were given and they included the percentage consumed. The DON was interviewed on 1/9/2020 at 10:17 p.m., and she confirmed she was aware of Resident #6's weight loss. She said the staff were trying to get her to eat with fewer distractions, but she would still, at times, become agitated, get up, and not want to continue eating. The DON said she was not aware that the nutritional supplement was not being given and confirmed it should have been given when the resident ate less than 50% of each meal.

Based on observations, record review and staff interviews, the facility failed to provide respiratory care consistent with professional standards for one (#18) of one resident reviewed for respiratory care out of 22 sample residents, plus an additional three residents. Specifically, the facility failed to ensure that nasal cannulas and oxygen therapy masks were stored in an appropriate manner when not in use. Findings include: I. Facility policy and procedure The Oxygen Therapy-Mask and Nasal Cannula policy, which was undated, was provided by the director of nursing (DON) on 1/9/2020 at 10:00 a.m. It documented when the masks and cannulas were not in use, they should be stored in a special plastic bag. II. Resident #18 [NAME] Resident status Resident #18, age 88, was admitted on [DATE]. According to the (MONTH) 2020 computerized physician orders [REDACTED]. According to the 10/30/19 minimum data set (MDS) assessment, the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of nine out of 15. She required supervision of one for bed mobility, transfers, ambulating with her rolling walker, toileting and personal hygiene. She received oxygen therapy. B. Physician orders The (MONTH) 2020 CPO documented the resident was ordered oxygen via nasal cannula at two to three liters per minute during the night, ordered 9/6/19. C. Care plan The care plan initially dated 9/6/19 documented the resident had potential for decreased oxygen saturation levels. The goal was for the resident to be comfortable when breathing and her oxygen saturations would remain in acceptable limits. Approaches included administering oxygen as ordered. The care plan did not include how the resident's respiratory equipment should be stored when not in use. D. Observations of Resident #18's respiratory equipment On 1/6/2020 at 2:52 p.m., Resident #18 was observed to be out of her room. In the resident's room, the nasal cannula (NC), which was not in use at the time, was observed hanging off the left side of the oxygen concentrator with the prongs touching the side of the concentrator. The cannula and oxygen tubing were not stored in the clear plastic bag attached to the concentrator. On 1/8/2020 at 8:40 a.m., while the resident was out of the room and her oxygen was not in use, the NC was observed draped over a rabbit decoration sitting on top of the dresser near the resident's bed. It was not properly stored in the plastic storage bag. -At 11:30 a.m., the respiratory equipment was observed in the same position as at 8:40 a.m. -At 11:48 a.m., after an unidentified certified nurse aide (CNA) was in the room making up the resident's bed, the NC remained in the same place, out of the storage bag attached to the concentrator. The resident was in the room at this time. -At 12:15 p.m., Resident #18 was observed out of her room, eating her lunch. The NC was observed to remain in the same position as 8:40 a.m. -At 4:35 p.m., the respiratory equipment remained in the same position. -At 5:10 p.m., the respiratory equipment remained in the same position. III. Additional observations in other resident rooms The respiratory equipment in the facility was observed on 1/8/2020 from 12:05 p.m. through 12:20 p.m. The following was observed: -Room A9: The resident was not in the room, but the continuous positive airway pressure ([MEDICAL CONDITION]) mask was uncovered and lying on top of the bedside dresser. -At 5:00 p.m., the [MEDICAL CONDITION] mask remained uncovered on the resident's dresser. -Room A18: The resident was not in the room, but the NC was lying on top of the bed, uncovered. It was not stored in the plastic bag attached to the concentrator. -At 4:37 p.m., the resident was observed being assisted to the dining room in his wheelchair by CNA #4. The resident's NC was observed touching the beige blanket on the bed. It was not stored in the plastic bag attached to the concentrator. -Room B11: The resident was not in the room, but the NC tubing was lying across a crumpled blanket on the foot of the bed. The prongs were directed touching the blanket. It was not stored in the plastic bag attached to the concentrator. IV. Staff interviews The minimum data set (MDS) coordinator was interviewed on 1/8/2020 at 2:05 p.m. She said she thought Resident #18's oxygen had been discontinued. She said she would research this issue. She returned at 2:30 p.m. and said Resident #18 still had oxygen ordered. CNA #4 was interviewed on 1/8/2020 at 4:50 p.m. He said when the resident's oxygen was not in use, the oxygen should be turned off and the tubing and NC should be placed in the plastic storage bag attached to the concentrator with the resident's name and date. CNA #2 was interviewed on 1/8/2020 at 4:55 p.m. She said when not in use, the oxygen tubing should be coiled up and stored in the plastic bag attached to the concentrator or the wheelchair. Licensed practical nurse (LPN) #2 was interviewed on 1/8/2020 at 5:05 p.m. She said the oxygen tubing and NC should be rolled up and placed in the plastic storage bag. She said the reason for this was to protect the respiratory equipment and keep it clean. CNA #1 was interviewed on 1/8/2020 at 5:30 p.m. She said when the oxygen was not in use, the oxygen should be turned off and the portable concentrators were removed from the rooms at night and taken to the nurse's station for refilling. She did not mention anything about storing the NC or tubing when not in use. The DON was interviewed on 1/9/2020 at 8:30 a.m. She said when the resident's oxygen was not in use, the NC and oxygen tubing should be stored in the plastic bags attached to either the resident's concentrator in their rooms or attached to their wheelchairs. She said leaving the tubing draped over items in the room or just leaving the uncovered NC on the bed or dresser was not an appropriate storage of the respiratory equipment.

Based on observations, record review, and interviews, the facility failed to ensure proper medication storage for one of one medication refrigerators. Specifically, the facility failed to store medications and vaccines at appropriate temperatures per the manufacturer's instructions. Findings include: I. Facility policy and procedure The facility's policy on medication storage, no date of inception or revision noted, provided by the minimum data set (MDS) nurse on 1/7/2020 at 1:11 p.m. stated it was the responsibility of the staff nurse to maintain control and accountability of all medications, their utilization, and administration during the shift for which he/she was responsible according to the policies and procedures approved by the pharmacy and therapeutics committee, pharmacy laws and regulations of the State of and Federal Regulations. Individual medications ordered for the patient by the physician shall be dispensed by the pharmacy, identified with the patient's name, dosage, frequency, and date on these containers. Medication storage shall be properly and safely maintained in accordance with the security of federal, state, and local laws. Drugs and biologicals used in the facility must have been labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. II. Observations The A resident hallway medication storage room was inspected with licensed practical nurse (LPN) #1 on 1/7/2020 at 12:00 p.m. The medication storage refrigerator temperature was observed to be 32 degrees fahrenheit and confirmed with the LPN. Inside the medication storage refrigerator the following unopened medications were observed: -[MEDICATION NAME] high dose influenza vaccine, -[MEDICATION NAME] 23, -[MEDICATION NAME] solution, -Humalog insulin, -[MEDICATION NAME], and -Liquid [MEDICATION NAME]. LPN #1 said 32 degrees was a safe temperature to store the medications inside the refrigerator. Registered nurse (RN) #1 was also in the vicinity and said the medication storage refrigerator should be kept above freezing. The temperature logs were requested and neither staff member knew where the logs were located. III. Record review The A resident hallway medication refrigerator temperature log was provided by the facility. The bottom of the log read, refrigerator temperature safety zone was 34-39 degrees and to call the maintenance department when temperatures were below 33 degrees or higher than 40 degrees. The following temperatures were recorded out of range: -On 1/5/2020 it was documented to be 30 degrees, and -On 1/6/2020, it was documented to be 28 degrees. The manufacturer's instructions for [MEDICATION NAME], provided by the facility, read to store at 35-46 degrees and do not freeze. Discard the vaccine if it had been frozen. The manufacturer's instructions for [MEDICATION NAME] 23, provided by the facility, read to store at 36-46 degrees fahrenheit. The manufacturer's instructions for [MEDICATION NAME] solution, provided by the facility, read to store at 36-46 degrees and do not freeze. The manufacturer's instructions for Humalog, provided by the facility, read to store unopened Humalog in the refrigerator at 36-46 degrees. The manufacturer's instructions for [MEDICATION NAME], provided by the facility, read to store unopened [MEDICATION NAME] in a refrigerator at 36-46 degrees. The manufacturer's instructions for [MEDICATION NAME], provided by the facility, read to store [MEDICATION NAME] at a cold temperature of 36-46 degrees. IV. Staff interview The director of nursing (DON) was interviewed on 1/9/2020 at 9:37 a.m. She said the night shift usually checked the refrigerator temperatures and logged them. They were to notify maintenance if the refrigerator was out of the range on the bottom of the log. She said they had been having problems with the refrigerators for some time since they had received them over the summer, and if they were too close to the wall the refrigerator would have a different temperature. She said all staff had been trained on medication storage temperatures and 32 degrees was too cold to be storing medications and vaccines.

Based on record review and interviews, the facility failed to ensure that eight (#14, #21, #27, #7, #18, #1, #30 and #19 ) of eight residents out of 18 sample residents received food prepared by methods that conserved nutritive value, flavor, and appearance, and food that was palatable, attractive and at the proper temperature. Specifically, the facility failed to ensure that foods which should be served warm were not served to the residents cold. Findings include: I. Facility policies and procedures The Food Temperatures policy, provided by the dietary manager (DM) on 10/18/18 at 10:32 a.m., documented, That food was prepared and served at proper temperatures in order to assure the safety of the residents. The temperatures were taken at the beginning of each service and as the last meal was served. Potentially hazardous foods, which had been cooked and then refrigerated, were reheated to 165 degrees Fahrenheit or higher throughout before being served or before being placed in the steam table. The Food Preparation and Serving policy, provided by the nursing home administrator (NHA) on 10/18/18 at 11:43 a.m., documented, That food was prepared by methods that conserved nutritive value, flavor and appearance, and were attractively served at the proper temperature and in a form that met individual needs, as well as likes and dislikes. The equipment was provided and procedures were established to maintain food at proper temperatures during storage and service. II. Resident interviews A. Resident #14 Resident #14, who was interviewed on 10/15/18 at 2:16 p.m. She was cognitively intact with a brief interview for mental status (BIMS) cognition score of 14 out of 15. She said that sometimes the food in the facility was good and sometimes it was bad. She said she was not a big fan of Navajo tacos, which the facility served often. She said the regular tacos were awful. She said the facility had been having problems with the cooks recently. She said the oven-fried chicken was usually over-cooked and if you could get past the large amount of breading that was used, there was not a lot of chicken meat on the bone. She said that mexican meals did not look appetizing because the cooks just slapped a tortilla down on the plate with some beans thrown on it. She said that lunch was the main meal in the facility and that the supper meal was not well balanced because they served a large amount of hot sandwiches and not much else. She said the gumbo and minestrone soup that was served the evening prior did not taste good. She ended the interview by saying the cooks needed to learn how to cook the vegetables enough so the residents could eat them. B. Resident #21 Resident #21, was interviewed on 10/16/18 at 9:59 a.m. She had a BIMS score of 12 out of 15. She said that half the time, the facility served food to the residents that was too cold and should have been warm. C. Resident #27 Resident #27, was interviewed the morning of 10/16/18. She had a BIMS score of 15 out of 15. She said the temperature of the food served in the dining room was always on the cool side. D. Resident #7 Resident #7, was interviewed on 10/15/18 at 2:54 p.m. She had a BIMS score of 13 out of 15. She said the new cook like to overcook the vegetables. She said she thought the facility could use another waiter in the dining room because sometimes her food was cold when she received it. E. Resident #18 Resident #18, was interviewed on 10/15/18 at 4:57 p.m. She had a BIMS score of 15 out of 15 She said the facility needed to train the cooks on how to cook hot cereal in the morning because the oatmeal and cream of wheat tasted like watery soup. She said she really liked hot cereal for breakfast if it was cooked properly. F. Resident #1 Resident #1 was interviewed the morning of 10/16/18. She had a BIMS score of 8 out of 15. She said the only complaint she had about the facility was the cold food she was continually served. III. Resident council minutes and interview A. Minutes The resident council minutes, provided by the activity director on 10/16/18 at 8:25 a.m., were reviewed from 3/28/18 through 9/26/18. They documented as follows: -3/28/18: Residents stated that the food was not being served hot. It was being served cold the majority of the time, but sometimes the food was served as slightly warm. -4/25/18: The issue of 3/28/18 was readdressed. The minutes reflected that this issue had improved, but was not fully resolved. The residents noted that the facility served too much starches. -5/23/18: The issue of food being served cold was documented exactly the same as on 4/25/18. -6/27/18: The residents were informed that the facility was still looking for a new dietary director. The issue of food being served cold was documented exactly the same as on 4/25/18. -7/25/18: The minutes documented the cooks were trying to find a happy medium between crunchy/crispy vegetables and mushy vegetables so that most (or all) residents are happy. -8/22/18: The residents complained that the vegetables continued to be cooked inconsistently. The staff announced that a new dietary director had been hired. See interview below B. Interview Two members of the resident council, Residents #30 and #9, were interviewed together on 10/17/18 at 2:00 p.m. The facility had determined both of these residents were interviewable. They both agreed with each other that sometimes the food in the facility was served too cold. Resident #30 said baked potatoes and scalloped potatoes were usually served cold. Resident #19 said when the facility only had one server working in the main dining room the food was usually cold due to not serving the meals in a timely manner. They said it was especially problematic with the evening meal. Resident #30, who described himself as a non-meat eater for the past [AGE] years said he was trying to eat meat again because he did not want to starve and that was the only reason. Resident #19 said that she had been a resident at the facility long enough to know which foods to avoid. She said that most vegetables, but especially broccoli, carrots and squash were undercooked. Resident #30 said that the cooking of the vegetables was inconsistent; sometimes they were overcooked and sometimes they were undercooked. He said the zucchini was always overcooked and soggy. Resident #30 said that the residents on Hall A, where he resided, tended to watch what he ordered and followed suit. He said if dietary aide (DA) #4 were working on any particular day, he would just order a fried egg sandwich because it was difficult to get that simple order wrong. Resident #30 complained that the facility served too much pork. Both residents said that the always available menu was not extensive enough to avoid ordering the same things every day. Resident #30 said the grilled cheese sandwich was the standard food the residents tended to end up ordering if they did not like the entrée offered that meal. He said he would order cottage cheese sometimes to mix things up. Resident #19 said the facility had a very nice soup and salad bar that she took advantage of often, but the facility did not set up the salad bar on weekends. She said she did not know why, but guessed there might not be enough kitchen staff working on the weekends. She said the soup was canned and not homemade. Resident #30 said he was not a big salad eater, but would eat salad about once a week, usually on Wednesdays. IV. Observations and testing of the test tray Meal service for residents in the A hall was observed on 10/17/18 from approximately 5:20 p.m to 5:50 p.m. A nursing aide transported a single open air cart with an insulated food box on top from the dining room toA hall. The final tray was delivered at 5:46 p.m., or 26 minutes after leaving the dining room. An unserved cup of milk left on the service cart was measured at 52 degrees Fahrenheit (F). A test tray, for a regular diet was evaluated immediately after delivery of the last room tray on B hall on 10/17/18 at 6:00 p.m. The ham was served on a room-temperature plate and was luke-warm to taste. The berry bowl dessert was 58 degrees F and the berries were mushy and disfigured. V. Staff interviews The activity director (AD) was interviewed on 10/17/18 at 4:45 p.m. She said she was the staff responsible for transcribing the resident council minutes. She said immediately after each resident council meeting, she typed up the notes and she would either give the NHA, the DM and every department head a copy of the minutes that same day or if the department heads were not working that day, she would place a copy of the minutes in their mailbox. The AD said she assisted in the dietary department, if need be. She said she was uncertain if the reason resident's food was often served cold was because the food warmer covers were not working. She said the facility had tried different types of covers. The facility used to use a metal cover, but they had also been trying out the hard plastic covers that were currently seen being used. She said she had heard from the residents the food was too cold and they could not eat it. She said she was guessing, but another possible problem was the kitchen was cooking the meals too soon before serving and the food was getting cold. She said she did not follow up herself with old business issues from the resident council to ensure that the resident's grievances were being addressed; she just ensured that every department head was given the minutes from the resident council meetings in a timely manner. The Dietary Director (DD) was interviewed on 10/18/18 at approximately 1:00 p.m. He said he had been with the facility less than two months. He said he had not attended the resident council meetings thus far. He said he addressed resident food concerns on the spot when he was aware of the issue. He said dissatisfaction with food temperatures was being addressed with the insulated food boxes purchased for room tray delivery. He said extended time for delivery could impact food palatability. Dietary aide (DA) #1 was interviewed on 10/18/18 at approximately 1:10 p.m. She said there had complaints about food temperatures for room trays and insulated boxes were purchased to address the issue. She said the boxes are for hot foods and cold foods were delivered on an open-air cart. She said nursing staff distributed room trays and the time from kitchen to resident room was not monitored.

Based on observations, record review and interviews, the facility failed to ensure all drugs and biologicals were properly stored in two of two medication storage refrigerators (A Hall and B Hall) and one of two medication carts (A Hall). Specifically, the facility failed to ensure multi-dose medications were dated as to when they were first opened. Findings include: I. Facility Policy The facility's policy on medication storage, no date of inception or revision noted, included it was the responsibility of the staff nurse to maintain control and accountability of all medications, their utilization, and administration during the shift for which he/she was responsible according to the policies and procedures approved by the pharmacy and therapeutics committee, pharmacy laws and regulations of the State and Federal Regulations. Individual medications ordered for the patient by the physician shall be dispensed by the pharmacy, identified with the patient's name, dosage, frequency, and date on these containers. Medication storage shall be properly and safely maintained in accordance with the security of federal, state, and local laws. Drugs and biologicals used in the facility must have been labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. II. Observations A. On 10/16/18 at 11:30 a.m., the Hall A medication cart and medication storage refrigerator were inspected with registered nurse (RN) #2. The following was observed in the medication storage refrigerator: -An open vial of [MEDICATION NAME] PPD solution was observed without a date of opening labeled on the vial or the box. RN #2 stated that he would typically label the medication vial upon opening a new medication. -An open vial of [MEDICATION NAME] Quadrivalent influenza vaccine was observed to be without a date of opening labeled on the vial or box. -An unlabeled three mL (milliliters) syringe with a capped needle attached containing 0.5 mL of a clear fluid was observed on the third shelf of the refrigerator. RN #2 discarded the unlabeled syringe into the sharps container and stated it looked like a flu shot. The following was observed in the A hall medication cart: -An open vial of [MEDICATION NAME] ophthalmic eye drops was not labeled with an open date. RN #2 stated the medication was received on 9/11/18 and these bottles were usually opened the day of receipt. -An open vial of Dorzolimide HCL [MEDICATION NAME] (eye drops) was observed without a labeled date of opening. B. On 10/16/18 at 11:16 a.m., the medication storage refrigerator on B Hall was inspected with RN #1. The following was observed: -An open vial of [MEDICATION NAME] PPD solution was not dated with an open date. RN #1 stated she would usually label the medication box not the vial upon opening a new medication. III. Record Review The manufacturer medication inserts for [MEDICATION NAME] PPD revised (MONTH) (YEAR) and [MEDICATION NAME] Quadrivalent influenza vaccine revised (MONTH) (YEAR) revealed: -[MEDICATION NAME] PPD vials in use more than 30 days should have been discarded due to possible oxidation and degradation which may affect potency. - [MEDICATION NAME] Quadrivalent influenza vaccine vials once the [MEDICATION NAME] of the multi-dose vial had been pierced must be discarded within 28 days. IV. Staff Interview The director of nursing (DON) was interviewed on 10/16/18 at 11:54 a.m. The DON stated the process for labeling and dating multi-use medication vials was that nurses should be dating the medicine vial itself upon opening and that multi-use vials should be discarded 30 days after opening. The DON stated the nurses should be labeling the medication vial and not the box, and that staff were aware of this labeling process. The DON stated the nurses should know to check expiration dates and that the night shift usually went through medications looking for expired medications.

Based on observations, record review and staff interviews, the facility failed to ensure food was stored under safe and sanitary conditions in two of two facility refrigerators located outside the kitchen. Specifically, the facility failed to minimize potential risks for foodborne illness as evidenced by: -Foods stored unlabeled and undated in the occupational therapy (OT) room refrigerator and the small dining room refrigerator; and, -Inadequate monitoring of the OT room refrigerator and dining room refrigerator. Findings include: A. Professional references 1. According to the Colorado Retail Food Establishment Rules and Regulations (effective 3/1/13) pg. 49, all ready to eat, time/temperature control for safety food (TCS) served in facilities providing food to highly susceptible populations shall be clearly marked to indicate the date the food should be consumed or discarded. 2. According to the Food and Drug Administration (FDA) (YEAR) Food Code, pp. 95-96, except during preparation, cooking, or cooling, or when time is used as the public health control, cold foods should be kept at 41 degrees Fahrenheit (F) or less. B. Facility policy and procedures 1. The Storage of Brought to Residents from Family/Friends policy, undated, provided by the nursing home administrator (NHA) on 10/16/18 at approximately 4:30 p.m. read in part: -Each refrigerated unit was maintained below 40 degrees Fahrenheit (F); -The temperature of each refrigerator was recorded at the beginning of the morning shift and then end of the evening shift; -All foods stored tightly sealed, impervious, non-absorbent containers; and, -No foods were stored over three days. 2. The Food Safety and Your Loved One form, undated, and provided by the NHA on 10/16/18 at approximately 4:30 p.m., read in pertinent part: -Foods not in original packaging with a manufacturer's expiration date should be labeled with the resident ' s name, current date and date to be discarded; -Unlabeled and undated foods should be discarded; and, -Foods stored past the manufacturers expiration date should be discarded. C. Observations In the facility dining room an approximately 30 inch high by 18 inch wide glass-front refrigerator and corresponding temperature monitoring sheet were observed on 10/15/18 at approximately 1:30 p.m. On the center shelf there was a 12 ounce (oz.) cup of milk covered with aluminum foil with no label and no used by date. On the top shelf there was one-half of a sandwich which was not labeled or dated. -The (MONTH) (YEAR) temperature monitoring form was not completed on two occasions and there were documented temperature readings of 45 and 46 degrees F respectively. There was no documentation of the corrections that were made for the temperatures that were recorded outside the appropriate range. The refrigerator and affixed temperature monitoring sheet in the occupational therapy (OT) room were observed on 10/15/18 at approximately 3:20 p.m. There were no temperatures recorded on 10/1/18, 10/2/18, 10/3/18, 10/13/18 and 10/14/18. -Inside the OT room refrigerator there was a 10 oz. bowl covered with aluminum foil with no identification label or use by date. There was an open and unsealed bag of salami with the illegible date marking and a 12 oz. plastic container of broth-based soup which was not labeled or dated. There was an unlabeled and undated approximate 4 oz. plastic container of what appeared to be chocolate pudding. The pudding had a dark brown-blackish colored skin extending from the inside edge of the bowl to the center. The OT room refrigerator was observed again on 10/16/18 at approximately 5:00 p.m. In addition to the previously observed items there was a dinner plate with what appeared to be diced chicken and green beans covered with plastic wrap. The plate was not labeled or dated. D. Record review The dining room refrigerator temperature log sheets for August, (MONTH) and through (MONTH) 17, (YEAR), provided by the dietary director (DD) on 10/18/18 revealed temperatures were not recorded on a total of 11 different occasions. On 10/7/18 at 8:00 p.m. a temperature of 45 degrees F was recorded with the next recorded temperature on 10/8/18 at 7:00 a.m. recorded as 46 degrees F. There were no documented corrective actions. E. Staff interviews Dietary aide (DA) #2 was interviewed on 10/18/18 at approximately 9:56 a.m. She said dietary staff was responsible for recording the dining room temperatures two times per day. She said thought dairy products should be discarded if the temperature was over 40 degrees F. She said the dining room refrigerator really was not for resident leftovers and all foods should be labeled and dated. The DD was interviewed on 10/18/18 at approximately 1:00 p.m. He said he was not aware of foods stored inappropriately in the dining room refrigerator. He said staff should notify himself or maintenance if the refrigerator temperature exceeded 41 degrees F. He said he planned to add the appropriate temperature range and corrective actions to the temperature monitoring form. The facilities director (FD), who also managed housekeeping, was interviewed as part of the environmental tour on 10/18/18 at approximately 10:10 a.m. He said the refrigerator in the OT room was the responsibility of the housekeeping department. He said the refrigerator should be checked and recorded by housekeeping staff each day. He said all foods should be tightly covered, labeled with the resident ' s name, and marked with the date placed in the refrigerator. He said food stored for greater than seven days was discarded on Friday of each week. He said other staff and residents had access to the refrigerator and additional education on food safety would be beneficial.

Based on resident and staff interviews and record review, the facility failed to ensure timely follow up on resident council food concerns for two (#19 and #30) of 18 sample residents and potentially affecting all facility residents. Specifically, the facility failed to address in a timely manner the resident council concerns that the food was not being served warm. Findings include: I. Facility policy and procedure The facility's grievance policy, no date of inception or revision provided, included it was the policy of the facility to encourage all residents and visitors to bring their concerns to the attention of the facility. Any resident, or legal representative, member of the resident's family, or the resident council may present a grievance to the nursing home administrator (NHA), verbally or written, within 30 days of the incident. The social services director would notify the NHA as soon as possible, within 24 hours, of any grievance received. The respective director would investigate the incident within three days of the grievance being reported and provide written findings and proposed solutions, if needed, to the complainant. If the complainant was not satisfied with the findings or solutions within 10 days of receiving the administrator and respective director's explanation, the complainant may file a verbal or written grievance along with any additional information. The NHA and respective director would confer with persons involved in the incident, and any other relevant persons, within 10 days of the written grievance and provide the findings and proposed solutions, if needed, to the complainant. If the complainant was not satisfied with the findings and proposed solutions and an agreeable solution could not be reached, the complainant may file a written grievance within 10 days of receiving the explanation in writing to the owner. If the complainant was not satisfied with the findings and proposed solutions of the owners, the complainant may file within 10 days of receipt of the findings to the Colorado Department of Public Health & Environment. II. Resident Interviews Interviews with residents, who per facility and assessment were cognitively intact and interviewable, revealed the following: A. Resident #19 Resident #19, age 91, was readmitted on [DATE]. The 9/13/18 minimum data set (MDS) assessment revealed the resident had no cognitive impairment and scored 15 out of 15 on the brief interview for mental status (BIMS) assessment. The resident was able to make herself understood, was able to understand others, and speech clarity was capable of distinct intelligible words. Resident #19 was interviewed as part of the resident council interview on 10/17/18 at 2:00 p.m. The resident stated the resident council met once a month, that she regularly attended meetings, and that she was the former resident council president. Resident #19 stated she ate in the dining room and the food was regularly cold, especially on the days they had one server, which was frequent, and especially on evening/dinner meals. B. Resident #30 Resident #30, age 62, was admitted on [DATE]. The 10/10/18 MDS assessment revealed the resident's cognition was intact with a BIMS of 14 out of 15. The resident had adequate hearing with no difficulty in normal conversation, clear speech with distinct intelligible words, and was able to make self understood with ability to express ideas and wants. Resident #30 was interviewed on 10/17/18 at 2:00 p.m. as part of the resident council meeting. The resident stated the food was sometimes served hot but was regularly not served warm or food was served lukewarm. The resident particularly stated that potatoes, especially the scalloped potatoes, and vegetables were regularly served cold. The resident stated that he ate in the dining room for meals. III. Record review The resident council minutes were obtained for the past seven months dating from 3/28/18 through 9/26/18, and revealed the following: -The resident council meeting minutes dated 3/28/18 at 3:00 p.m. documented, The food is not being served hot. It is being served most of the time cold, but sometimes it can be a little warm. -The resident council meeting on 4/25/18 at 3:01 p.m. documented, The food is not being served hot. It is being served most of the time cold, but sometimes it can be a little warm. It was noted in the minutes that some improvement had been made but the issue was not fully resolved. A suggestion of covering the meals with the metal lid until it was served was proposed by the resident council. -The resident council meeting minutes, dated 5/23/18 at 2:56 p.m., again documented, The food is not being served hot. It is being served most of the time cold, but sometimes it can be a little warm. This has been improved but is not fully resolved. -The resident council meeting minutes, dated 6/27/18 at 3:01 p.m., again documented, The food is not being served hot. It is being served most of the time cold, but sometimes it can be a little warm. This has been improved but is not fully resolved. It was also noted that residents were informed during this meeting that the facility was still seeking a new dietary director and that the NHA had been filling in to help in the kitchen. -The resident council minutes, dated 7/25/18 at 3:03 p.m., noted the addition of three new staff members including a new dietary aide and three new cooks. It was also noted that residents were made aware there was still not a dietary director and the NHA continued to fill in for this role and help out in the kitchen when needed. The NHA had suggested according to the minutes to have nursing assistants help serve drinks and run trays to help out during lunch and dinner as these were the busiest times when most residents were down for meals at the same time. -The resident council minutes, dated 8/22/18 at 3:01 p.m., documented the residents were made aware that a new dietary director was hired. No reference to food temps was made. -The resident council minutes dated 9/26/18 at 2:59 p.m. stated that a new menu was to start for the fall season and residents could look forward to seeing new dishes coming out. IV. Staff interview The nursing home administrator (NHA) was interviewed on 10/18/18 at 10:22 a.m. The NHA stated residents were informed on how to file or voice a complaint or grievance upon admission with social services, and a grievance policy and grievance form was made readily available to residents. The NHA stated that once residents were already admitted , all staff in the facility had been trained to take a complaint or grievance and knew how to get that grievance to the correct staff member for review. The social services director, according to the NHA, was the point person for grievances, or her staff assistant on weekends, so that someone was always readily available at all times. The NHA also stated that the grievance process information was posted at the entrance of the facility alongside the state ombudsman information. The NHA stated that from start to finish of an identified grievance he would expect grievances to be resolved within 24 to 72 hours if reasonably possible. The NHA said he would return to the complainant with the grievance form and the plan of correction, and have the complainant sign off if they were in agreeance. The NHA acknowledged he was aware of the resident council's concerns over the food temperatures. The NHA also acknowledged he was aware that the same concern of food temperature had surfaced at resident council meetings for the past several months. The NHA stated they had been trying to address the issue of food temperature; however, the turnover of staff with constant new staff members in the kitchen had made it difficult to resolve the resident council's concern. The NHA said a year ago the facility incorporated the use of the hot boxes in an attempt to keep the room trays warm. The NHA also stated that back in (MONTH) of (YEAR), they transitioned from light duty plate covers to heavy metal plate covers without success, and most recently, just three to four weeks ago, had initiated the use of black insulated plate covers. The NHA believed at the time of the interview that there had been progress towards resolving this issue with these recent changes. The NHA stated he had been constantly making new changes and worked on educating staff on this issue and how important it was to get food trays to rooms as quickly as possible. The NHA stated the turnover in the kitchen had been a key issue leading to this concern, and that at times the new staff would not use the plate warmers in the kitchen because they either forgot or did not know how to use them at all. The NHA stated he wished the resolution to this concern of food temperature would be quicker, but it had been more difficult to resolve than it seemed.

Based on observations, record review, and interviews, the facility failed to ensure one (#16) of one resident reviewed for pressure ulcers of 17 sample residents received care consistent with professional standards of practice to prevent pressure injuries. Specifically, the facility failed to: -Prevent the development of pressure ulcers for Resident #16; -Consistently complete and document weekly wound assessments; and, -Administer nutritional supplement to Resident #16 as ordered. Findings include: I. Professional standard According to the National Pressure Ulcer Advisory Panel (NPUAP), Prevention and treatment of [REDACTED].npuap.org/wp-content/uploads/2014/08/Quick-Reference-Guide-DIGITAL-NPUAP-EPUAP-PPPIA-Jan2016.pdf, 10/22/18, interventions for prevention and treatment of [REDACTED]. -Reassess the individual, the pressure ulcer and the plan of care if the ulcer does not show signs of healing as expected despite appropriate local wound care and pressure redistribution. Expect some signs of pressure ulcer healing within two weeks. -Assess the pressure ulcer initially and reassess it at least weekly. Weekly assessments provide an opportunity for the health professional to assess the ulcer more regularly, detect complications as early as possible, and adjust the treatment plan accordingly. -Assess and document physical characteristics including: location, category/stage, size, tissue type(s), color, periwound condition, wound edges, sinus tracts, undermining, tunneling, exudate, and odor. II. Facility policy and procedure The Skin Condition Stage I (1)-Stage IV (4) policy and procedure, undated, was provided by the nursing home administrator (NHA) on 10/17/18 at 12:01 p.m., and included the following guidance: -A program of prevention, care, and treatment of [REDACTED]. -Resident's skin will be examined by a direct caregiver CNA (certified nurse aide) and/or licensed nurse for the development of redness, discoloration, or blisters over areas each week. These areas include heels. -The prevention of pressure ulcers included the development of an individualized comprehensive care plan that might include the use of protective heel boots or multi podus boots to support the heels and decrease the pressure and shearing process. Skin conditions were to be observed weekly. -Documentation is made by direct caregivers who were a licensed staff member. A weekly record of the skin condition report should include the following: stage of wound, size, length, width, depth, drainage, odor, color, treatments, supplements, and any pertinent changes. -If no changes or improvements noted to decubitus after 2-4 weeks with current treatment plan, the following shall be initiated: Re-evaluation of the treatment plan including determining whether to continue or modify the current interventions as indicated, notify/update physician, and document in clinical record the rationale for continuing or changing treatment plan. The policy and procedure did not include or address suspected deep tissue injury (SDTI) or unstageable pressure ulcers. III. Resident #16 A. Resident status Resident #16, older than 80, was admitted on [DATE]. According to the (MONTH) (YEAR) computerized physician orders [REDACTED]. The 9/12/18 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of six out of 15. She required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene, and had no rejection of care. She was at risk of developing pressure ulcers and had one or more unhealed pressure ulcers at a stage 1 or higher. Her current number of unstageable pressure ulcers was one, had no pressure ulcer present on the previous assessment, and did not currently have a SDTI. She had a pressure-reducing device for the chair and bed, was on a turning/repositioning program, and was receiving pressure ulcer care. The previous MDS assessment, dated 6/26/18, identified the resident was at risk of developing pressure ulcers and had no pressure ulcer at a stage 1 or higher. The care plan, initiated 9/17/18 and last revised 10/2/18, identified the resident had potential for alteration in skin integrity related to decreased mobility. The interventions included: -Encourage/assist to change position as needed. -Offer a health shake for meal intake of 50% or less. Record amount consumed. Report any decrease in appetite or weight to charge nurse or medical doctor (MD) as needed. -Refer to (local area hospital) podiatry for heel bruising, obtain labs, place [MEDICATION NAME] to heel, and keep the pressure off heel (revised 9/1/18). -Slippers as ordered (revised 9/4/18). -Noted bilateral pressure ulcers to heels, must wear off-loading boots when in bed. Apply footrests to wheelchair. Keep ulcer dry and covered. Monitor swelling. Return to doctor in three weeks. Encourage placement of positioning pillows to float heels (revised 9/10/18). B. Record review The Nursing Admission Assessment, dated 3/30/18, revealed the resident did not have a history of pressure ulcers, was not admitted with a pressure ulcer, and did not have any open [MEDICAL CONDITION] on her feet. The Braden Scale skin assessments for predicting pressure ulcer risk were reviewed and documented the following: -3/30/18: Total score 16 = mild risk -4/19/18: Total score 14 = moderate risk -Undated: Total score 14 = moderate risk -8/18/18: Total score 16 = mild risk A physician's orders [REDACTED]. 1) Refer resident to (local area hospital) orthopedics to see podiatrist regarding left heel bruising/pain. 2) Use slippers on left foot to relieve pressure on heel. 3) [MEDICATION NAME] (dressing) to left heel, change every two days. 4) When in bed, keep left heel above mattress. Protect heel. A progress note dated 9/4/18, documented by therapy staff, revealed the following: Attempted to put shoes on when Resident #16 complained of sharp pain in the heel. Noticed two-inch round heel ulcer, Stage II (2), to left heel, and soft, mushy, and sensitive to palpating of same area of right heel. Nursing staff were notified, who were aware of it as of yesterday, and issued the resident heel protection and footrests for wheelchair. The director of nurses (DON) advised not to use shoes, only slippers, with walking and heel protection all other times while in bed and wheelchair. The weekly Wound Assessment Reports for the left heel pressure ulcer were reviewed from 9/4/18 (wound onset) through 10/7/18 and documented the following: -9/4/18: New deep tissue injury to left heel first identified, cause unknown, measured 2.00 centimeters (cm) length (L) x 1.50 cm width (W) x zero cm depth (D). There was no drainage, skin color was normal skin color, and the resident complained of pain in the wound and she grimaced. -9/9/18: Measured 2.50 cm L x 1.00 cm W x 0 cm D, area was covered with eschar, and there was no drainage or signs of infection. The area was cleaned with normal saline, dried, and [MEDICATION NAME] placed over it. Patient and staff are instructed to wear heel protectors and keep heels floating off bed. Appointment with (local podiatrist) made for 9/10/19. No complaints of pain. -9/21/18: (12 days since last weekly wound assessment), 2.00 cm L x 1.50 cm W x zero cm D. There was no drainage, skin color was normal skin color, and resident complained of pain in the wound that included grimacing. -10/7/18: (16 days since last weekly wound assessment), 2.00 cm L x 1.50 cm W x zero cm D. There was no drainage, skin color was normal skin color, and resident complained of pain in the wound that included grimacing. Area continues to have eschar present. Patient is now in off-loading boots at all times and area is clean and dry, no signs or symptoms of infection, patient denies any pain at this time. Will continue to monitor. The weekly wound assessment reports for the right heel pressure ulcer were reviewed from 9/4/18 (wound onset) through 10/7/18, and revealed one assessment in total had been completed, dated 10/16/18. It documented the right heel pressure ulcer was first identified on 10/16/18 and was unstageable due to SDTI. The wound measured 2.00 cm L x 2.50 cm W x zero cm D, and the resident complained of pain in the right heel area. The form provided areas to document drainage, infection, wound edges, tunneling, and undermining, but was void of documentation. -Six weekly wound assessments should have been completed from 9/4/18 to 10/16/18, but were not performed. The weekly interdisciplinary team meeting minutes, dated 9/12/18, documented Resident #16 had unstageable-both heels, DON to talk to MD regarding treatment not working, ordering multi podus boots. The meeting was attended by the social services director (SSD), registered nurse (RN/charge nurse) #4, MDS coordinator, dietary director, and physical therapy assistant (PTA) #1. The weekly interdisciplinary team meeting minutes, dated 9/26/18, documented Resident #16 had multi-podus boots on bilaterally, and nursing was to review her orders. There were no additional notes or orders documented that addressed her pressure injuries. The CPO for (MONTH) (YEAR) revealed the following orders: -When in bed keep heel above mattress to protect heel (started 9/1/18). -Heel protectors to be worn to bilateral lower extremities at all times (started 9/4/18) -Must wear off-loading boots at all times in bed and wheelchair. Apply footrests to wheelchair to prevent heel scooting (started 9/10/18). -Place pillows behind calves so that heels are floating when resident is resting in bed (started 9/10/18). -Keep left heel ulcer dry. Monitor for increased swelling, redness, drainage (started 9/25/18). The Medication Administration Record [REDACTED]. The scheduled administration times were 9:00 a.m. and 2:00 p.m. There was no documentation on the MAR indicated [REDACTED]. C. Resident #16 observations On 10/15/18 at 2:31 p.m., Resident #16 was observed sitting in her wheelchair in her room and she was wearing multi podus boots on both feet. Her right foot had fallen below the right wheelchair footrest and was resting on the floor. On the afternoon of 10/16/18, a request was made to RN #1 to observe Resident #16's left heel pressure ulcer. At 1:35 p.m., Resident #16 agreed to the observation, and RN #1 lifted up the resident's right heel and revealed a 50-cent sized darkened purple bruise on the lateral aspect of her heel. The skin was intact and there was dry, flaky skin on the surface of the heel. Resident #16 complained of pain in the right heel area and explained the pain usually occurred on the left heel, but the pain in the right heel was new. RN #1 said this was the first time she had observed the right heel SDTI and said it was a new wound. She stated, We look at her heels every day, and this is the first time I've seen that dark purple color on the right heel. She said the resident had been wearing her multi podus boots every day and did not know how it developed. The left heel pressure ulcer was observed next,to be a quarter-sized black, dried, wound. The skin surrounding the wound bed was pink and dry. On 10/17/18, continuous observation of Resident #16 was done from 12:32 p.m. to 1:10 p.m. She was sitting in her wheelchair at a table in the dining room. Her right cheek was resting on her right fist and she was pushed back from the edge of the table approximately 10 inches. She had a turkey roll-up, mashed potatoes, turkey gravy, and broccoli cut up in a small dice on her plate, and a full pumpkin spice layered dessert. No food on her plate had been touched or eaten and she did not receive any cueing or assistance throughout the meal. At 1:10 p.m., she propelled herself away from the table and out of the dining room without eating anything for lunch.She was not offered a substitute meal or a supplement shake by staff to help with her nutritional intake to promote healing. On 10/17/18 at approximately 4:00 p.m., Resident #16 was sitting in her wheelchair in her room. She was wearing multi podus boots on both feet and her right foot had fallen underneath the right footrest and was resting on the floor. D. Staff interviews The registered dietician (RD) was interviewed on 10/17/18 at 12:21 p.m., and she said she was at the facility twice each month to review the residents' nutritional status. She said she was familiar with Resident #16 and was aware of her left heel pressure injury. She confirmed both of the residents' heels had skin breakdown in (MONTH) (YEAR) and she had requested to start a (name of nutritional supplement) at that time in order to ensure the resident received more calories and protein. She said on 10/10/18, she was notified by the dietary director that the resident had an unstageable pressure injury on the right heel and the left heel had improved significantly. The RD said the (name of supplement) was not started until 10/16/18, and she did not know why there had been such a lag time between when it was recommended and when it was started. CNA #1 was interviewed on 10/17/18 at 2:50 p.m., and he confirmed he routinely cared for Resident #16. He said he checked her heels every morning and then put her multi podus boots on her feet, which stayed on all day long, every day. He said she did not like to wear the boots, but wore them anyway, and did not have an air mattress on her bed. He said he was unclear as to when the heel wounds started, which heel it was on, or if it was on both. RN #1 was interviewed on 10/17/18 at 4:55 p.m., and she confirmed she routinely cared for Resident #16. She said skin assessments were completed once a week for each resident, and the charge nurse did them. She said there used to be inconsistencies when the floor nurses completed them, so the charge nurses took them over a couple months ago, and they kept track of who was due for their assessment. She said the Medicare meeting was held on Wednesdays, and pressure ulcers were discussed during that meeting. RN #1 said residents had a skin assessment completed upon admission and if they were at high risk for skin breakdown, they would put them on a (name of a mattress overlay) or air mattress, depending on how much they could move, and were encouraged to reposition every two hours. She said when a pressure injury was first identified the nurse would document it on the Wound Man, which was a skin assessment, then notify the doctor, and charge nurse. She said after the Wound Man documentation was completed initially by the nurse who identified the injury, the charge nurse would take over doing it weekly. - RN #1 said she did not know how Resident #16 developed her pressure injuries on her heels and stated, She has been wearing those multi podus boots, and to me when she is sitting, the pressure isn't on her heels. She has been wearing them for weeks. RN #1 said the resident's left heel pressure injury was first identified within the last three weeks, and the right heel pressure injury was first identified yesterday. She said there were no new treatments implemented yesterday when the pressure ulcer was found and stated, Because she still has the multi podus boots and is still floating her heels. RN #3, who was also a charge nurse, was interviewed on 10/17/18 at approximately 5:15 p.m. She said routine skin checks were performed daily, wound assessments were performed weekly, and a comprehensive head-to-toe skin assessment was performed monthly. She clarified these skin assessments were all completed by the nurse working on the medication cart, and the weekly assessments were split up between day- and night-shift nurses. She said if a wound dressing were ordered to be changed three times per week, then the nurse changing the dressing would measure the wound three times per week and document it. RN #3 said all skin assessments were to be documented in the resident's electronic medical record on the wound assessment. She clarified the Wound Man was part of the weekly and monthly comprehensive assessments and should be completed by the medication nurse. RN #3 said Resident #16 developed a pressure injury on her left heel within the past month or so, and was not aware of one found on her right heel until it was reported to her that day in a meeting with upper management. She explained there was previous documentation of the wound on her right heel, but the nurse who identified it originally did not document it on the Wound Man to carry ongoing assessments forward and ensure they were completed. RN #3 said she thought the wounds on her heels might have developed when she used to wear some tight fitting shoes that were too small for her. She said the resident dragged her feet to move herself and the family was told the shoes were too small. RN #3 said they began to put (name of protective barrier) on her heels once they started developing the pressure ulcer to prevent it from breaking down and stated, They just popped up all of a sudden. She said she did not consider Resident #16 to be at high risk for developing pressure ulcers and she had never had any skin breakdown in the past. She said the resident did not move around a lot and she needed to be repositioned. RN #3 did not know if the heel injuries were getting smaller or not, and said she would have to defer to the night shift nurse and look at the resident's skin assessments. She said as the charge nurse, she had hoped the nurses who did the weekly measurements would inform her if the wounds were not getting any better so that she could contact the doctor, dietician, and DON. RN #3 said the left heel should have been measured since 9/21/18, and then they should have been measured weekly and stated, I think we need to have a staff meeting and go over this. The DON was interviewed on 10/17/18 at 11:00 a.m., she said skin assessments were completed weekly on all residents. She explained they were in the process of turning the responsibility over to the charge nurses because they had been trained to perform them and they had charge nurses who worked full time, so they were available to do that. She said she wanted to limit the number of people looking at the skin for consistency. She explained the nursing staff and CNAs were educated about pressure injuries every time we get someone in who has one, and clarified there had not been any formal training on pressure injuries, but she planned to put that on her list of things to do. She said the staff were pretty knowledgeable about repositioning residents and floating their heels. The DON said when residents developed pressure injuries, the information would be passed on to her in report in the mornings. She said usually in the mornings when she came in, she would go to each nurses' station and ask for an update on the residents and would expect to be notified at that time. Then the physician and family would be notified as well, and a treatment plan would be initiated, including a weekly wound assessment and measurements documented by the charge nurse. The DON said they had an IDT that met every Wednesday and all pressure injuries were reviewed and discussed at that time. The DON said Resident #16's pressure ulcers caught us by surprise, because she was out of bed every day and very mobile in her wheelchair. She said they thought her heel pressure ulcers developed from using the sides of her feet to propel herself around the facility. She said she did not think Resident #16 was at risk to develop pressure ulcers because she had a decent meal intake, was up in her chair every day, and transferred with assistance. She said she did not know how long both wounds had been on her heels and thought it had probably been approximately five weeks or so. She said the resident rarely refused care and she had observed the resident not wearing her multi podus boots twice. She said she would expect to get the doctor involved to get new treatments started if the wounds were not measuring smaller over the period of one month. She did not know why the nutritional supplement had not been administered or why the right heel pressure injury had not been assessed weekly since the time it was first identified in September.

Based on observations, staff interviews and record review, the facility failed to follow sanitary practices for food storage and preparation in one of one kitchen and two of two medication room refrigerators regarding: -Safely storing and preparing eggs; -Dating nutritional supplements when removed from the freezer; -Disposing of expired nutritional supplements; -Cooling potentially hazardous foods; -Hairnet use; and, -Readily visible thermometers for monitoring refrigerator and freezer temperatures. The findings included: I. Safe Egg Preparation and Storage A. Facility Expectations The undated Infection Control policy, provided by the nursing home administrator (NHA) on 7/6/17 at 3:30 p.m., included, Proper techniques are employed to prevent the possibility of . food-borne illnesses, including: . using only whole, crack-free eggs, or pasteurized egg products. The undated Purchase & Rotation of Food policy, provided by the NHA, included, Only clean whole eggs with shell intact and without cracks are purchased from an approved source. All liquid, frozen, or dry eggs or dry egg products used are pasteurized. B. Observations and Staff Interviews The initial kitchen observation, conducted at 12:50 p.m. on 7/3/17, revealed a deep, clear plastic container of loose, undated eggs was stored in the refrigerator. A few white eggs were stamped with a red P for pasteurized. Several brown eggs were stored in the same container below the pasteurized eggs. The eggs were unmarked and undated, and one of the eggs was slightly cracked. When asked, the dietary aide said they ran out of eggs and had to borrow some eggs from the occupational therapy kitchen. She said a new shipment of pasteurized eggs was supposed to come in tomorrow. A dietary aide was interviewed in the dining room at 8:20 a.m. on 7/4/17. She said the pasteurized eggs had arrived at 6:30 a.m. and they were able to serve residents soft-served eggs. The posted breakfast menu in the dining room included eggs any style. Two residents were observed being served eggs with soft yolks: one resident with a soft boiled egg and one resident with eggs cooked over-medium. The kitchen was observed during dinner preparation beginning at 4 p.m. on 7/5/17. No pasteurized eggs were observed in the refrigerator. -Approximately nine eggs, all with large cracks, were observed stored in a deep clear plastic container in the refrigerator. The dietary manager said he did not know why they were there, and disposed of the damaged eggs. -A large, mostly full, new box of eggs was observed in the refrigerator, which the DM said had been delivered the previous morning and some had been used. The eggs were not stamped with a red P and the box did not show that the eggs were pasteurized. The DM said he would check with the supplier. The dietary manager was interviewed at 3:30 p.m. on 7/6/17. He said the supplier had incorrectly delivered unpasteurized eggs, and they had served a handful of residents soft-cooked eggs on the mornings of 7/4 and 7/5/16. He said they were having pasteurized eggs delivered and would ensure no soft-cooked eggs were served until they had pasteurized eggs available. To avoid the mistake in the future, he said they would revise their order forms so the only option was to order pasteurized eggs. II. Nutritional Supplements A. Manufacturer's Recommendation According to the Hormel Mighty Shake manufacturer's instructions website, http://www.hormelhealthlabs.com/mtyshks-van-75-4oz (7/11/17), Storage Range Recommended: Frozen . B. Professional Reference According to the State Board of Health Colorado Retail and Food Establishment Rules and Regulations (last amended 11/21/12, effective 3/1/13) page 26, Food shall be in sound condition, free from spoilage or contamination and shall be safe for human consumption. C. Observations During the kitchen tour initiated at 12:50 p.m. on 7/3/17, two boxes containing several individual serving size Mighty Shake supplements were observed in the refrigerator. The dietary aide said they had been frozen and were thawing. However, the supplements had not been dated when removed from the freezer. During kitchen observations on 7/5/17 at 4 p.m., multiple Mighty Shake cartons, which had been removed from the freezer and were thawing or thawed, remained undated. During medication storage observations on 7/6/17 at 10 a.m., observations of the A hall and B hall medication room refrigerators revealed: -Boxes of Juvan nutritional supplement packets, 24 grams, fruit punch flavored, were stored in the medication refrigerators. -Twelve Juven packets expired on 4/1/17 and 37 Juven packets expired 5/1/17. D. Staff Interview The dietary manager was interviewed at 3:30 p.m. on 7/6/17. He acknowledged the nutritional supplements needed to be dated individually when removed from the freezer, and that expired supplements should be discarded. III. Cooling Potentially Hazardous Foods A. Facility Expectations The undated Storage of Refrigerated Food policy, provided by the NHA, included: -Potentially hazardous food that requires refrigeration after preparation is rapidly cooled to a temperature of 45 degrees F or below within a period of 4 hours or less. Large quantities of such foods are rapidly cooled by one or more of the following methods: a. Placing the hot food in a container not deeper than 3 inches. b. Stirring the contents of the container periodically to speed chilling. c. Quick chilling by placing storage container in an ice water bath. During this method it is mandatory that the container be sealed properly in order to prevent the ice water from getting into the food. Leftover ice is disposed of. .Potentially hazardous foods that require refrigeration after preparation are NOT allowed to stand at room temperature to cool, but are placed in the refrigerated unit immediately. B. Observation The kitchen was observed during dinner preparation beginning at 4 p.m. on 7/5/17. -The cook was observed placing a large, deep clear plastic container of green chili into the refrigerator. The container was very warm to the touch. The cook said it was for dinner the next evening. C. Staff Interview The dietary manager was interviewed on 7/6/17 at 3:30 p.m. He said he had checked the temperature on the green chili at approximately 5:30 p.m. yesterday, about an hour and a half after it had been placed in the refrigerator. He said the chili measured 50 degrees F at that time. He said it had been set out at room temperature to cool, which he usually did for about three hours, then he would leave the cover slightly open so it would cool completely in the refrigerator. He acknowledged this method might not be safe for the residents, and said he would re-read the regulations and speak with the registered dietitian regarding the best methods for quick chilling potentially hazardous foods. IV. Hairnets A. Facility Expectations The undated Hygiene and Conduct of Staff policy, provided by the NHA, included, Food service employees will use effective hair restraints which prevent the contamination of food or food-contact surfaces. B. Observations During the initial kitchen observation beginning on 7/3/17 at 12:50 p.m., the cook was observed finishing lunch preparation. He was wearing a hair net and beard cover but his mustache was uncovered. The dietary manager was wearing a baseball cap which covered the top of his head, but did not cover the back and sides of his hair. During dinner preparation observations on 7/6/17 beginning at 4 p.m., the dietary manager was wearing a baseball cap that did not cover his hair to the sides and back. The cook was wearing a hairnet and beard cover that did not cover his mustache. The dietary aide wore her hair pulled up and back with a hairnet, but long hair at the back of her neck was uncovered. V. Thermometers A. Facility Expectation The undated Storage of Refrigerated Food policy, provided by the NHA, included: Each refrigerated unit is provided with a numerically scaled indicating thermometer, accurate to (plus or minus) 3 degrees F., located to measure the air temperature in the upper one-third of the unit. Thermometers are located so that they are easily readable. B. Observations and Staff Interviews The initial kitchen observation, conducted at 12:50 p.m. on 7/3/17, revealed no thermometers were visible inside the refrigerator and freezer. The dietary aide was also unable to find thermometers. She said they recorded/logged the digital temperatures displayed outside the refrigerator and freezer. She said they did have thermometers at one time, but they may have been discarded. The kitchen was observed during dinner preparation beginning at 4 p.m. on 7/5/17. No thermometers were observed in the refrigerator or freezer. The dietary manager demonstrated the thermometers had been located and were hanging under the bottom shelves of the refrigerator and freezer. He pulled out each thermometer to show the temperature, which recorded appropriate temperature ranges. However, he acknowledged the thermometers were not readily visible inside the refrigerator and freezer, and it was not clear which temperatures (inside or outside the refrigerator/freezer) were being recorded on the logs. VI. Staff Interview The registered dietitian (RD) was interviewed on the afternoon of 7/6/17 regarding the above findings. She acknowledged the findings, said the dietary personnel had experienced significant turnover and had a new dietary manager. She said she and the dietary manager would provide additional staff training and resources.

Based on record review, resident observation and staff interviews, the facility failed to ensure that five (#116, #113, #31, #48 and #41) of five residents reviewed for medication use of 26 sample residents were free from unnecessary drugs. Specifically, the facility failed to: - Track hours of sleep for the use of a hypnotic for residents #116, #113, #31, #48 and #41; - Develop specific, individualized target behaviors for residents #116, #48 and #41; - Document that non-pharmacological interventions had been attempted prior to administering prn [MEDICATION NAME] (a benzodiazepine) to resident #116; and, - Stop documenting behaviors on [MEDICATION NAME] (an anti-psychotic medication) that resident #113 was not receiving in the facility. The findings included: 1. Facility Policy The policy #14-1.12, entitled Psychoactive Drug Usage, read in pertinent part, Management of the type of dosage of drugs for the resident shall be closely monitored by the pharmacy, nursing personnel and medical director through the drug regiment reviews monthly. Use of [MEDICAL CONDITION] drugs should be kept to a minimum, used for specific symptoms .Dosage should be as low as possible and resident observed closely for the onset of extrapyramidal symptoms such as [DIAGNOSES REDACTED]s, dyskinesis, akathisias, and/or Parkinsonian reactions .[MEDICAL CONDITION] medications are those prescribed to manage behavior. These drugs are the option of last resort. 2. Resident #116 Resident #116, age 82, was admitted on [DATE]. According to the face sheet, [DIAGNOSES REDACTED]. Resident #116 was a very recent admission and this resident did not have a minimum data set (MDS) assessment completed yet. A. Record Review Medication Administration Record The July 2017 Medication Administration Record [REDACTED] - [MEDICATION NAME] DR (an anti-depressant), 30 mg QD (daily) X 7 days, then increase to 60 mg QD: This was ordered on [DATE] and was to be discontinued on 7/5/17. - [MEDICATION NAME] DR, 60 mg QD. This was ordered on [DATE] and was to begin at this dose on 7/6/17. - [MEDICATION NAME] (a benzodiazepine), 0.5 mg BID (twice a day) for anxiety. This was ordered 6/30/17. - [MEDICATION NAME], 0.25 mg Q 8 hours prn (every eight hours as needed) for breakthrough anxiety. This was ordered 6/29/17 (The resident received this medication on 7/2/17 at 2:16 a.m., 7/2/17 at 12:19 p.m. 7/3/17 at 6:17 a.m., 7/3/17 at 2:33 p.m., 7/4/17 at 2:26 a.m., and 7/4/17 at 10:34 a.m. - [MEDICATION NAME] (an herbal medication used for [MEDICAL CONDITION]), 5 mg QHS (every hour of sleep). This was ordered 6/28/17. The June 2017 MAR indicated [REDACTED] - [MEDICATION NAME] (a benzodiazepine), 0.5 mg Q 6 hours (every six hours as needed) for breakthrough anxiety. This was ordered on [DATE] and discontinued on 6/29/17. - [MEDICATION NAME], 0.5 mg QD: Ordered 6/28/17 and discontinued 6/28/17. - [MEDICATION NAME], 0.5 mg BID (twice a day): Ordered 6/28/17 and discontinued 6/29/17. Behavior Monitoring According to the July 2017 behavior monitoring sheet for the use of this resident's [MEDICATION NAME], the facility was monitoring anxiousness only. The behavior monitoring did not specify exactly how this resident displayed symptoms of anxiousness. Additional information provided by the medical records technician #4 on 7/5/17 at 12:11 p.m., showed the facility was going to monitor the behavior of anxious for the use of [MEDICATION NAME] for this resident. There was no documentation the facility had been monitoring hours of sleep for the use of [MEDICATION NAME] for resident #116. There was no documentation the facility had attempted any non-pharmacological interventions with this resident prior to giving the resident prn [MEDICATION NAME]. According to the June 2017 behavior monitoring sheet for the use of this resident's [MEDICATION NAME], the facility was monitoring anxiousness only. Again, the facility did not specify how this resident displayed anxiousness. There was no documentation the facility had been monitoring hours of sleep for the use of [MEDICATION NAME] for resident #116. Care Plans The care plan dated 6/28/17 read, (Resident's name) has socially inappropriate/disruptive behavior - yells out help me, help me. Is not easily re-direct able. The care plan dated 6/28/17 read, (Resident's name) has high levels of anxiety, admitted with [MEDICATION NAME] and prn [MEDICATION NAME]. 6/29/17: [MEDICATION NAME] discontinued due to being on two anxiolytics. However due to bad reactions to [MEDICATION NAME], the [MEDICATION NAME] was restarted BID and for breakthrough anxiety. The goal was (Resident's name) will be able to relax via use of medications/relaxation techniques. Interventions included: Staff will encourage (resident's) family to stay with her to help reduce her anxiety about being left alone. Monitor and document behavior daily and report any abnormal observations to physician. Administer medications as ordered by physician. Document (resident's name's) response to pharmacological therapy daily . The care plan dated 6/28/17 read, Shirley demonstrates difficulty in adjusting to long-term placement with a sense of feeling overwhelmed/out of control/fearful. POA only wants to discuss discharge during comprehensive assessments. The interventions included encouraging family to bring in favorite items from home. B. Resident Observations On 7/4/17 at 9:23 a.m., resident #116 was observed lying in bed, in a hospital gown, and was tearful, anxious and wanted to speak with her son. On 7/5/17 at 1:45 p.m., this resident was observed to be sound asleep in bed with her mouth open at the time. During all observations the evening of 7/4/17 and thus far on 7/5/17, this resident has not been observed to be calling out and seemed somewhat sedated. On 7/5/17 at 2:35 p.m., the resident was observed to be awake and said she wanted to get out of bed and into her recliner. She appeared to have increased energy, a brighter affect and she smiled twice. On 7/5/17 at 3:55 p.m., the resident asked this worker for a diet Pepsi and plain potato chips. This request was shared with the director of nursing (DON) immediately after the interaction with the resident. On 7/5/17 at 5:42 p.m., this resident was observed in her recliner, covered totally with a blanket and was asleep. On 7/6/17 at 9:26 a.m., this resident asked for her breakfast tray to be removed and her purse picked up off the floor where she dropped it and could not reach it. She was thankful for visit and her affect was a bit brighter than prior. On 7/6/17 at 11:45 a.m., the resident was sitting in her recliner with her purse; she was drinking water and smiling. On 7/6/17 at 1:31 p.m., the resident was observed to be up in her recliner. She was awake, had a blanket on and was continuing to eat her sandwich for lunch. Her purse was near her and she was calm at this time. C. Staff Interviews Licensed practical nurse (LPN) #15 was interviewed on 7/5/17 at 11:10 a.m. She said there was an area that popped up on the MARs for each shift, either mid-morning for the night shift and around 2:00 p.m. for the day shift. She said she did input hours of sleep for the use of [MEDICATION NAME], but did not know how it was printed out and suggested I speak to medical records. She said resident #116 had been on [MEDICATION NAME] since she was admitted on [DATE] and she did expect to see a behavior monitoring log for this medication, but at present, she did not seeing that triggering in the MAR for this resident. The DON and the medical records technician #4 were interviewed together on 7/5/17 at 11:30 a.m. The DON said the facility did track hours of sleep for the use of hypnotics and information was used in the [MEDICAL CONDITION] drug committee and QAPI. The medical records technician, who had been working in that position for two months, could not see how to print the hours out, but said she would work on it. She admitted she did not know how to create the behavior monitoring form for this resident's [MEDICATION NAME] and she did not know the generic name and did not realize duloxetine was an anti-depressant. The DON said the facility did track behaviors for anti-depressants (even though tracking anti-depressants was not a requirement). The medical records technician said she was on the phone with their corporate office for assistance about the issue when the survey team started to ask questions about [MEDICAL CONDITION] medications and behavior monitoring. She was asked for June and July 2017 hours of sleep and a copy of target behaviors to be used to track effectiveness of [MEDICATION NAME] for resident #116. These copies were never provided. The DON was interviewed on 7/5/17 at 11:58 a.m. She was shown the behavior monitoring sheets for this resident for the use of [MEDICATION NAME]. She was asked how the facility monitored effectiveness for the routinely scheduled [MEDICATION NAME] and how they documented if any non-pharmacological interventions were attempted prior to administering the prn [MEDICATION NAME] for breakthrough anxiety. The DON reviewed the documents and said the interventions section was missing from this resident's behavior monitoring sheets. The DON was interviewed on 7/5/17 at 3:55 p.m. She said, I know when she was admitted , the [MEDICATION NAME] and [MEDICATION NAME] were not working. She said the primary care physician planned to add [MEDICATION NAME] to see if it would work on atypical anxiety/depression and if she responded to the [MEDICATION NAME], the plan was to discontinue the [MEDICATION NAME]. She said that was why she felt comfortable having the same target behavior for both classes of medications (i.e. benzodiazepines and anti-depressant medications). 3. Resident #113 Resident #113, age 45, was admitted on [DATE], discharged home on[DATE] and re-admitted on [DATE]. According to the face sheet, [DIAGNOSES REDACTED]. Resident #113 was a very recent admission and this resident did not have a current minimum data set (MDS) assessment completed yet. According to the MDS assessment dated [DATE], this resident was fully cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. It read this resident felt down, depressed or hopeless; had trouble concentrating and had trouble sleeping during two to six (or several) days during the 14-day lookback period. No behavior symptoms were noted. A. Record Review Medication Administration Record According to the July 2017 MAR, the resident received: - [MEDICATION NAME] (an anti-depressant), 20 mg QD (daily). This was ordered on [DATE]. - [MEDICATION NAME] SR (an anti-depressant), 150 mg QD. This was ordered on [DATE]. - [MEDICATION NAME], 3 mg QHS (every hour of sleep). This was ordered on [DATE]. Behavior Monitoring According to the July 2017 behavior monitoring sheet for the use of this resident's [MEDICATION NAME] (an anti-psychotic medication), the facility was tracking the behavior of withdrawn. The behavior monitoring sheet noted this behavior was observed on 7/2/17 and 7/4/17 on the evening shift and the outcome remained unchanged. It should be noted the resident's [MEDICATION NAME] was discontinued on 6/29/17 and the resident had not been receiving this medication at all the month of July after being readmitted back into the facility. According to the July 2017 behavior monitoring sheet for the use of this resident's [MEDICATION NAME], the facility was tracking loss of interest as the only target behavior for this medication: behaviors were observed on 7/2/17 and 7/4/17 on the evening shift and the outcome remained unchanged. There were no behavior monitoring sheets seen for use of [MEDICATION NAME] or [MEDICATION NAME] for resident #113. There was no evidence that hours of sleep were being tracked for the use of [MEDICATION NAME] for resident #113. Care Plans The care plan dated 7/1/17 read, (Resident's name), aka (resident's nickname), has [DIAGNOSES REDACTED]. Interventions included: Medication as prescribed; monitor for effectiveness and side effects; notify physician as needed .Try non-medical interventions; monitor for effectiveness. The care plan dated 7/3/17 read, (Resident's name) has periods of [MEDICAL CONDITION] - prescribed [MEDICATION NAME] prn. The interventions included: Administer medication as ordered. Record effectiveness Try non-pharmaceutical methods to promote sleep prior to prn medication. It should be noted this resident was not receiving prn [MEDICATION NAME]; the resident had scheduled [MEDICATION NAME]. Miscellaneous There was a note on the admission notice, which read, Saw bugs in his hospital room (delusions). The hospital history and physical (H&P) dated 6/29/17 read in pertinent part, admitted on [DATE] and DC'ed on 6/29/17 after CABG X 3 .Neurology: [MEDICAL CONDITION] & Confusion versus sleep deprivation - resolved. Home SSRI started. [MEDICATION NAME] no effect. [MEDICATION NAME] improved/resolved [MEDICAL CONDITION]. [MEDICATION NAME] for sleep, change from prn to scheduled. This H&P noted this resident did carry a [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. B. Resident Observations Resident #113 was observed several times throughout the day on 7/6/17. For the most part, the resident was observed sitting in his room, on the side of his bed, watching television. He was pleasant and social when approached for a conversation. C. Staff Interviews The DON was interviewed on 7/6/17 at 9:10 a.m. She said she needed to track down what [DIAGNOSES REDACTED]. She said the facility could not find any hours of sleep being tracked for residents throughout the facility, but it was her expectation to see [MEDICATION NAME] being monitored and hours of sleep to be tracked. She said if this same thing was cited last year, they definitely should have corrected the issue for this year. She said, I don't know what's going on here, but maybe they can revamp the system. The DON was interviewed on 7/6/17 at 2:15 p.m. She said she had an issue with staff doing behavior monitoring on a medication the resident was not receiving. She said the behavior monitoring sheet for the use of [MEDICATION NAME] should not have been created. The DON said someone should have manually deleted this behavior monitoring sheet. She said staff should have seen the name of the medication on the top of the pop-up page and realized this resident was not prescribed [MEDICATION NAME] in the facility. The facility's pharmacy consultant #20 was interviewed via telephone on 7/6/17 at 2:37 p.m. He said the facility and he discussed the resident's behaviors during the quarterly [MEDICAL CONDITION] meetings and the discussions should be documented on those meeting notes. He said, as a practice, hours of sleep should be documented and monitored in relation to the use of any medication or herbal as a hypnotic; he said he would expect to see hours of sleep being tracked for [MEDICATION NAME] being used for [MEDICAL CONDITION]. He said, If you take a hypnotic of any kind, including herbals, hours of sleep should be documented. He said when he did his monthly medication reviews, he did not, as a rule, track the target behaviors. He said agitation or anxiousness were not accepted [DIAGNOSES REDACTED]. He said there was a need for behaviors to be refined, that specific behaviors came under the guise of [MEDICAL CONDITION] medications and those medications were reviewed on a quarterly basis. He said it was a problem if the facility was tracking behaviors on a medication the resident had not been receiving, unless they were continuing to see delusional, psychotic behaviors continuing post-surgery in relation to resident #113. This pharmacy consultant followed up via e-mail on 7/6/17 at 5:45 p.m. and re-iterated, Regarding the [MEDICATION NAME], if they are written as a sleeper, then I would recommend to the facility to monitor sleep patterns. I will reinforce that at our next [MEDICAL CONDITION] and QA meeting in July. 4. Resident #48 Resident #48, age under 65, was admitted on [DATE]. According to the face sheet, [DIAGNOSES REDACTED]. According to the 5/13/17 MDS assessment, the resident was cognitively intact with a BIMS score of 15 out of 15, and had depressive mood symptoms with a severity score of five. She required limited assistance with activities of daily living, and took antidepressant and anticoagulation medication daily. No hypnotic medication use was noted. A. Record Review Care Plan The care plan, initiated 11/23/16 and not revised, identified periods of [MEDICAL CONDITION] - prescribed [MEDICATION NAME] routine. The goal was for the resident to have a restful night's sleep. Approaches included administer medication as ordered and record effectiveness. Physician Orders The July 2017 physician orders [REDACTED].>-[MEDICATION NAME] 50 mg tablet, one tablet every evening at bedtime for [MEDICAL CONDITION], order start date 5/10/16. -Behavior monitoring for [MEDICATION NAME]. Target behavior sleeplessness, order start date 5/10/16, order interval daily. Medication Administration Records (MARs) Review of June and July 2017 MARs revealed the resident was administered [MEDICATION NAME] per physician orders, but there was no evidence that hours of sleep were monitored. Nurses' Notes Nurses' notes, reviewed 2/1/17 through 7/5/17, revealed no documentation of hours of sleep or [MEDICATION NAME] effectiveness. B. Staff Interviews LPN #15, who was familiar with the resident, was interviewed on 7/5/17 at 3 p.m. She reviewed the resident's electronic record and confirmed that hours of sleep were not documented. She acknowledged that hours of sleep should have been documented for the use of [MEDICATION NAME] for [MEDICAL CONDITION], otherwise there was no way to know if it was effective. The DON was interviewed on 7/6/17 at 9:15 a.m. The DON acknowledged hours of sleep were not documented, and said they needed to put a better system in place to address the issue. 5. Resident #41 Resident #41, age 73, was admitted on [DATE]. According to the face sheet, [DIAGNOSES REDACTED]. According to the 4/14/17 MDS assessment, the resident had severe cognitive impairment with a BIMS score of seven out of 15. No behavioral symptoms were noted with the exception of wandering. Depressive symptoms were noted with a mood severity score of eight. She needed supervision for activities of daily living. She took antidepressant medication daily. A. Record Review Care Plan The care plan, initiated 5/1/17, identified exhibits episodes of resisting care, she especially resists bathing, getting blood work done. 7/3/17 Started on [MEDICATION NAME] QD (every day). The goal was for episodes of resisting care to decrease. Approaches included: -Change how you introduce activities known to cause resistance. -Explain what you will be doing before starting and repeat as often as needed. -If resident resists, back off and try again later. -Change the way you approach the resident. -Avoid situations that are antecedents to the resident's behavior, don't rush or push her into doing anything she declines doing. -Contact resident's daughter if assistance is needed, especially with bathing, getting dressed, etc. The 5/1/17 care plan further identified the resident self-isolated in her room and slept in the middle of the day. She will go to the dining room if comfortable and collect used creamer containers and organize the condiments. The care plan initiated on 5/22/17 identified physical behaviors (related to) her advancing Alzheimer's and slapped a nurse who was trying to draw blood from her. Behavior Monitoring Review of behavior monitoring documentation revealed the target behaviors for the resident's antidepressant, antianxiety and antipsychotic medications were vague, i.e. anxiety, agitation. Further, the target behaviors were not individualized in order to identify and monitor which medication was administered for which specific target behaviors. Progress Notes A palliative care visit note dated 5/31/17 included: Seen for anxiety and agitation . increased confusion and increased anxiety . wandering more frequently . episodes of agitation and one known episode of aggression. Primary restarted [MEDICATION NAME] order with some use over the last week . staff report [MEDICATION NAME] neither helps nor harms patient's behavior and s/s (symptoms). Will increase [MEDICATION NAME] from 22.5 mg to 30 mg every day at hs (bedtime). Will monitor for efficacy. Family reports relief of anxiety/agitation symptoms w/ medication care plan change. -The resident's medications included [MEDICATION NAME] (antianxiety) 0.5 mg three times daily as needed and [MEDICATION NAME] (antidepressant) 30 mg daily. A physician visit progress note dated 7/3/17 included: Discussed with NP (nurse practitioner) who will call pt's dtr to trial [MEDICATION NAME] 25mg PO mornings. If she's doing better in 1 week, will start to wean [MEDICATION NAME] at that time. Physician Orders July 2017 physician orders [REDACTED].>-[MEDICATION NAME] (antipsychotic) 25 mg daily, start date 7/3/17 -[MEDICATION NAME] (antidepressant) 15 mg tab, give one and one half (22.5 mg) every evening, start date 7/11/17 -[MEDICATION NAME] 0.5 mg give one tablet by mouth every 8 hrs as needed for anxiety or agitation, start date 5/22/17 -Behavior monitoring flow sheet related to [MEDICATION NAME]. Monitor target behavior aggressiveness every shift. -Behavior monitoring flow sheet related to [MEDICATION NAME]. Monitor target behavior agitation every shift. -There was no order for behavior monitoring for [MEDICATION NAME] other than the order (above) for anxiety or agitation. Medication Administration Record Review of the July 2017 MAR indicated [REDACTED] -Behavior monitoring notes for [MEDICATION NAME] and aggressiveness, ordered 4/5/17. Nurses were checking off and noting zero behaviors at 2 a.m., and marked one behavior on 7/4/17. -Behavior monitoring notes for [MEDICATION NAME] and agitation, ordered 7/3/17, showed no evidence documentation of behavioral symptoms. -[MEDICATION NAME] had no target behavior monitoring instructions, and was not given during June or July 2017. B. Staff Interview The DON was interviewed on 7/6/17 at 9:15 a.m. She acknowledged the resident's target behaviors were not individualized and needed to describe how anxiety, agitation and aggressiveness were exhibited. The DON said they needed to put a better system in place to address the issues. 6. Resident #31 Resident #31, age 94, was admitted to the facility originally on 10/6/14 and re-admitted [DATE]. According to the current physician orders, [DIAGNOSES REDACTED]. According to the 5/21/17 MDS assessment, resident #31 had a BIMS score of nine out of 15, which indicated she was moderately impaired. She had trouble falling or staying asleep or sleeping too much, and no [MEDICAL CONDITIONS] or rejection of care. She had no physical or verbal behavioral symptoms directed toward others. She received antipsychotic, antidepressant, and hypnotic medications seven of the previous seven days during the look-back period, and anti-anxiety medications four of the previous seven days. She required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. A. Record Review and Initial Interviews [MEDICATION NAME] Record Review The care plan, initiated 4/30/17 and not yet updated, identified the resident had a [DIAGNOSES REDACTED]. The approaches included administering [MEDICATION NAME] as ordered and monitoring and recording the effectiveness, when offering assistance, approach her in a calm manner and call her by name, speak to her in clear, concise sentences and allow ample time for her to answer, and encourage her to participate in activities of her choice. The current orders for July 2017 included the following orders: -[MEDICATION NAME] 25 mg tablet by mouth at bedtime for the [DIAGNOSES REDACTED]. -Behavior monitoring related to [MEDICATION NAME]. Monitor target behavior: Agitation, started 4/23/17 The Medication Administration Record [REDACTED]. The MAR for July 1-4, 2017 was reviewed and documented the same as above. According to Saunders Nursing Drug Handbook 2016, (2016), pages 1045 and 1046: [MEDICATION NAME] .Produces moderate sedation .Half-life: six hours . The MAR indicated [REDACTED]. Monitor target behavior agitation, which was scheduled at 2:00 a.m. and 2:00 p.m. each day. A total of eight day shifts had documentation one behavior occurred on each of those days. However, the behavior monitoring did not include documentation of specific targeted behaviors. Interview The licensed practical nurse (LPN) #16 who was caring for resident #31 was interviewed on 7/6/17 at 1:18 p.m., and she confirmed the resident was receiving [MEDICATION NAME] for dementia with behavior disturbances. She said she had noticed the resident to be sleepy or drowsy during the day and stated, Two naps is her routine. The LPN explained the resident's agitated behaviors included ripping her brace off after hip surgery and refusing to wear it and throws it on the ground. She said she was also combative with cares at times and would call her daughter on the phone late at night. The LPN showed the [MEDICATION NAME] blister pack from the medication cart and verified it was not an extended release tablet. [MEDICATION NAME] (Cross-Reference F428) Record Review The care plan, initiated 4/30/17 and not yet updated, identified the resident had difficulty sleeping at night and took [MEDICATION NAME] (hypnotic) for [MEDICAL CONDITION], with a goal to sleep six-to-eight hours each night. The approaches included encouraging her to be up in a chair and out of her room for each meal, encourage her to be active during the day and participate in activities of choice, Sleep Hygiene protocol, offer warm milk or tea at bedtime, lotion massage at bedtime, and encourage to stay up later in the evenings, and document on the Medication Administration Record [REDACTED] The current orders for July 2017 included the following order: [MEDICATION NAME] 8 milligrams (mg), give one-half (4 mg) tablet by mouth at bedtime, started 4/23/17. The orders did not include the instructions to monitor for hours of sleep. The MAR for June 2017 was reviewed and documented the [MEDICATION NAME] 4 mg (half tablet) was given by mouth at bedtime each evening, and was scheduled at 8:00 p.m. The MAR for July 1-4, 2017 was reviewed and documented the same as above. The medical record was reviewed in its' entirety and was found to be void of any documentation of the resident's hours of sleep. Interview LPN #16 was interviewed on 7/6/17 at 1:18 p.m., and she confirmed resident #31 was receiving [MEDICATION NAME] to help her sleep. She said hours of sleep were routinely monitored for residents who received hypnotic medications during the night shift, but she did not document any during the day. [MEDICATION NAME] Record Review The care plan, initiated 4/30/17 and last updated 5/4/17, identified the resident exhibited moderate to extreme anxiety related to dementia or concern/worry as evidenced by verbal expressions of distress or persistent worrying, frequent complaints, or motor agitation. She had an [MEDICATION NAME] (anti-anxiety) order to be given as needed for anxiety or agitation. The approaches included evaluating potential causative factors that might contribute to feelings of anxiety like hunger, thirst, and pain, and address those factors, encourage her to talk to staff about anything bothering her to get it off her mind, encourage participation in activities, administer medication for anxiety as needed, and staff would remind resident when she was being non-compliant of the dangers of her behaviors. The current orders for July 2017 included the following order: [MEDICATION NAME] 0.5 mg tablet by mouth every eight hours as needed for anxiety/agitation, started 7/1/17. The orders did not include instructions to monitor for specific target behaviors of her anxiety or agitation. The MAR for June 2017 was reviewed and documented the [MEDICATION NAME] was given eight times and included the following notes: -6/1/17 at 7:36 p.m. = medicated for anxiety per patient request .negative statements -6/2/17 at 6:57 p.m. = negative statements -6/3/17 at 6:44 p.m. = negative statements -6/4/17 at 2:24 p.m. = grabbing -6/6/17 at 6:07 p.m. = negative statements -6/7/17 at 6:32 p.m. = negative statements -6/25/17 at 6:22 p.m. = negative statements -6/30/17 at 8:02 p.m. = negative statements The MAR for July 1-4, 2017 was reviewed and documented the [MEDICATION NAME] had not yet been given. Interview LPN #16 was interviewed on 7/6/17 at 1:18 p.m., and she confirmed resident #31 received [MEDICATION NAME] because she became combative at times, and she felt the medication helped the resident calm down. B. Resident Observations On 7/4/17 at 2:49 p.m., resident #31 was observed sitting in a recliner in the common TV room on the B hall. The TV channel was on a game show and she did not appear to be engaged in it, and she appeared fidgety, adjusting her scarf and sweater and picking up food bits and putting them in her mouth. On 7/5/17 at 9:28 a.m., resident #31 was observed lying in bed in her room and appeared to still be asleep with covers pulled up to her shoulders. The room door was open to the hallway and the window shades were open. On 7/6/17 at 8:44 a.m., resident #31 was observed sitting in her wheelchair at a table alone in the main dining room. Her eyes were closed and she appeared to be asleep. She had food on her plate that appeared partially eaten. C. Staff Interviews Certified nurse aide (CNA) #21 was interviewed on 7/6/17 at 1:24 p.m., and she confirmed she routinely cared for resident #31. She said she did not observe the resident to be agitated very often and explained she sometimes would become verbally accusatory toward staff, and the behaviors would occur more in the evenings, towards the end of her shift. Registered nurse #13 was interviewed on 7/6/17 at 9:48 a.m., and he said he would expect hours of sleep to be documented if a resident was receiving a hypnotic medication specifically for sleep. The pharmacy consultant was interviewed on 7/6/17 at 2:40 p.m., and he confirmed he was at the facility once or twice each month. He said he was unsure why resident #31 was receiving [MEDICATION NAME] or [MEDICATION NAME] and explained he would look it up and provide further information. He said the resident behaviors were discussed at the quarterly [MEDICAL CONDITION] meetings and documented in those notes on a quarterly basis. He said, Agitation covers a lot of stuff and is usually not an accepted [DIAGNOSES REDACTED]. He said if a resident was receiving a hypnotic medication, hours of sleep should be monitored by the facility staff. -The pharmacy consultant sent an email with follow up information at 5:45 p.m., later that day and explained resident #31 previously had a [MEDICATION NAME] AM dose reduced (stopped) on 4/13/17, and the physician wanted to see how the single evening dose worked with her delusional disorder. The DON was interviewed on 7/6/17 at 10:17 a.m., and she was asked to explai