Every finding on record at Gallatin Center for Rehabilitation and Healing

Based on the policy review, medical record review, observation, and interview, the facility failed to ensure medications were properly stored when there was opened and undated medication on 1 of 19 (medication cart 1B) med storage areas. The findings include: 1. Review of the facility's policy titled, Medications Storage, non dated, revealed .It is the policy of the facility that medications and biologicals are stored securely and properly following manufacturer's recommendations or those of the supplier .Outdated, contaminated, or deteriorated medications containers that are cracked, soiled, or without secure closures and removed from stock, disposed of according to procedure for medication disposal and reordered from the pharmacy . 2. Review of the medical record revealed Resident #172 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease and Depression. Review of Minimum data Set (MDS) dated [DATE], revealed a Brief interview for Mental Status (BIMS) score of 15, which indicated Resident #172 had intact cognition. Review of the physician order dated 7/24/2024, revealed .Ipratropium-Albuterol Solution [a combination of bronchodilators that are breathed in through the mouth to open up the air passages in the lungs] 0.5-2.5 (3) MG [milligram]/3ML [milliliter] 3 ml inhale orally via [by] nebulizer every 6 hours for Bronchospasm . Observation during med pass at the 1b med cart on 4/22/2025 at 3:04 PM, revealed LPN DD an opened and undated Ipratropium-Albuterol Solution (individual plastic vials of breathing treatment). LPN confirmed the Ipratropium-Albuterol Solution box and aluminum packaging was opened and needed an open date. LPN DD asked LPN Manager U what to do since the aluminum package and box had no open date. LPN Manager U stated .dispose . LPN DD put the Ipratropium-Albuterol Solution (individual plastic vials of breathing treatment) in the trash bag on the med cart. During an interview on 4/ 4/22/2025 at 3:58 PM, LPN Manager U confirmed the med cart's trash bag is not an appropriate place to dispose the Ipratropium-Albuterol Solution. During an interview, in the conference room, on 4/23/2025 at 4:24 PM Director of Nurses (DON) confirmed the Ipratropium-Albuterol Solution packaging should not be opened and undated. 51740

Based on facility policy review, medical record review, and interviews, the facility failed to properly destroy narcotic medications for 1 resident (Resident #918) of 13 residents reviewed for narcotic medication use. The findings include: 1. Review of the facility's undated policy titled, Controlled Substances, revealed .controlled substances shall be destroyed/ wasted in the presence of 2 licensed nurses and documentation to reflect as such . 2. Review of the medical record revealed Resident #918 was admitted to the facility on [DATE], with diagnoses including Right Pubis (Pelvis) Fracture, Muscle Weakness, and Osteoarthritis. Review of the comprehensive care plan for Resident # 918 dated 2/22/2025, revealed the resident was at risk for pain with interventions to observe for pain with medication side effects every shift. Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #918 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. The resident required staff set up/ clean up assistance with eating and personal hygiene. Further review revealed the resident received opioid medications for pain. Review of a physician's order for Resident #918 dated 3/13/2025, revealed an order for Hydrocodone-Acetaminophen (APAP) (narcotic pain-relieving medication) 7.5-325 milligrams (MG) administer 1 tablet by mouth every 4 hours as needed (PRN) for pain. Review of a Controlled Drug Administration Record for Resident #918, revealed the following recorded entries for the Hydrocodone-APAP 7.5-325 MG medication: .date .3/13 [2025] .time .1800 [6 PM] .amt [amount] used .0 [tablet] .amt wasted .1 [tablet] .witnessed [blank] .admin [administered] by .[Licensed Practical Nurse (LPN) DD] .wasted [handwritten by LPN DD] .amt rem [remaining] .18 [tablets] .date .3/13 [2025] .time .1830 [6:30 PM] .amt used .0 .amt wasted .1 .witnessed [blank] .admin by .[LPN DD] .wasted [handwritten by LPN DD] .amt rem .17 .3/13 [2025] .2100 [9:00 PM] .amt used .0 .amt wasted .1 .witnessed [blank] .admin by .[LPN DD] .wasted [handwritten by LPN DD] .amt rem .16 .3/13 [2025] .2130 [9:30 PM] .amt used .0 .amt wasted .1 .witnessed [blank] .admin by .[LPN DD] .wasted [handwritten by LPN DD] .amt rem .15 .3/13 [2025] .2200 [10:00 PM] .amt used .0 .amt wasted .1 .witnessed [blank] .admin by .[LPN DD] .wasted [handwritten by LPN DD] .amt rem .14 .3/13 [2025] .2230 [10:30 PM] .amt used .0 .amt wasted .1 .witnessed [blank] .admin by .[LPN DD] .wasted [handwritten by LPN DD] .amt rem .13 .3/13 [2025] .2300 [11 PM] .amt used .0 .amt wasted .1 .witnessed [blank] .admin by .[LPN DD] .wasted [handwritten by LPN DD] .amt rem .12 . 3/13 [2025] .2230 [11:30 PM] .amt used .0 .amt wasted .1 .witnessed [blank] .admin by .[LPN DD] .wasted [handwritten by LPN DD] .amt rem .11 .3/14 [2025] .0000 [12 AM] .amt used .0 .amt wasted .1 .witnessed [blank] .admin by .[LPN DD] .wasted [handwritten by LPN DD] .amt rem .10 .3/14 [2025] .0030 [12:30 AM] .amt used .0 .amt wasted .1 .witnessed [blank] .admin by .[LPN DD] .wasted [handwritten by LPN DD] .amt rem .9 . During a telephone interview on 4/22/2025 at 5:31 PM, LPN EE stated she worked night shift on 3/13/2025 through 3/14/2025 with LPN DD (assigned on the adjacent hallway). LPN EE stated LPN DD did not ask her to witness the destruction or waste of the narcotic medications for Resident #918 at any time during her shift on 3/13/2025 through 3/14/2025. During a telephone interview on 4/23/2025 at 8:34 AM, the Medical Director (MD) stated he expected the nurses to follow the facility's policy for narcotic medication destruction which included destroying or wasting the narcotic medication with a witness. During an interview on 4/23/2025 at 9:35 AM, the Administrator confirmed LPN DD did not follow the facility's policy for narcotic medication destruction when LPN DD failed to destroy or waste Resident #918's Hydrocodone-APAP medication multiple times on 3/13/2025 through 3/14/2025.

Based on medical record review, and interview, the facility failed to maintain accurate medical records related to dental appointments for 1 of 2 (Resident #130) reviewed for dental services. The findings include: 1. Review of the facility's undated policy titled, Dental Services, revealed .Social services representative will assist residents with appointments, transportation arrangements .Direct care staff will assist residents with denture care .All dental services provided are recorded in the residents medical record . 2. Review of the medical record revealed Resident #130 was admitted to the facility on [DATE], with diagnoses including of Hemiplegia/Hemiparesis, Cerebral Atherosclerosis, Atrial Fibrillation, and Anemia. Review of the significant change Minimum Data Set (MDS) dated [DATE], revealed Resident #130 had a Brief Interview for Mental Status Score (BIMS) of 14, indicating the resident was cognitive intact and required set up for oral and personal hygiene. Review of the facility's Transportation Scheduling List for February 2025 revealed .[Named Resident #130] .2:00 PM .Appointment with [Named Dentist] .Transport With .Van . Review of the facility's ancillary services February 2025 calendar revealed dental onsite clinic scheduled for 2/7/2025 and again on 2/20/2025. Review of a [named dental service] Progress Note dated 2/7/2025 revealed .Not Seen Resident was not seen because . resident did not present to clinic. Review of the facility's ancillary services April 2025 calendar revealed dental hygienist onsite clinic scheduled for 4/4/2025. Review of the Care Plan dated 4/3/2025, revealed .at risk for oral/dental health problems r/t [related to] missing teeth .Observe for s/sx [signs and symptoms] of oral/dental problems .Pain .toothache .Abscess .Teeth missing, loose, broken, eroded, decayed .Provide mouth care as tolerated . Review of a [Named Dental Service] dated 4/15/2025, confirmed Resident #130 was on the dental hygienist list to be seen. Review of a [Named Dental Service] Progress note dated 4/15/2025, revealed .Not seen Resident was not seen, not brought to dentist. Review of the medical record revealed the facility was unable to provide documentation that Resident #130 failed to show up for dental appointments. During an interview on 4/22/25 at 2:58 PM, the Social Service Director (SSD) was asked to read a [named dental service] dental progress note and to explain what it meant when it stated, resident did not present to clinic or resident was not brought to clinic. The SSD stated, I can't recall . During an interview on 4/23/25 at 2:45 PM, the Administrator confirmed that documentation should be in the resident's medical record when residents are unable to present to the dental clinic for appointments and should be rescheduled.

Based on the policy review, medical record review, observation, and interview, the facility failed to ensure proper infection control practices were followed when 1 of 6 staff members (Licensed Practical Nurse (LPN) DD) failed to disinfect reusable equipment before use and after use and failed to properly perform hand hygiene. When 2 of 2 staff members (Certified Nurse Assistant (CNA) EE and Registered Nurse (RN) FF) failed to wear Personal Protective equipment (PPE) in a Contact Isolation room and during direct care in an Enhanced Barrier Precautions room. The findings include: 1. Review of the undated facility's policy titled, HAND HYGIENE, revealed .This facility considers hand hygiene the primary means to prevent the spread of infections .Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations .When hands are visibly soiled .After patient care encounter and/or hand sanitizer .After contact with a resident with infectious diarrhea including but not limited to infections caused by norovirus, salmonella, shigella and C. difficile .The use of gloves does not replace hand washing/hand hygiene . Review of the facility's policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment, dated 2001, revealed .Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected using appropriate cleaning/disinfecting agents as required .Non-critical items are those that come in contact with intact skin but not mucous membranes .Reusable items are cleaned and disinfected or sterilized between residents .stethoscopes, durable medical equipment . Review of the undated facility's policy titled, Nebulizer Treatment Protocol, revealed .This policy is to instruct the proper use of aerosolized medications to the lower airways via small volume nebulizer .Rinse medication nebulizer after each use and change routinely and as needed . Review of the undated facility's policy titled, Enhanced Barrier Precautions, revealed .Enhanced barrier precautions (EBPs) are utilized to reduce the transmission of multi-drug resistant organisms (MDROs) to residents .EBPs employ targeted gown and glove use in addition to standard precautions during high contract resident care activities .EBPs are indicated for residents with wounds and/or indwelling medical devices regardless of MDRO colonization .Wounds generally include chronic wounds .Indwelling medical devices include central lines, urinary catheters, feeding tubes, and tracheostomies. Peripheral IV catheters are not considered an indwelling medical device for purpose of EBPs . Review of the facility's policy titled, Medications Storage, non dated, revealed .It is the policy of the facility that medications and biologicals are stored securely and properly following manufacturer's recommendations or those of the supplier .Outdated, contaminated, or deteriorated medications containers that are cracked, soiled, or without secure closures and removed from stock, disposed of according to procedure for medication disposal and reordered from the pharmacy . Review of the facility's policy titled, Isolation - Categories of Transmission-Based Precautions, dated 2001, revealed Transmission-Based Precautions shall be used when caring for residents who are documented or suspected to have communicable diseases or infections that can be transmitted to others. Implement Contact Precautions for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact. 2. Review of the medical record revealed Resident #172 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease and Depression. Review of quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief interview for Mental Status (BIMS) score of 15, which indicated Resident #172 had intact cognition. Review of the physician order dated7/24/2024, revealed .Ipratropium-Albuterol Solution [a combination of bronchodilators that are breathed in through the mouth to open up the air passages in the lungs] 0.5-2.5 (3) MG [milligram]/3ML [milliliter] 3 ml inhale orally via [by] nebulizer every 6 hours for Bronchospasm . Observation during med pass, at 1b med cart on 4/22/2025 at 3:04 PM, revealed LPN DD touched her face, failed to perform hand hygiene, gather the resident's items, and entered the resident's room. LPN DD gave the oral medication, removed the pulse oximeter (ox-a device, placed on the finger, used to measure oxygen saturation) out of her pants pocket and place it on the resident's right finger. LPN failed to disinfect the pulse ox before use. LPN DD used the stethoscope to listen to the resident's lung sounds and placed the stethoscope around her neck. LPN DD connected the nebulizer tubing to the machine, opened and poured the medication in the nebulizer, and started the machine. After the completion of the treatment, LPN DD failed to disconnect and rinse the mouthpiece and place it on a barrier to dry before placing it in a clear plastic bag. LPN DD removed the stethoscope from around her neck and removed the pulse ox from her pocket, listened to the resident's lung sounds and placed the pulse ox on the resident's finger. LPN DD failed to clean the stethoscope and the pulse ox before use. LPN DD returned to the med cart, used an alcohol pad to wipe the stethoscope and placed the pulse ox in her pocket. LPN DD failed to properly disinfect the stethoscope and pulse ox after use. 3. Review of the medical record revealed Resident #181 was admitted to the facility on [DATE], with diagnoses including Clostridium Difficile, Diarrhea, and Psychosis. Review of the admission MDS dated [DATE], revealed a BIMS score of 7, which indicated Resident #181 had severely impaired cognition. Review of the physician order dated 4/18/2025, revealed Resident #181 had an order for Contact isolation related to Clostridium Difficile (c-diff a bacterium that causes an infection, a symptom is usually diarrhea). Review of the physician order dated 4/21/2025, revealed Resident #181 had an order Vancomycin [an antibiotic, used to kill bacteria or prevent its growth] for c-diff. Observation and interview during dining on 4/22/2025 at 7:51 AM, revealed CNA EE entered Resident #181's room with no PPE on, left the door opened, placed the meal tray on the resident's over the bed table, rearranged and placed the resident's bed sheet on the resident, used the bed remote to raise the head of bed, pushed the over the bed table closer to the resident. CNA EE removed the lid from the meal tray, opened the resident's juice and yogurt. CNA EE failed to perform hand hygiene after touching potentially contaminated objects. CNA EE confirmed the resident had a contact precautions signage on the door and a gown and gloves should have been worn before the room was entered. CNA EE confirmed staff should remove and dispose of PPE inside the contact isolation room and perform hand hygiene before leaving. CNA EE failed to wear PPE in a contact isolation room and failed to perform hand hygiene after touching potentially contaminated items. 4. Review of the medical record revealed Resident #393 was admitted to the facility on [DATE], with diagnoses including Infection to Right Knee and Diabetes. Review of the admission MDS dated [DATE], revealed a BIMS score of 15, which indicated Resident #393 had intact cognition. Resident #393 had a PICC line (Peripherally Inserted Central Catheter, used as a route of medication through the veins). Review of the physician order dated 4/15/2025, revealed . Enhanced Barrier Precautions every day and night shift for PICC. Review of the physician order dated 4/17/2025, revealed .Change PICC [peripherally inserted central catheter] dressing once weekly .every Mon [Monday] AND as needed . Review of the physician order dated 4/17/2025, revealed Resident #393 had an order for Ceftriaxone [an antibiotic] to be given intravenously (iv) one time a day for right knee prosthetic joint infection. Review of the physician order dated 4/18/2025, revealed ' .Venofer Intravenous Solution 20 MG[milligram]/ML [milliliter] (Iron Sucrose) Use 100 mg intravenously one time a day for supplement for 5 Days . A random observation in the resident's room on 4/23/2025 at 8:38 AM, revealed. RN FF connected Resident #393's iv tubing to the PICC line with no gown on. RN FF failed to wear proper PPE during direct care at the resident's PICC line. During an interview on 4/23/2025 at 8:47 AM, RN FF was asked should a gown and gloves be worn during care at a PICC line. RN FF stated, No. During an interview, in the conference room, on 4/23/2025 at 4:04 PM and 4:16 PM, the Director of Nurses (DON) confirmed staff should wear a gown and gloves when entering a resident's room who is on contact isolation. The DON confirmed residents with wounds, foley catheters, a picc line or midline should be on enhanced barrier precautions and staff should wear a gown and gloves when providing direct care or in close contact. During an interview, in the conference room, on 4/23/2025 at 4:24 PM Director of Nurses (DON) confirmed the stethoscope and pulse ox should be cleaned before and after use with sanitizing wipes. The DON confirmed when removed from a staff 's pocket, the pulse ox should be cleaned before use. 51740

Based on policy review, financial document review, medical record review, and interview, the facility failed in their fiduciary responsibility in holding, safeguarding, managing, and accounting for the deposited personal funds for 13 of 80 (Resident #3, #5, #15, #48, #51, #58, #75, #80, #84, #92, #97, #116, and #119) sampled residents. The findings: 1. Review of the facility policy titled, Management of Residents' Personal Funds, dated 2001, revealed .Should the facility manage the resident's funds, the facility will act as a fiduciary of the resident funds and hold, safeguard, manage, and account for the personal funds of the resident .funds will be managed in accordance with local, state, federal regulations . 2. Review of medical record revealed Resident #3 was admitted on [DATE], with diagnoses including Diabetes, Hypertension, and Bipolar. Review of the Patient Trust Fund Quarterly Statement, dated 4/21/2025, revealed Resident #3's balance was $6067.87 which was $3167.87 over the $2900.00 limit. 3. Review of medical record revealed Resident #5 was admitted on [DATE], with diagnoses including Diabetes, Cognitive Communication Deficit, and Rheumatoid Arthritis. Review of the Patient Trust Fund Quarterly Statement, dated 4/21/2025, revealed Resident #5's balance was $11,053.23 which was $8153.23 over the $2900.00 limit. 4. Review of medical record revealed Resident #15 was admitted on [DATE], with diagnoses including Dementia, Diabetes, and Schizophrenia. Review of the Patient Trust Fund Quarterly Statement, dated 4/21/2025, revealed Resident #15's balance was $8380.37 which was $5480.37 over the $2900.00 limit. 5. Review of medical record revealed Resident #48 was admitted on [DATE], with diagnoses including Dementia, Kidney Disease, and Hypertension. Review of the Patient Trust Fund Quarterly Statement, dated 4/21/2025, revealed Resident #48's balance was $6,027.00 which was $3127.00 over the $2900.00 limit. 6. Review of medical record revealed Resident #51 was admitted on [DATE], with diagnoses including Diabetes and Chronic Obstructive Pulmonary Disease. Review of the Patient Trust Fund Quarterly Statement, dated 4/21/2025, revealed Resident #51's balance was $4531.72 which was $1631.72 over the $2900.00 limit. 7. Review of medical record revealed Resident #58 was admitted on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Diabetes, and Schizoaffective disorder. Review of the Patient Trust Fund Quarterly Statement, dated 4/21/2025, revealed Resident #58's balance was $7254.24 which was $4354.24 over the $2900.00 limit. 8. Review of medical record revealed Resident #75 was admitted on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Paraplegia, Diabetes, and Heart Failure. Review of the Patient Trust Fund Quarterly Statement, dated 4/21/2025, revealed Resident #75's balance was $3166.38 which was $266.38 over the $2900.00 limit. 9. Review of medical record revealed Resident #80 was admitted on [DATE], with diagnoses including Dementia. Review of the Patient Trust Fund Quarterly Statement, dated 4/21/2025, revealed Resident #80's balance was $13167.48 which was $10267.48 over the $2900.00 limit. 10. Review of medical record revealed Resident #84 was admitted on [DATE] with diagnoses including Alzheimer's, Dementia, and Bipolar. Review of the Patient Trust Fund Quarterly Statement, dated 4/21/2025, revealed Resident #84's balance was $4537.48 which was $1637.48 over the $2900.00 limit. 11. Review of medical record revealed Resident #92 was admitted on [DATE], with diagnoses including Dementia and Bipolar. Review of the Patient Trust Fund Quarterly Statement, dated 4/21/2025, revealed Resident #92's balance was $5051.65 which was $2151.65 over the $2900.00 limit. 12. Review of medical record revealed Resident #97 was admitted on [DATE], with diagnoses including Heart Failure and Diabetes. Review of the Patient Trust Fund Quarterly Statement, dated 4/21/2025, revealed Resident #97's balance was $7579.98 which was $4679.98 over the $2900.00 limit. 13. Review of medical record revealed Resident #116 was admitted on [DATE], with diagnoses including Cerebral Palsy and Paraplegia. Review of the Patient Trust Fund Quarterly Statement, dated 4/21/2025, revealed Resident #116's balance was $10,416.96 which was $7516.96 over the $2900.00 limit. 14. Review of medical record revealed Resident #119 was admitted on [DATE], with diagnoses including Heart Failure and Diabetes. Review of the Patient Trust Fund Quarterly Statement, dated 4/21/2025, revealed Resident #119's balance was $11.440.87 which was $ 8540.87 over the $2900.00 limit. 15. During an interview on 4/23/2025 at 11:36 AM, with the Regional Business Office Consultant (RBOC), the EBOC was asked when she became aware of the balance overages for the resident trust funds. The RBOC stated, I came to the facility when the previous Business Office Manager left on 2/26/2025. I became aware of it then. The RBOC was asked when she attempted to resolve the trust fund overages. The RBOC stated, This week.

Based on facility policy review, personnel file review, medical record review, facility documentation review, and interview, the facility failed to ensure the residents' rights to be free from misappropriation of property due to diversion of medications including controlled substances was maintained for 3 residents (Resident #911, #910, and #52) of 13 residents reviewed for misappropriation of resident property. The findings include: 1. Review of the facility policy titled, Residents Rights, dated 2001, revealed .Federal and state laws guarantee certain basic rights to all residents of this facility .these rights include the resident's right to .be free from abuse, neglect, misappropriation of property, and exploitation . Review of the facility policy titled, Controlled Substances, undated, revealed .The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled substances .The Director of Nursing [DON] Services will identify staff members who are authorized to handle controlled substances .Nursing staff must count controlled medications at the end of each shift .nurse coming on duty and the nurse going off duty must make the count together .They must document and report any discrepancies to the Director of Nursing Services .Director of Nursing/Designee Services shall investigate any discrepancies in narcotics reconciliation to determine the cause and identify any responsible parties and shall report to the Administrator .The Director of Nursing Services/Designee shall consult with the provider pharmacy and the Administrator to determine whether any further legal action in indicated . 2. Review of Registered Nurse (RN) I's personnel file revealed the RN was employed by the facility from 6/7/2023 through 6/30/2023. In 11/2023, RN I was found guilty of aggravated criminal trespassing and theft of up to $1,000.00. RN I was sentenced to 180 days of supervised probation, monetary restitution, and court costs. 3. Review of the medical record revealed Resident #911 was admitted to the facility on [DATE], with diagnoses including Encounter for Orthopedic Aftercare following Surgical Amputation, Diabetes, Chronic Pain, and Hypertension. Review of the physician orders for Resident #911 dated 6/13/2023, revealed Hydrocodone-Acetaminophen (APAP) Tablet (opioid pain-relieving medication)10-325 milligram (mg), give 1 tablet by mouth 4 times a day for Chronic Pain. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #911 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment, which indicated Resident #911 was cognitively intact. The resident received antianxiety, antidepressant, and opioid medications. Review of the Medication Administration Record (MAR) dated 6/1/2023 through 6/30/2023, for Resident #911 revealed the resident's pain level was assessed every shift. Further review revealed Hydrocodone-APAP 10/325 mg tablet had been administered 4 times daily. Review of the facility's document titled, Controlled Drug Administration Record, for Resident #911 dated 6/14/2023 through 6/28/2023, revealed the following regarding the Hydrocodone-APAP 10-325mg tablet: 6/14/2023 RN I signed out the medication at 6:00 AM. RN I did not work that day. 6/15/2023 RN I signed out the medication at 6:00 AM. RN I did not work that day. 6/16/2023 RN I signed out the medication at 6:00 AM although RN FF (night shift nurse) had already signed out the medication and signed the MAR that RN FF had already administered the medication at 5:00 AM that morning (night shift nurses administer the 6:00 AM doses of medication). 6/17/2023 RN I signed out the medication at 5:00 PM X (times) 2 tablets. The documentation revealed the 1st dose appeared to have been wasted but the initials of the nurse who witnessed the wasting with RN I did not match any nurse that worked at the facility. 6/18/2023 RN I signed out the medication 6:00 AM although LPN GG (night shift nurse) had already signed out the medication on the controlled drug sheet and the MAR as being administered. RN I worked the day shift on 6/18/2024, but the night shift nurse administered the morning dose at 5:00 AM. 6/23/2024 RN I signed out 1 dose at 11:30 PM, 12:00 PM, 5:00 PM, and 6:00 PM. RN I had signed out the extra doses on separate narcotic sheets for the same medication. RN I had also signed out another dose without documenting the time. 6/24/2023 RN I signed out doses of the medication at 5:20 PM and 6:00 PM. 6/25/2023 RN I signed out the medication at 12:00 PM and 6:00 PM. RN I did not work that day. 4. Review of the medical record revealed Resident #910 was admitted to the facility on [DATE], with diagnoses including Dementia, Hypertension, and Chronic Respiratory Failure. Review of the physician orders for Resident #910 dated 1/25/2023, revealed Hydrocodone-APAP Tablet 5-325 mg, give 1 tablet by mouth at bedtime for Arthritis/Scoliosis. Review of the MAR dated 6/1/2023 - 6/30/2023 for Resident #910 revealed the resident's pain level was assessed every shift. Further review revealed Resident #910 was administered Hydrocodone-APAP 5-325 mg at bedtime per the physician's orders. Review of a quarterly MDS assessment dated [DATE], revealed Resident #910 scored a 7 on the BIMS assessment, which indicated Resident #910 had moderate cognitive impairment and received antidepressant and opioid medications. Review of the facility's document titled, Controlled Drug Administration Record, for Resident #910 dated 6/18/2023 through 6/28/2023, revealed the following related to the Hydrocodone-APAP 5-325 mg tablet: 6/19/2023 RN I signed out the medication. RN I did not work that day. 5. Review of the medical record revealed Resident #52 was admitted to the facility on [DATE], with diagnoses including Heart Failure, Diabetes, and Hypertension. Review of the physician orders for Resident #52 dated 6/22/2023, revealed Oxycodone-APAP 7.5-325 mg tablet (opioid pain-relieving medication) give 1 tablet by mouth every 6 hours as needed for pain. Review of the MAR dated 6/1/2023 - 6/30/2023 for Resident #52 revealed the resident's pain level was assessed every shift. Further review revealed Resident #52 was administered Oxycodone-APAP 7.5-325 mg every 6 hours as needed for pain. Review of a Medicare 5-day MDS assessment dated [DATE], revealed Resident #52 scored a 15 on the BIMS assessment, which indicated the resident was cognitively intact and received opioid medications. Review of the facility's document titled, Controlled Drug Administration Record, for Resident #52 dated 6/23/2023 - 6/28/2023, revealed the following related to the Oxycodone-APAP 7.5-325 mg tablet: 6/23/2023 RN I signed out the medication at 8:00 AM and 6:30 PM. RN I did not work that day. 6/25/2025 RN I signed out the medication at 4:00 AM, 10:00 AM, and 3:00 PM. RN I did not work that day. Review of the NP Progress note for Resident #52 dated 6/29/2023, revealed .patient seen and examined per nursing and facility request for evaluation .has been readmitted with orders for Percocet (Oxycodone-APAP) 7.5-325 mg, initially 1 tablet every 4 hours as needed which was decreased to 1 tablet every 6 hours as needed and is now decreased to every 8 hours as needed .nursing reports patient is requesting pain management approximately 1-2 times daily .does not appear to be in any acute distress .chronic pain .monitor for any increase in pain or discomfort related to decrease of medications . Review of the Progress Notes for Resident #52 dated 6/28/2023, revealed .no c/o pain/discomfort reported . Review of the Progress Notes for Resident #52 dated 6/29/2023, revealed .Social worker met with resident this afternoon. Resident was pleasant, engaged and did not voice any concerns at this time. Resident did not appear to be in any distress. Social services will continue visits and provide support as needed . Review of the Progress Notes for Resident #52 dated 6/30/2023, revealed .Social worker checked on resident this afternoon. Resident did not appear to be in any distress. Resident has been doing well today. No concerns expressed. Social services will continue visits and provide support as needed . 6. Review of the facility's document titled, Investigation Packet, for Residents #911, #910, and #52 dated 6/28/2023, revealed .ADM [administrator] spoke with .[Police department] on 6/28/2023 with Officer .ADM explained situation .concerns with narcotics and nurse [RN I] .officer indicated that he would need to speak with his supervisor for direction and stepped out of the office .officer returned and indicated there was nothing the PD could do .ADM asked officer for incident number to reflect the facility attempted to have the matter addressed by the police .gave incident number .res [resident] narcotic records were audited .residents assess by provider . Review of the facility's document titled, Investigation Packet, for Residents #911, #910, and #52 dated 6/29/2023, revealed .notified the Pharmacy rep [representative] on 6/29/2023 of all .medications that would need to be replaced at the facility's expense as a result of the complete audit conducted of medication administration activity with regards to nurse [RN I] . Review of the DON's witness statement for Resident #911, #910, and #52 dated 6/29/2023, revealed .[RN I] called me to ask if she was being reported for anything .told her the investigation was underway .encourage RN I to be truthful .[RN I] stated, I took 3 pills from [Resident #911] and 2 pills from [Resident #52] .I signed them out for days I was not there . Review of the facility's document titled, Investigation Packet, for Residents #911, #910, and #52 dated 6/30/2023, revealed .ADM spoke with Officer [police officer] .on 6/30/2023 [regarding the possible drug diversion] .Explained the situation and he indicated that his department would take the information and look into possible steps and would let us know if they needed anything further from the facility to aide in a case against nurse [RN I] . During an interview on 4/21/2025 at 7:16 PM, RN I stated she worked at the facility for a short period of time in 6/2023. RN I stated she thought she had taken approximately11 tablets total from 3 different residents during that time. RN I stated she was in the Tennessee Professional Assistance Program (TNPAP) when she was hired at the facility and had informed the facility. RN I stated that she had taken the medications for her personal use and after being terminated from the facility had gone into an inpatient rehabilitation. During an interview on 4/22/2025 at 8:50 AM, the DON stated she had conducted routine audits of the narcotic sheets and noticed some suspicious entries. Residents were immediately assessed to ensure pain was controlled and if the residents had missed any medication doses. RN I was immediately suspended pending an investigation. The DON stated she was aware RN I was part of the TNPAP program and the nurse did not have any narcotic restrictions. During an interview on 4/22/2025 at 9:30 AM, Resident #52 stated she had not had any issues with obtaining pain medications.

Based on policy review, medical record review, observations, and interviews the facility failed to provide adequate personal hygiene and bathing for 2 of 4 residents (Resident #81 and Resident #131) reviewed for Activities of Daily Living (ADL's). The findings include: 1. Review of the undated facility policy titled, Bathing, revealed .It is the policy of the facility to make every effort to respond to the residents' requests and needs .It is the policy of this facility to promote cleanliness .The residents will be offered the required number of showers each week as per regulations . 2. Review of the medical record revealed Resident # 81 was admitted to the facility on [DATE], with diagnoses including Cerebral Infarction, Gastrostomy, Anxiety, and Depression. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident # 81 was cognitively intact. Resident required substantial/maximal assistance with bathing and dependent on staff to perform transfers. Review of the Care Plan dated 3/27/2025, revealed .requires assist with ADL's .Prefers bed baths over showers . Review of the facility's form titled, Shower List 3B, revealed Resident #81 was scheduled to have showers on Tuesdays and Fridays. Review of the .Documentation Survey Report . Certified Nursing Assistant (CNA) Bathing Task for March 2025 and April 2025, revealed Resident #81 did not receive a shower or bath on the following days: 3/1/2025, 3/2/2025, 3/5/2025, 3/6/2025, 3/8/2025, 3/12/2025, 3/16/2025, 3/27/2025, 3/28/2025, 3/29/2025, 3/30/2025, 3/31/2025, 4/2/2025, 4/3/2025, 4/5/2025, 4/6/2025, 4/7/2025, 4/9/2025, 4/11/2025, 4/13/2025, 4/14/2025, 4/16/2025, 4/17/2025, 4/20/2025, and 4/21/2025. Review of the medical record revealed no documentation for shower or bed bath on 3/3/2025, 3/9/2025, 3/13/2025, 3/17/2025, 3/19/2025, 3/20/2025, 3/23/2025, 3/26/2025, 4/10/2025, and 4/19/2025. The facility was unable to provide documentation that Resident #81 was offered a shower or provided bathing for 35 out of 53 days reviewed. Observation in the Resident's room on 4/21/2025 at 3:25 PM, 4/22/2025 at 7:56 AM and 11:36 AM, 4/23/2025 at 8:14 AM and 4/24/2025 at 11:17 AM, revealed strong foul smell of body odor. 3. Review of the medical record revealed Resident #131 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, Diabetes, and Chronic Obstructive Pulmonary Disease. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 5, which indicated Resident #131 was severely cognitively impaired without behaviors. Resident required substantial/maximal assistance with bathing and dependent on staff to perform transfers. Review of the Care Plan dated 2/5/2025, revealed .requires assist for ADL's .The resident will receive necessary level of ADL care as needed . Review of the facility form titled, Shower List 3B, revealed Resident #131 was scheduled to have showers on Monday and Thursday night shift. Review of the .Documentation Survey Report . CNA Bathing Task for March 2025 and April 2025, revealed a shower or bed bath was documented as not applicable on 3/1/2025, 3/2/2025, 3/4/2025, 3/8/2025, 3/10/2025, 3/14/2025, 3/15/2025, 3/16/2025, 3/27/2025, 3/29/2025, 3/30/2025, 4/1/2025, 4/2/2025, 4/3/2025, 4/4/2025, 4/6/2025, 4/7/2025, 4/13/2025, 4/15/2025, 4/16/2025, 4/20/2025, 4/21/2025, and 4/22/2025. Review of the medical record revealed, no documentation for shower or bed bath on 3/3/2025, 3/5/2025, 3/9/2025, 3/11/2025, 3/12/2025, 3/17/2025, 3/19/2025, 3/20/2025, 3/23/2025, 3/26/2025, 4/9/2025, 4/10/2025, 4/17/2025, and 4/19/2025. The facility was unable to provide documentation that Resident #131 was offered bathing for 37 out of 53 days reviewed. Observations in resident's room on 4/21/2025 at 3:25 PM, 4/22/2025 at 7:56 AM, 4/22/2025 at 4:03 PM, 4/23/2025 at 8:14 AM, 4/24/2025 at 11:17 AM, revealed strong foul smell of body odor and dirty disheveled hair. 4. During an interview on 4/23/2025 at 4:24 PM, the Director of Nursing (DON) confirmed that residents should be offered a shower on their shower date and that it should be documented if care was provided or refused. During observation and interview with Licensed Practical Nurse (LPN) HH on 4/24/2025 at 11:17 AM, in both resident's room, LPN HH was asked if she noticed any odors, LPN HH stated, .a stinky smell . LPN HH confirmed that the smell could be body odor and stated, .I can't tell which one (Resident) .

Based on facility policy review, medical record review, and interviews, the facility failed to follow a physician's order related to narcotic medication administration for 4 residents (Resident #917, #66, #908, and #909) of 13 residents reviewed for narcotic medication administration. The findings include: 1. Review of the facility's policy titled, Administering Medications, dated 2001 (exact date unknown), revealed .medications must be administered in accordance with the orders, including time frame . 2. Review of the medical record revealed Resident #917 was admitted to the facility on [DATE], with diagnoses including Chronic Pain, Muscle Weakness, and Osteoarthritis. Review of the comprehensive care plan for Resident #917 dated 3/5/2025, revealed Resident #917 was at risk for pain with interventions to observe for pain with medication side effects every shift. Review of a Physician's Order for Resident #917 dated 3/10/2025, revealed an order for Hydrocodone-Acetaminophen (APAP) (narcotic pain-relieving medication)10-325 milligrams (MG) administer 1 tablet by mouth every 8 hours as needed (PRN) pain. Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #917 scored a 9 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was moderately cognitively impaired. The resident required staff set up/ clean up assistance with eating and staff supervision or touching assistance with personal hygiene. Further review revealed the resident received opioid medications for pain. Review of a Controlled Drug Administration Record for Resident #917 dated 3/11/2025 - 3/15/2025, revealed the Hydrocodone-APAP 10-325 MG medication was administered by Licensed Practical Nurse (LPN) DD on 3/14/2025 at 6:00 PM, 3/15/2025 at 12:00 AM (6 hours after previous dose), and 3/15/2025 at 6:00 AM (6 hours after previous dose). Further review revealed the pain-relieving medication (Hydrocodone-APAP) was administered every 6 hours and was not administered every 8 hours as ordered by the physician. Review of the monthly Treatment Administration Record for Resident #917 dated 3/2025, revealed the resident had no medication side effects to include sedation or drowsiness. 3. Review of the medical record revealed Resident #66 was admitted to the facility on [DATE], with diagnoses including Left Femur Neck Fracture, Dementia, and Thoracic Spondylosis. Review of a significant change MDS assessment dated [DATE], revealed Resident #66 scored a 1 on the BIMS assessment which indicated the resident was severely cognitively impaired. Further record review revealed the resident received opioid medications. Review of the comprehensive care plan for Resident #66 revised 10/3/2024, revealed the resident was at risk for pain with interventions in place. Review of a Physician's Order for Resident #66 dated 10/17/2024, revealed an order for Hydrocodone -APAP 5-325mg 1 tablet every 12 hours as needed for pain X (times) 14 days (to end on 10/31/2024). Review of a Physician progress note for Resident #66 dated 11/7/2024, revealed .patient has no complaints .Continue pain management with Tylenol 650 mg T.I.D. [three times daily], tramadol 25 mg T.I.D . Review of the facility's document titled, Medication Occurrence Form, dated 11/7/2024 revealed .Hydrocodone given on 11/1/2024, 11/2/2024, 11/3/2024, 11/4/2024, and 11/6/2024 without .physician's order .NP [Nurse Practitioner [ eval [evaluate] .no adverse outcome to resident .meds [medications] were replaced .nurse suspended .terminated at end of investigation . Review of a Social Services progress note for Resident #66 dated 11/8/2024, revealed .Resident did not appear to be in any distress or discomfort at this time . Review of a NP progress note for Resident #66 dated 11/8/2024, revealed .Left hip pain .Currently she is on tramadol 25 mg 3 times a day scheduled in addition to Tylenol 650 mg 3 times a day .She is noted with improved status of discomfort and currently she is pleasant and interactive without any distress . Review of the Medication Administration Record (MAR) for Resident #66 dated 11/1/2024 - 11/30/2024, revealed the resident was monitored every shift for pain and was treated with the Tylenol or Tramadol. 4. Review of the medical record revealed Resident #908 was admitted to the facility on [DATE], with diagnoses including Dementia, Malignant Neoplasm of Colon, and Left Intertrochanteric Femur Fracture. Review of a Physician's Order dated 10/29/2024 for Resident #908 revealed Ativan 0.5 mg tablet Give 0.25mg per oral (by mouth) (PO) twice daily for increased anxiety. Review of a Controlled Drug Administration Record #908 dated 10/30/2024, revealed the Ativan was administered by LPN J on 11/1/2024 11:00 PM, 11/2/2024 4:00 AM (5 hours later), on 11/2/2024 11:00 PM, and 11/3/2024 4:00 AM (5 hours later). Further review revealed the Ativan was administered 5 hours apart, were not due at those times, LPN J had administered extra doses of the Ativan and did not follow the physician orders to administer as twice daily. Review of the facility's document titled, Medication Occurrences Reporting Form dated 11/7/2024 for Resident #908 revealed, .nurse [LPN J] signed out medications [Ativan] at times not supported by order according to narc [narcotic] sheet .NP eval .no adverse outcomes to resident . Review of a Social Services progress note for Resident #908 dated 11/8/2024, revealed .Resident did not appear to be in any distress or discomfort at time of visit .No noted concerns by staff at this time . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #908 scored an 8 on the BIMS assessment which indicated the resident was moderately cognitively impaired. The resident required set up/ clean up assistance from staff with eating. The resident required partial/ moderate staff assistance with personal hygiene. Further review revealed the resident received scheduled pain medication, antianxiety medication, and opioid medication. Review of a comprehensive care plan for Resident #908 dated 11/24/2024, revealed .resident does receive antianxiety medications .observe for lethargy .drowsy .hard to arouse .notify MD/NP [Medical Doctor/Nurse Practitioner] immediately . 5. Review of the medical record revealed Resident #909 was admitted to the facility on [DATE], with diagnoses including Dementia, Generalized Muscle Weakness, and Dysphagia. Review of the physician's order for Resident #909 dated 5/14/2024, revealed .Trazodone 50 mg tablet Give 0.25mg by mouth at bedtime for depression . Review of a quarterly MDS assessment dated [DATE], revealed Resident#909 scored a 4 on the BIMS assessment which indicated the resident was severely cognitively impaired. The resident required partial/ moderate assistance from staff with eating. The resident required substantial/ maximal staff assistance with personal hygiene. Further review revealed the resident received antidepressant and opioid pain medications. Review of the Controlled Drug Administration Record for Resident #909 dated 11/2/2024, revealed LPN J administered Trazodone 25 mg at 2:00 AM. Further review revealed that LPN J did not follow physician's order prescribed for medication to be given at bedtime. Review of the facility's document titled, Medication Occurrence Reporting Form, dated 11/7/2024 for Resident #908 revealed .trazodone given at 2:00 AM without order according to narc sheet .NP eval .no adverse outcome to resident .meds replaced . Review of a NP progress note for Resident #909 dated 11/8/2024, revealed .stable and she does not appear to be in any acute distress . Generalized pain and discomfort . Review of a Social Services progress note for Resident #909 dated 11/8/2024, revealed .Resident was pleasant and smiling .did not appear to be in any distress or discomfort at this time .No concerns noted by nursing staff at this time . Review of a Nurse progress note for Resident #909 dated 11/9/2024, revealed .No acute discomfort or pain observed . Review of the comprehensive care plan for Resident #909 revised 11/14/2024, revealed .receiving psychotropic medications .for antidepressant .monitor for any side effects and notify to NP/MD . 6. During a telephone interview on 4/23/2025 at 8:34 AM, the Medical Director (MD) stated LPN DD did not follow the ordered parameters for administering Resident #917's Hydrocodone-APAP when she administered the medication every 6 hours instead of every 8 hours which resulted in medication errors. The MD stated Resident #917 was assessed and had no adverse outcome for the medication errors. The MD stated he expected the nurses to follow the physician's orders when administering medications to the residents to prevent medication errors. During a telephone interview on 4/23/2025 at 8:45 AM, the MD stated that LPN J did not follow physician's orders when administering Hydrocodone to Resident #66, Ativan to Resident #908, and Trazodone to Resident #909. The MD stated Residents #66, #908, and #909 were assessed and had no adverse outcomes for the medication errors. The MD stated that he expected the nurses to follow physician's orders when administering medications to residents to prevent medication errors. During an interview on 4/23/2025 at 9:35 AM, the Administrator confirmed LPN DD signed acknowledgement she had administered the Hydrocodone-APAP to Resident #917 every 6 hours instead of every 8 hours on 3/15/2025 which resulted in 2 medication errors. The Administrator stated it was the facility's expectation the licensed nurses follow physician orders when administering medications. During an interview on 4/23/2025 at 9:45 AM, the Administrator confirmed LPN J signed to acknowledge she administered Hydrocodone 5 times to Resident #66 after the medication had been discontinued resulting in 5 medication errors, administered Ativan to Resident #908 at nonscheduled time resulting in 4 medication errors, and Trazodone to Resident #909 at nonscheduled time resulting in 1 medication error. The Administrator stated it was the facility's expectation the licensed nurses follow physician orders when administering medications.

Based on facility policy review, medical records review, observations, and interview, the facility failed to follow physician orders for 1 of 3 (Resident #493) sampled residents. The findings include: 1. Review of the facility policy titled, Administering Medications, dated 2001, revealed .Medications .shall be administered in a safe and timely manner, and as prescribed .Medications must be administered in accordance with the orders . Review of the undated facility policy titled, Oxygen Administration, revealed .The purpose of this procedure is to provide guidelines for safe oxygen administration .Verify that there is a physicians order .Review the physician's order .for oxygen administration . 2. Review of the medical record revealed Resident #493 was admitted to the facility on [DATE], with diagnoses including Volvulus (an obstruction due to twisting or knotting of the gastrointestinal tract), Diabetes, Dysphagia, Colostomy, Dementia, and Heart Failure. Review of the annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 9, which indicated moderate cognitive impairment. Review of Care Plan dated 4/16/2025 revealed .Administer medication as prescribed, as tolerated .oxygen as ordered/ tolerated . Physician's Orders dated 4/11/2025 revealed .Oxygen 2 L/min per nasal cannula as needed . Observation in the resident's room on 4/21/2025 at 11:53 AM, on 4/22/25 at 8:01 AM, on 4/23/2025 at 8:21 AM, revealed the resident's oxygen set at 4 liters. During an interview on 4/23/25 at 4:44 PM, the Director of Nursing confirmed that physician's orders be followed regarding oxygen settings. During an interview on 4/24/2025 at 9:22 AM, RN FF confirmed that Resident #493's oxygen order was for 2 Liters and stated, .He shouldn't be on 4 liters .I will change that right now .

Based on policy review, medical record review, and interview, the facility failed to provide dental services for 1 of 2 (Resident #130) reviewed for dental services. The findings include: 1. Review of the facility's undated policy titled, Dental Services, revealed Routine dental services are provided to our residents through .A contract agreement with a licensed dentist that comes to the facility .Referral to the resident's personal dentist .Referral to community dentists or Referral to other health care organizations that provide dental services .Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care .Social services representative will assist residents with appointments, transportation arrangements .Direct care staff will assist residents with denture care .All dental services provided are recorded in the residents medical record . 2. Review of the medical record revealed Resident #130 was admitted to the facility on [DATE], with diagnoses including of Hemiplegia/Hemiparesis, Cerebral Atherosclerosis, Atrial Fibrillation, and Anemia. Review of the facility's Transportation Scheduling List for February 2025 revealed .[Named Resident #130] .2:00 PM .Appointment with [Named Dentist] .Transport With .Van . Review of the facility's ancillary services February 2025 calendar revealed dental onsite clinic scheduled for 2/7/2025, and again on 2/20/2025. Review of a [named dental service] Progress Note dated 2/7/2025 revealed .Not Seen Resident was not seen because . resident did not present to clinic. Review of the facility's ancillary services March 2025 calendar revealed dental hygienist [dental assistant] onsite clinic scheduled for 3/10/2025. Review of the significant change Minimum Data Set (MDS) dated [DATE], revealed Resident #130 had a Brief Interview for Mental Status Score (BIMS) of 14, indicating the resident was cognitive intact and required set up for oral and personal hygiene. Review of the facility's ancillary services April 2025 calendar revealed dental hygienist onsite clinic scheduled for 4/4/2025. Review of the Care Plan dated 4/3/2025 revealed .at risk for oral/dental health problems r/t [related to] missing teeth .Observe for s/sx [signs and symptoms] of oral/dental problems .Pain .toothache .Abscess .Teeth missing, loose, broken, eroded, decayed .Provide mouth care as tolerated . Review of a [Named Dental Service] dated 4/15/2025 confirmed Resident #130 was on the dental hygienist list to be seen. Review of a [Named Dental Service] Progress note dated 4/15/2025 revealed .Not seen Resident was not seen, not brought to dentist. Review of the medical record revealed the facility was unable to provide documentation that Resident #130 had been seen by a licensed dentist for her increasing dental concerns since 7/23/2024. During observation and interview in Resident #130's room on 4/21/25 at 4:05 PM, Resident#130 stated, I was told I had good dental insurance when I came here and I have been having trouble with my teeth and I have not seen the dentist yet, my teeth are bad and my mouth hurt sometimes . During an interview on 4/22/25 at 2:58 PM, the Social Service Director (SSD) confirmed that there is a dental service that comes onsite to give dental care to residents and that the residents or family representative signs an agreement upon admission or at any time and they are added to the dental list. The SSD confirmed that residents may also seek offsite dental services if they chose to. The SSD confirmed Resident #130 had some teeth extracted in the past by the onsite dental service. The SSD was asked who is responsible to ensure residents get to their onsite dental appointments. The SSD confirmed that floor staff are to make sure residents get to their appointments. The SSD was asked to read a [named dental service] dental progress note and to explain what it meant when it stated, resident did not present to clinic or resident was not brought to clinic. The SSD stated, I can't recall . During an interview on 4/23/25 at 2:45 PM, the Administrator confirmed it is a collaboration of the interdisciplinary team (all staff) to ensure residents make it to dental appointments and along with ensuring that residents are rescheduled if appointments are missed.

44447 Based on observations and interviews the facility failed to properly store oral hygiene equipment in a sanitary manner for 5 of 106 resident rooms (room [ROOM NUMBER], #326, #327, #328, and #329) observed. The findings included: Observation in room [ROOM NUMBER] and interview on 4/17/2023 at 11:40 AM revealed, Certified Nursing Assistant (CNA) #10 confirmed an unlabeled toothbrush and denture cup was sitting on the vanity and could not be stored on the vanity shared by multiple residents. Observations in room [ROOM NUMBER] on 4/17/2023 at 11:44 AM, on 4/18/2023 at 2:40 PM and on 4/19/2023 at 9:55 AM, revealed an unlabeled toothbrush stored in a cup on the sink vanity in the room shared by multiple residents. Observations in room [ROOM NUMBER] on 4/17/2023 at 11:50 AM, on 4/18/2023 at 2:22 PM revealed an unlabeled toothbrush stored in a used flower pot and an unlabeled denture cup stored on the sink vanity in the room shared by multiple residents. Observation in room [ROOM NUMBER] and interview on 4/18/2023 at 2:25 PM revealed Registered Nurse (RN)/Unit Manager #6 observed and confirmed personal oral hygiene items could not be stored on a vanity shared by multiple residents. She stated she would dispose of the toothbrush and denture cup and replace the items for the resident. Observations in room [ROOM NUMBER] on 4/17/2023 at 12: 00 PM, on 4/18/2023 at 2:58 PM and on 4/19/2023 at 10:06 AM revealed an unlabeled toothbrush and denture cup stored on the sink vanity in the room shared by multiple residents. Observations in room [ROOM NUMBER] on 4/17/2023 at 12: 05 PM, on 4/18/2023 at 3:04 PM and on 4/19/2023 at 10:10 AM revealed an unlabeled denture cup stored on the sink vanity in the room shared by multiple residents.

Based on medical record review and interview, the facility failed to evaluate and have behavior monitoring for 1 of 5 (Resident #136) sampled residents for unnecessary medications. The findings include: Review of the medical record revealed Resident #136 was admitted to the facility on [DATE] with diagnoses which included Bipolar Disorder, Post Traumatic Stress Disorder (PTSD), and Generalized Anxiety. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #136 had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Resident #136 felt down, depressed, and tired with no energy two to six days during the 14 day look back period. Review of the care plan dated 4/5/2023 revealed .[named Resident #136] is taking an Antipsychotic medication r/t [related to] Bipolar Disorder, PTSD . Review of the Medication Administration Record (MAR) dated 2/8/2023 revealed .Haloperidol [antipsychotic] Oral Tablet 5 mg [milligram] Give 1 tablet by mouth every 12 hours as needed for agitation related to Post-Traumatic Stress disorder . The medication was discontinued on 2/14/2023. Continued review revealed no behavior monitoring for agitation behavior related to the Haloperidol medication. Review of the Nurse Practitioner (NP) noted dated 2/13/2023 revealed .Bipolar Disorder/Generalized Anxiety and post-traumatic stress disorder. Discussions with patient who is requesting increased frequency of Haldol treatment. We will increase to a dose of 5 mg q.8 [every eight hours] PRN [as needed]. Psych NP [Psychiatric Nurse Practitioner] to evaluate and treat as indicated . Review of the Physician Order dated 2/14/2023 revealed .Haloperidol Oral Tablet 5 mg Give 1 tablet by mouth every 8 hours as needed for agitation related to Bipolar Disorder hold for drowsiness. The medication was discontinued 4/24/2023. Review of the medical record revealed no Psychiatric Evaluation for 2/28/2023. Review of the NP notes dated 3/18/2023 revealed .Facility requested clinical evaluation of patient for anxiety and the need for Xanax [Antianxiety] refills. Visit was requested via telehealth. Patient in agreement for telehealth assessment and is accompanied by facility nursing staff. The patient is in no apparent distress. She is sitting up in wheelchair. generalized anxiety. The patient to continue Alprazolam [Anti-anxiety] 1 mg three times a day .Continue Seroquel [antipsychotic] 400 mg at bedtime and Haldol 5 mg every 8 hours as needed . Continued review revealed no evaluation for the usage of the Haldol 5 mg every 8 hours as needed. Review of the MAR dated 3/2023 revealed no behavior monitoring for agitation behavior related to the Haloperidol medication. Review of the MAR dated 4/2023 revealed no behavior monitoring for agitation behavior related to the Haloperidol medication. During an interview on 4/24/2023 at 12:40 PM, Registered Nurse #6 stated Resident #136 was followed by the Psychologist and Nurse Practitioners. During an interview on 4/24/2023 at 8:00 PM, the NP [Nurse Practitioner] #1 stated Resident #136 was closely monitored weekly and the reason she was not on a scheduled dosage because of the resident's past history of sedation and illicit drug usage.

Based on facility policy review, medical record review, observations, and interviews, the facility failed to ensure a Peripheral IV (intravenous) catheter was administered and maintained according to professional standards of practice for 1 of 3 sampled residents (Resident #185) reviewed. The findings include: Review of the facility's undated policy titled, Peripheral IV Catheter Insertion, revealed, .The following information should be recorded in the residents medical record: .date and time of the procedure .type of solution or medication infusing .amount of medication to be infused .rate of infusion .signature and title of the person recording data . Review of the facility's undated policy titled, Charting, Documentation and Notification, revealed, .Services provided to the resident .shall be documented in the resident's record .Documentation of procedures and treatments should include care-specific details such as but not limited to a. The date and time the procedure/treatment was provided, b. The name and title of the individual(s) who provided the care . Review of the medical record revealed Resident #185 was admitted to the facility on [DATE] with diagnoses which included Paroxysmal Atrial Fibrillation, Acute Pulmonary Edema and Acute Systolic (Congestive) Heart Failure. Review of the Medication Administration Record (MAR) dated 4/1/2023-4/30/2023 revealed an order for Sodium Chloride Solution 0.45% given intravenously with a start date of 4/17/2023. No administration was documented on 4/17/2023 and documentation on 4/18/2023 at 1:39 AM. There was not an order on the MAR to monitor/maintain the IV site. Review of the nursing progress notes and Skilled Nursing notes for Resident #185 revealed there was no documentation related to the insertion of a Peripheral IV Catheter on 4/17/2023 and 4/18/2023. Observation and interview on 4/18/2023 at 1:48 PM revealed Resident #185 had a Peripheral IV in her right forearm. The Assistant Director of Nursing (ADON) observed the IV dressing and confirmed the dressing was not dated. The ADON confirmed according to professional standards of care, all IV dressings would be dated and initialed by the person that applied the dressing. Observation and interview on 4/18/2023 at 1:58 PM revealed Licensed Practical Nurse (LPN) #18 reviewed the electronic health record (EHR) and confirmed there was no documentation of the peripheral IV insertion. LPN #18 stated, I called the Nurse Practitioner (NP) this morning and got orders to discontinue the order for iv fluids at about 10:41 AM. I stopped the IV fluids at about 12:00 PM and left the IV in place. I did not document related to discontinuing the fluids or the IV site. During an interview on 4/18/2023 at 2:14 PM, Registered Nurse (RN)/Unit Manager #6 reviewed the medical record for Resident #185 and confirmed there was no documentation related to the insertion of a Peripheral IV on 4/17/2023 and 4/18/2023. She stated, I would expect the nurse to document in the chart related to the insertion of an IV. I expect the nurse to sign and date the IV dressing when applying the dressing.

Based on medical record review, observations, and interviews, the facility failed to ensure a wound dressing was maintained according to professional standards of practice for 1 of 9 sampled residents (Resident #185) reviewed. The findings included: Review of the medical record revealed Resident #185 was admitted to the facility on [DATE] with diagnoses which included Paroxysmal Atrial Fibrillation, Acute Pulmonary Edema, and Acute Systolic (Congestive) Heart Failure. Review of the Medication Administration Record (MAR) dated 4/1/2023-4/30/2023 revealed an as needed order for wound care to Resident #185's right forearm for lesion pending wound care evaluation dated 4/5/2023. Wound care was documented on MAR for 4/5/2023. No other wound care dressing change noted on MAR. Observation in Resident #185's room on 4/17/2023 at 12:00 PM, revealed Resident #185 had a gauze dressing on her right forearm. The dressing was frayed, dirty, and undated. Resident #185 stated she had a sore caused by an IV (intravenous) insertion and the nurse had put on a dressing. Resident #185 stated, I really do not recall when the last time the nurse changed my dressing. I don't think it has been changed since the nurse put it on when I was over on the other hall. Observation and interview on 4/17/2023 at 4:37 PM revealed Wound Care Nurse #1 reviewed the Treatment Administration Record (TAR) for Resident #185 and stated she did not see an order for wound care. The wound care nurse observed the dressing on Resident #185's right forearm and confirmed the dressing was frayed and dirty. Wound Care Nurse #1 refused to confirm the dressing did not have a date, and stated she would check the records to determine when the dressing was applied. During an interview on 4/19/2023 at 9:32 AM the Director of Nursing (DON) stated when a wound dressing is applied she expected the dressing to be dated and initialed.

Based on medical record review and interview, the facility failed to conduct care plan conferences for 4 of 56 (Resident #39, #69, #81 and #103) sampled residents reviewed. The findings included: Review of the medical record revealed Resident #39 was admitted to the facility on [DATE] with diagnoses which inlcuded Chronic Obstructive Pulmonary Disease and Type 2 Diabetes. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Review of the face sheet revealed Resident #39 was his own responsible party. During an interview on 4/17/2023 at 3:14 PM, Resident #39 stated he had not been included in the care plan conferences. During an interview on 4/19/2023 at 2:45 PM, the Social Worker (SW) confirmed Resident #39 did not have a care plan conference. Review of the medical records revealed Resident #69 was readmitted to the facility on [DATE] with diagnoses which included Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left Non-Dominant Side and Type 2 Diabetes Mellitus with Diabetic Neuropathy. Review of the Quarterly MDS assessment dated on 2/24/2023 revealed a BIMS score of 5, indicating severe cognitive impairment. During an interview on 4/18/2023 at 12:01 PM, Resident #69 stated she had not been invited to care plan meetings and would like to be involved. Review of medical records revealed the last documented care plan meeting was on 6/30/2021. Review of the Progress Notes revealed no recent invitation to care conference meetings. During an interview on 4/20/2023 at 2:30 PM, the SW confirmed, there was no documentation to verify whether a recent care plan meeting was done. Review of the medical record revealed Resident #81 was admitted to the facility on [DATE] with diagnoses which included Paraplegia and Type 2 Diabetes. During an interview on 4/17/2023 at 2:29 PM, Resident #81 stated he could not remember the last time he had a care plan conference. During an interview on 4/19/2023 at 2:54 PM, the SW confirmed Resident #81 did not have documentation of a care plan conference. Review of the medical record revealed Resident #103 was admitted to the facility on [DATE] with a diagnosis which included Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Right Dominant Side. Review of the 5 day MDS assessment dated [DATE] revealed Resident #103 had a BIMS score of 15, indicating no cognitive impairment. Review of the care conference note dated 1/2/2023 revealed .Social worker attempted to contact resident's [named family member] to schedule a care plan meeting. Unable to make contact. Left message requesting returned call . During an interview on 4/17/2023 at 4:03 PM, Resident #103 stated he had not participated in a care plan conference. During an interview on 4/19/2023 at 10:30 AM, the SW confirmed the facility would have held a care conference meeting with residents with a BIMS of 10 or higher. 47127

Based on facility policy review, medical record review, and interviews, the facility failed to conduct a thorough investigation in response to allegations of misappropriation for 1 of 21 (Resident #118) sampled residents reviewed for abuse. The findings included: Review of the undated policy titled, Abuse, Neglect, and Exploitation of Residents, revealed, .It is the policy of the facility that acts of physical, verbal, mental, and financial abuse including neglect and exploitation directed against residents are absolutely prohibited. Each resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, mistreatment, neglect, exploitation and misappropriation of property .once an allegation of abuse has been made, the supervisor who initially received the report must inform the Administrator/Director of Nursing/designee immediately or as soon as practically possible an initiate gathering requested information. An investigation MUST be directed by the Administrator/designee immediately and no later than twenty-four (24) hours of their knowledge of the alleged incident .the Administrator shall report such findings to the local police department, the ombudsman and the state licensing certification agency within 24 hours of the results of the completion of the investigation, as indicated, and to the state survey and certification agency within five (5) days of the completion of the investigation . Review of the policy titled Abuse Reporting revealed, .the facility will not condone resident abuse of anyone, including staff members, other residents, consultants, volunteers, and staff of other agencies serving the resident, resident representative, family members, legal guardians, sponsors, friends, or other individuals. The facility adheres to the reporting stipulations put forth in the Elder Justice Act .the regulation requires that alleged violations of misappropriation of resident property be reported immediately. CMS [Centers for Medicare and Medicaid Services] has defined 'immediately' as soon as possible but not to exceed 24 hours after forming suspicion .if there is reasonable suspicion that a crime has been committed, the facility must report to the appropriate government agencies as required by regulation/law . Review of medical record revealed Resident #118 was admitted to this facility on 6/15/2022 with a readmission on 8/25/2022 with diagnoses which included Chronic Kidney Disease, Stage 3, Type 2 Diabetes Mellitus with Diabetic Neuropathy, and Major Depressive Disorder, Recurrent Moderate. Review of the Quarterly MDS (Minimum Data Set) assessment for Resident #118 dated 1/18/2023 revealed a Brief Interview of Mental Status (BIMS) score of 15 which indicated no cognitive impairment. Review of the staff statement dated 2/13/2023 at 11:30 AM, the Social Worker stated (Resident #118) had a missing debit card. Review of the written statement dated 2/13/2023, revealed Licensed Practical Nurse (LPN) #17 stated, .On February 13th, 2023 [Named Resident] Resident #118 gave LPN #1 [Unit Manager] permission to search his room for weekly room search. A little bit after his room search was completed, he stated that his debit card was missing. When room search was conducted there was no debit card seen in the resident's room [Resident #118] . Review of a text message from Resident #118 dated 2/13/2023 10:38 PM to LPN #17 stated, .Hey this is [Named Resident #118]. I was trying to get a hold of you y'all have lost my debit card it was in my dresser drawer and since y'all have searched it I cannot find it do you know where it may be . Review of the written statement revealed, .This nurse along with LPN #17 performed resident's [Resident #118] weekly room search on 2/13/2023 with his consent. No abnormal findings were noted. Resident [Resident #118] stated that his debit card was missing . During an interview on 4/18/23 at 1:47 PM, Resident #118 stated he had a debit card and money missing, and his funds were not replaced. The missing items were reported to LPN #1. Continued interview revealed 2 days prior to the card being discovered missing, Resident #118 had given a CNA permission to use his card to get a drink from the vending machine. Resident #118 kept his card and cash in a zip lock bag and placed it in the drawer of his bed side table. During an interview on 4/19/2023 at 5:32 PM, the Administrator confirmed there was no thorough investigation regarding Resident #118's missing debit card due to the fact, He did not say it was stolen, he said that it was missing. She also confirmed that it was not reported to law enforcement and was not reported to the State Agency's Office.

Based on facility policy review, observations, and interviews, the facility failed to ensure a safe, clean, comfortable and homelike environment in 9 of 106 rooms (#301, #322, #324, #325, #326, #327, #328, #329, and #330) observed. The findings included: Review of the facility's undated policy titled Quality of Life-Homelike Environment, revealed, .Residents are provided with a safe, clean, comfortable, and homelike environment . Observations in rooms #301 and #322: Observation in room [ROOM NUMBER]'s bathroom on 4/17/2023 at 11:39 AM revealed a brown dry substance on the wall near the assistance bar. Observation in room [ROOM NUMBER] on 4/17/2023 at 3:15 PM revealed a clear substance on the back of the door. Observation and interview in room [ROOM NUMBER] on 4/18/2023 at 10:36 AM and 10:42 AM revealed a clear substance on the back of the door. The Environmental Service Supervisor (EVS) confirmed there was a clear substance on the back of the door. Observation and interview in room [ROOM NUMBER]'s bathroom on 4/18/2023 at 10:38 AM revealed the brown dry substance on the wall near the assistance bar. The EVS confirmed there was a brown dry substance on the wall near the assistance bar. During an interview on 4/18/2023 at 10:47 AM, the EVS stated the rooms were to be cleaned on a daily basis and staff were supposed to check on the rooms and bathrooms throughout the day. The staff had a list of high touch areas to clean daily. The facility had a schedule for deep cleaning of the rooms, and they were to be done weekly. Observations in rooms #324-#330: Observations in room [ROOM NUMBER] on 4/17/2023 at 11:30 AM, on 4/18/2023 at 2:30 PM, and on 4/19/2023 at 9:46 AM, revealed laminate on closet doors broken with sharp edges exposed. Laminate missing with rough material exposed. Continued observation revealed the bathroom (shared with room [ROOM NUMBER]) had a strong pungent urine odor with dried orange/brown substance around the base of the toilet and dried brown/black debris around bases of the walls. Flooring in the bathroom of room [ROOM NUMBER] had scattered debris and was sticky to touch. Observations in room [ROOM NUMBER] on 4/17/2023 at 11:35 AM, on 4/18/2023 at 2:34 PM, and 4/19/2023 at 9:50 AM, revealed four large reclining wheelchairs stored in front of the closets. Residents could not readily access the closets. Food items were stored on the floor beside C Bed and incontinent supplies were stored on the floor in the bathroom. The floor in the bathroom had debris scattered in front and behind the toilet. There was dried black debris around the base of the bathroom walls. Laminate on closet doors broken with sharp edges exposed. Laminate missing with rough material exposed. Interview on 4/17/2023 at 11:40 AM revealed, Certified Nursing Assistant (CNA) #10 stated the chairs blocked the residents' access to the closets. CNA #10 confirmed incontinent supplies and food should not be stored on the floor. Observations in room [ROOM NUMBER] on 4/17/2023 at 11:44 AM, on 4/18/2023 at 2:40 PM and on 4/19/2023 at 9:55 AM, revealed paint peeling on the bathroom door, pungent urine odor in the bathroom and dried brown/black debris around bases of the walls. Flooring in the bathroom and room [ROOM NUMBER] had scattered debris and was sticky to touch. Observations in room [ROOM NUMBER] on 4/17/2023 at 11:50 AM, on 4/18/2023 at 2:22 PM and on 4/19/2023 at 10:00 AM, revealed C bed's left side rail rusted and peeling paint. The floor had debris scattered and was sticky. Observations in room [ROOM NUMBER] on 4/17/2023 at 12: 00 PM, on 4/18/2023 at 2:58 PM and on 4/19/2023 at 10:06 AM, revealed the bed was without linen and not made. Bathroom floor had paper debris scattered on floor around the toilet. The call light device in the bathroom and beside the entrance door of the room was broken with sharp edges exposed. Observations in room [ROOM NUMBER] on 4/17/2023 at 12: 05 PM, on 4/18/2023 at 3:04 PM and on 4/19/2023 at 10:10 AM, revealed the bathroom floor had scattered debris, and the base of the bathroom walls had dried black/brown debris. Laminate on baseboards was missing on both sides of the wall beneath the sink with wood splintered and exposed. Observations in room [ROOM NUMBER] on 4/17/2023 at 12:12 PM, on 4/18/2023 at 3:10 PM and on 4/19/2023 at 10:15 AM, revealed paint peeling on bathroom door, paper peeling on bathroom wall, tile missing around toilet base, and scattered brown/black debris on floor and wall bases of bathroom. The floor throughout the room was sticky to touch. Lamination was missing and broken on the closet doors with rough and sharp edges. Observation in room [ROOM NUMBER]-#330 and interview on 4/19/2023 at 10:28 AM revealed the Maintenance Director observed and confirmed peeling paint, exposed splintered wood, broken laminate on closets and vanity bases and 2 broken call light boxes in room [ROOM NUMBER]. During an interview on 4/19/2023 at 10:42 AM, Housekeeper #2 stated she had completed cleaning in rooms #324-#330. Observations in rooms #324-#330 and interview on 4/19/2023 at 10:45 AM, the EVS confirmed the rooms and bathrooms were not properly cleaned. He stated his expectations included clean floors and walls in all resident rooms. 44447

Based on facility policy review, medical record review, observations, and interviews, the facility failed to report an incident of abuse to the State Agency for 1 of 19 residents (Resident #16) reviewed. Review of the facility's undated policy titled, Abuse, Neglect and Exploitation of Residents, revealed, .It is the policy of the facility that acts of physical, verbal, mental and financial abuse including neglect and exploitation directed against residents are absolutely prohibited. Each resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion, mistreatment, neglect, exploitation and misappropriation of property. Residents will not be subjected to abuse by anyone .Administrator/designee is responsible for operationalizing all policies and procedures that prohibit abuse, neglect and exploitation. They are also required to report instances of suspected or actual abuse, neglect or exploitation occurring within the facility .It is the responsibility of all staff to identify inappropriate behaviors towards residents, which may include but is not limited to .rough handling of residents .Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish .Physical abuse is the inappropriate physical contact with a resident which harms or is likely to harm the resident. This includes, but is not limited to hitting, slapping, pinching .It also includes control of resident's behavior through corporal punishment .For any allegation of physical assault with evidence of injury or witnessed physical assault the police will be contacted immediately . Review of the facility's undated policy titled, Abuse Reporting, revealed, .The facility will not condone resident abuse by anyone, including staff members, other residents, consultants, volunteers, and staff of other agencies serving the resident, resident representative, family members, legal guardians, sponsors, friends or other individuals .All personnel .are required to immediately report any incident or suspected incident or resident abuse .'Reasonable cause' is defined as when, upon review of the circumstances there is sufficient evidence for a prudent person to believe that abuse, neglect .has occurred .Circumstances to be reviewed that may lead to a reasonable cause conclusion might include but are not limited to: The presence of a physical condition (e.g. bruise) which is inconsistent with the history of course of treatment of the resident .The facility must report to the state agencies alleged violations of abuse, mistreatment, neglect, exploitation, injuries of unknown origin .if and when the 'reasonable cause' threshold has been achieved .Should an alleged/suspected violation or substantial incident of mistreatment, neglect, exploitation, injuries of unknown source, or abuse (including resident to resident abuse) be reported, the facility administrator/designee will promptly notify the following persons or agencies (verbally/written) of such incident as required by state regulations .the state licensing/certification agency responsible for surveying/licensing the facility . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses which included Chronic Kidney Disease, Restlessness and Agitation, and Vascular Dementia. Review of the Annual Minimum Data Set (MDS) for Resident #1 dated 9/15/2022 revealed a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment. Continued review revealed he had no behaviors exhibited during the assessment period. Continued review revealed he required extensive assistance of 2 persons with dressing, toilet use, eating, toilet use, personal hygiene and bathing. Review of the undated Care Plan for Resident #1 revealed problems/assessments for, .[Named Resident] has BEHAVIOR symptoms such as physically aggressive toward staff, resistive to care; Cognitive impairment .[Named Resident] is at risk for SKIN breakdown, r/t incontinence, decreased mobility, hx [history] of falls, poor safety awareness .[Named Resident] is at risk for being a victim of abuse due to inability to understand surroundings r/t, Cognitive impairment, being physically abusive . Interventions included, .Investigate all allegations of abuse/neglect promptly .Observe for abuse/neglect (ex. Bruises, behavior, weight loss, psycho-social status) and report to appropriate r[Named Resident] is at risk for SKIN breakdown r/t incontinence, decreased mobility, hx [history] of falls, poor safety awareness .10/20/2022 (L) [left] forearm abrasion . During an interview on 11/15/2022 at 8:57 AM, while reviewing the Facility Reported Incident (FRI) dated 11/3/2022 reported by the Administrator regarding Resident #1, the Administrator confirmed she documented, .Abuse could not be substantiated based on resident had no redness or discoloration to skin in area that was alleged . She then confirmed she documented on the FRI report, .Question: Describe any type of Harm to Alleged Victim(s) Whether serious bodily injury occurred, if known? - No Describe any type of injury such as a bruise, scratch, laceration, puncture wound, fracture, bleeding, redness on the skin, etc. - small purple bruise noted above right eyebrow . When asked if she saw the bruise, she stated No. The Unit Manager reported it to me. It was not part of the area [Named CNA [Certified Nursing Assistant] #3 reported as being struck. When asked if the bruise on Resident #1's face was investigated and reported, she stated, We talked about it during the investigation, but no, I did not properly investigate it or report it. When asked what their policy stated regarding investigating and reporting abuse, she confirmed the bruise should have been investigated and reported. During an interview on 11/15/2022 at 10:41 AM, Licensed Practical Nurse (LPN) #2 stated she had no idea what caused the bruise on Resident #1's face on 11/3/2022. She stated she told the Administrator about it. She stated she was the one who did the skin assessment after the allegation of abuse was reported. She stated she did not document the bruise on the skin assessment. She stated, I would report a bruise that I didn't know how it happened. I reported the bruise to [Named Administrator] but didn't do an investigation. The protocol is to do an investigation. During an interview on 11/15/2022 at 1:03 PM, the Nurse Practitioner stated she evaluated Resident #1 after the alleged abuse allegation on 11/3/2022. She stated she noted a bruise near the right eyebrow which she described as not acute. She stated it was purple in color.

Based on the facility's policy review, medical record review, and interviews the facility failed to promote a resident's right to receive services with reasonable accommodation of preferences for 1 of 19 sampled residents (Resident #5) reviewed. The findings include: Review of the facility's policy titled, Resident Rights, revised 12/2016, revealed, .Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence. b. be treated with kindness and respect. c. be free from abuse, neglect .e. self- determination . Review of the facility's policy titled, Resident Self Determination and Participation, revised 8/2022, revealed, .Our facility respects and promotes the right of each resident to exercise his or her autonomy regarding what the resident considers to be important facets of his or her life .In order to facilitate resident choices, the administration and staff: b. gather information about the residents' preferences on initial assessment and periodically thereafter, and document these preferences in the medical record. c. include information gathered about the resident's preferences in the care planning process . Review of the FRI #20221091194 dated 10/9/2022, revealed Resident #5's family member reported Certified Nursing Assistant (CNA) #1 transferred the resident without using a lift after the resident requested the use of a mechanical device for transfer on 10/8/2022. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses which included Covid-19, Muscle Weakness, and Unspecified Subluxation of the Right Shoulder Joint, and Unspecified Subluxation of the Left Shoulder. Review of the Quarterly Minimum Data (MDS) assessment dated [DATE] revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Review of Resident #5's current care plan revealed focuses which included risk for potential abuse/neglect related to dependence on others for Activities of Daily Living (ADL) care-Transfers: totally dependent x2 staff (Mechanical Lift), and risk for increased bruising/bleeding related to anticoagulant use. Review of therapy notes for Resident #5 revealed, .Certification Period 10/20/2022-11/15/2022 .Occupational Therapy .Reason for Referral: Patient referred to skilled OT [Occupational Therapy] services to assess patient's safety and complete education with functional transfers in order to avoid injury Patient was recently injured during functional transfer due to unsafe technique without use of full body lift .Impressions .Patient experiences impaired ROM [range of motion] of the B [both] shoulders as baseline due to bilateral shoulder subluxation .need of full body lift for safety with transfers . During an interview on 11/15/2022 at 8:34 AM, Resident #5 stated, I told the tech to leave me alone because she could not find a sling for the lift. I really do not think she looked very hard for the sling. She was just hell bound to make me transfer without a lift. She [CNA] #1 called it a free lift, said she does it all the time. She said she had 20 something years of experience. I told her I didn't care; she was not going to transfer me without the lift. Then she just pulled my legs across the bed and pulled me up, all the time I was yelling for her to stop. She plopped me in the chair and then pulled me back into the chair. Resident #5 confirmed she had demanded the CNA to stop, and she yelled out to let her know she was hurting her. She confirmed the nurse came into her room to check on her because she was yelling, and she told her what had happened. She did not remember who the nurse was that she told about the incident. She stated there was more than 1 nurse taking care of her that day. Resident #5 confirmed she had not been transferred by any other CNA without the use of a mechanical lift device. She confirmed she always made sure to tell any/all of the staff taking care of her she could not transfer without using the lift because of pain in her shoulders and legs. During an interview on 11/15/2022 at 8:47 AM, Licensed Practical Nurse (LPN) #2 confirmed if a resident tells a staff member to stop and do not lift them without a mechanical lift, the staff member should stop and listen to the resident. She confirmed a resident's preference should be honored if at all possible. During an interview on 11/15/2022 at 9:00 AM, CNA #4 confirmed staff should honor a resident's preference for transfer as long as it was not unsafe for the resident. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE]. Review of the Quarterly MDS assessment for Resident #6 dated 10/12/2022 revealed a BIMS score of 14, which indicated no cognitive impairment. During an interview on 11/15/2022 at 9:40 AM, Resident #6 stated, The CNA [CNA #1] came into the room that day [10/8/2022] to get [Named Resident] #5 up and put her in the chair. She went to look for a sling and said she could not find one. She told [Named Resident] #5 her she could transfer her without using a lift and [Named Resident] #5 told her no she would not get her up without a lift. Then the CNA just snatched her legs across the bed and [Named Resident] #5 yelled oh that hurts, leave me alone. That CNA just would not stop, she was determined to put [Named Resident] #5 in the chair by herself, without a lift. She stated, [Named Resident] #5 told anyone that came into the room about the CNA hurting her arm and leg. She could not recall who the nurse on duty was that came into the room. During an interview on 11/15/2022 at 1:03 PM, the Nurse Practitioner (NP) stated there had been X-rays ordered by the on-call provider on 10/9/2022 related to Resident #5's complaints of pain and bruising following the incident involving an unsafe transfer on 10/8/2022. She confirmed she saw Resident #5 on 10/10/2022 and discussed the symptoms of pain and bruising. She confirmed there was a large diffuse bruise on the upper left arm, and a small bruise on the top of the right knee. She stated, nursing reported a discoloration on the right foot/ankle, but I do not recall looking at her foot. She stated, [Named Resident] #5 has extensive medical knowledge and is very aware of her needs. She is able to discuss her medical history and preferences of care with staff and make her needs known. She prefers the use of a lift because she has so much pain in her shoulders related to arthritis. During an interview on 11/15/2022 at 2:01 PM, CNA #7 stated, [Named Resident] #5 transfers by [Named mechanical lift device]. She will let you know if you are going to transfer her, you must use the lift. She has not ever agreed to transfer without the use of the lift. During an interview on 11/15/2022 at 2:15 PM, LPN #4 confirmed on 10/9/2022 Resident #5's family member voiced concerns related to a CNA hurting her during a transfer against her will on 10/8/2022. She stated she expected staff to honor a resident's choice to not be transferred without using a lift. She confirmed a resident has the right to preferences related to care. During an interview on 11/15/2022 at 3:00 PM, Occupational Therapist #1 confirmed she had completed an evaluation for Resident #5 after the incident on 10/8/2022. She confirmed she had determined Resident #5 required the use of a full body lift due to pain and safety during transfer. During a telephone interview on 11/15/2022 at 3:26 PM, Resident #5's responsible party stated, The reason [Named Resident] #5 had been admitted to the facility was because she could no longer transfer her without using a lift due to severe pain. Everyone that takes care of her knows she has to be transferred using a lift. I have discussed the issue of pain during transfer with therapy and the nursing staff. [Named Resident] #5's preference for the lift is well known by staff, I have made sure of that since she first came into the nursing home. [Named Resident] #5 tried therapy and would refuse due to pain. Therapy used a lift to transfer her and said she would continue to be a lift transfer for safety due to pain. During an interview on 11/15/2022 at 3:41 PM, the Administrator confirmed a resident had the right to refuse any care the facility provided and if possible a resident's preferences for care would be honored. She confirmed Resident #5's preference for transfer was with a lift only. She stated she expected the resident's preference to be on her care plan. She confirmed the transfer of Resident #5 on 10/8/2022 without the use of a lift, violated the resident's right for self-determination of care. She confirmed she had investigated the incident and had not been able to prove willful intent of physical abuse. She confirmed CNA #1 she did not respect Resident #5's request to not be transferred without a lift. During an interview on 11/15/2022 at 4:02 PM, the Director of Therapy confirmed Resident #5 was evaluated and treated following her admission in 4/2022. She stated, PT [Physical Therapy] discharged [Named Resident] #5 to Long Term Care with use of a full body lift for transfers. When we got the orders to evaluate for her decline in functioning after having Covid-19, she was discharged as an extensive assist with one person. When surveyor asked if Resident #5 became more able to transfer safely following Covid-19, the Director of Therapy stated, [Named Resident] #5 refused to transfer without using a lift due to pain, but she can transfer with assistance. Therapy evaluates on the ability of the resident, not necessarily the preferences of the resident. The resident has a right to refuse the extensive assistance without a lift. During an interview on 11/21/2022 at 2:08 PM, CNA #9 stated she had been assigned to Resident #5 multiple times. She stated, [Named Resident] #5 refused to be transferred without using a [Named mechanical lift device] because it was too painful to move her around manually. During an interview on 11/21/2022 at 4:59 PM, the DON confirmed she expected a resident's preferences for care would be honored by staff and indicated on the care plan. She confirmed Resident #5 did not have a care plan for the preference related to transfers with a lift. She confirmed CNA #1 did not honor Resident #5's preferences for care when she transferred her without using a mechanical lift.

Based on facility policy review, medical record review, Facility Reported Investigation (FRI) review, facility video footage review, observations, and interviews, the facility failed to prevent abuse from occurring for 1 of 19 residents (Resident #16) reviewed. The findings include: Review of the facility's undated policy titled, Abuse, Neglect and Exploitation of Residents, revealed, .It is the policy of the facility that acts of physical, verbal, mental and financial abuse including neglect and exploitation directed against residents are absolutely prohibited. Each resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion, mistreatment, neglect, exploitation and misappropriation of property. Residents will not be subjected to abuse by anyone .Administrator/designee is responsible for operationalizing all policies and procedures that prohibit abuse, neglect and exploitation. They are also required to report instances of suspected or actual abuse, neglect or exploitation occurring within the facility .It is the responsibility of all staff to identify inappropriate behaviors towards residents, which may include but is not limited to .rough handling of residents .Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish .Physical abuse is the inappropriate physical contact with a resident which harms or is likely to harm the resident. This includes, but is not limited to hitting, slapping, pinching .It also includes control of resident's behavior through corporal punishment .For any allegation of physical assault with evidence of injury or witnessed physical assault the police will be contacted immediately . Review of the medical record revealed Resident #15 was admitted to the facility on [DATE] with diagnoses which included Paraplegia, Pressure Ulcer of Other Site, Stage 4, and Cocaine Abuse. Review of the Quarterly Minimum Data Set (MDS) assessment for Resident #15 dated 9/15/2022 revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Review of the undated Care Plan for Resident #15 revealed assessments/problems for, .Behavioral problem related to using inappropriate language towards staff .[Named Resident] exhibits physical aggressive/abusive behavior towards others . Appropriate goals and interventions were implemented. Review of the progress notes for Resident #15 revealed, .10/18/2022 IDT [Interdisciplinary Team] met to discuss incident that occurred at 1438 [2:38 PM] on 10/18/2022. Resident with a BIMS (15) Stressful Life Experience (10) Hx [history] of Paraplegia, Seizures, Neurogenic Bladder, Pressure Ulcers, Depression. Techs heard resident voices at nurses station. On review of the video footage, at 1438 [2:38 PM] another resident threw juice in the face of this resident that was rolling by in his wheelchair. This resident wheeled closer and grabbed the other resident by both arms and hit him in the face with a closed fist 2 times and 1 slap all making contact with his face. He then wheels back towards this resident, grabs his arm and continues to have aggressive looking behavior and grabs his right arm again. At one point, staff appear on camera and separate the two residents. Resident then picks up wet floor sign and throws it at the other residents face and chest. When this writer arrived on the unit, this resident [Resident #15] was sitting inside the nurses station. Resident remained 1:1 with a staff member. [Named City] Police Department were called to the facility. They issued a ticket for assault. The police department informed the facility that they would have to provide transportation to have this resident booked and fingerprinted once the warrant was ready .Resident returned from hospital at 2200 [10:00 PM] . Review of the Psych-Services Progress Notes for Resident #15 dated 10/19/2022 revealed, .He demonstrates no empathy or a lack of remorse . Review of the Incident Report for Resident #15 dated 10/18/2022 revealed, .While doing rounds two techs heard elevated voice in the hallway in front of the nurses station. Resident with BIMS (15) He threw juice in my face so I hit him. Watch the cameras. You will see .Residents immediately separated. This resident placed 1:1 with staff member . Review of the [Named City] Police Department report # 459744, dated 10/18/2022 revealed Resident #15 was issued a citation for simple assault and was scheduled to appear in court on 11/21/2022 at 9:00 AM. Review of the medical record revealed Resident #16 was admitted to the facility on [DATE] with diagnoses which included Type 2 Diabetes, Pulmonary Fibrosis, and Unspecified Psychosis. Review of the Quarterly MDS assessment for Resident #16 dated 11/3/2022 revealed a BIMS score of 7, which indicated severe cognitive impairment. Review of the UIRS [Unusual Incident Reporting System] FRI report #20221018161125 dated 10/24/2022 revealed the Administrator reported a resident-to-resident altercation that occurred on 10/18/2022 between Resident #15 and Resident #16. The report stated the staff heard a splash and heard Resident #15 state, 'Why you throw that Gatorade on me?' The report states Resident #15 and #16 were involved in a physical altercation before being separated by staff. Each resident was assessed by the nurse and first aid rendered. The police were notified, and Resident #15 was issued a citation for simple assault. Review of the video footage on 10/18/2022 regarding the altercation between Residents #15 and Resident #16, revealed Resident #16 was sitting in the hallway in a reclined gerichair against the wall when Resident #15 rolled beside him in his wheelchair. Resident #16 threw a glass of liquid on Resident #15, at which time Resident #15 started punching Resident #16 with his fists. There were no staff present in the hallway that could be seen on camera. Within seconds, a staff member came into the camera viewing field and separated the residents. During an interview on 11/16/2022 at 9:58 AM, the Administrator confirmed Resident #15 willfully attacked Resident #16, meaning to cause harm. She stated, The police department didn't really want to do anything about it, but I pushed the issue to make sure something was done to [Named Resident #15] because I was angry at him hitting [Named Resident #16.]

A complaint investigation was conducted on 8/31/2022 to 9/1/2022 at [NAME] Center For Rehabilitation and Healing Health deficiencies were cited in relation to complaints TN00058640 under 42 CFR PART 483, Requirements for Long Term Care Facilities, which resulted in an Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified related to the facility failed to protect 1 of 3 sampled Resident's (Resident #4) for Elopement. Based on facility documentation review, facility's policy review, medical record review, observation, and interview, the facility failed to provide adequate supervision to prevent elopement (Residents who have a history of leaving or trying to leave the facility or have wandered or have the potential to wander into unsafe areas), for 1 of 3 resident's (Resident #4) reviewed who was an ambulatory cognitively impaired Resident who eloped from the facility on 8/27/2022. The weather on 8/27/2022 was partly cloudy with a temperature of 93 degrees. The facility's failure placed the resident in an Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The facility failed to supervise Resident #4 which resulted in an elopement from the facility on 8/27/200. The Administrator and Regional Staff were notified of the Immediate Jeopardy on 9/1/2022 at 11:26 AM in the Administrator's Office. The facility was cited Immediate Jeopardy at F-689 . The facility was cited at F-689 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy was removed onsite and was effective from 8/27/2022 to 9/1/2022. An acceptable Immediate Action Removal Plan, which removed the immediacy of the jeopardy, was received on 9/1/2002 at 2:55 PM. The corrective actions were validated onsite by the surveyors on 9/1/2022 at 2:55 PM. The facility's noncompliance at F-689 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction. The findings include: Review of the facility's documentation titled, Investigative Summary, dated 8/27/2022, revealed, .Camera review exhibited that alarm sounded at 11:51 am, and staff responded in approximately 40 seconds as staff were engaged in patient care. Camera review showed that no staff exited the doors at the time the alarm was sounding. Camera review showed that resident (Resident #4) was out of view at the time that staff searched the immediate area outside exit door . Review of the facility's documentation titled, Investigative-Camera Review, dated 8/27/2022, revealed, .11:51:07 Resident is leaving door on the outside, walking rapidly vs. [verses] jogging from doorway across facility grass, and toward trees near side of premises .11:51:47 Resident is behind trees, and is no longer visible .Camera view shows that resident was near the exit door for approximately 23 seconds. Resident was moving rapidly, and it took her only 38 seconds to get from the door outside to the tree line where she was no longer visible .12:03 pm Notified supervisor that resident was unable to be located .12:05 pm Missing Person Alert paged overhead, Search of the building and premises was initiated, Employees also used vehicles to search surrounding roadways .12:20 pm DON (Director of Nursing) and Administrator notified that resident was unable to be located at facility .12:25 pm [named police department] notified for assistance .1:00 pm Resident was located at local gas station by Police Dept [Department], and transported to the hospital for general eval [evaluation] . Review of the undated facility policy titled, Abuse, Neglect and Exploitation of Residents, revealed, .It is the policy of the facility that acts of physical, verbal, mental and financial abuse including neglect and exploitation directed against residents are absolutely prohibited. Each resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, mistreatment, neglect, exploitation, and misappropriation of property .Neglect: The failure to provide goods or services which are necessary to maintain physical or mental health, and necessary to avoid physical harm, mental anguish, or mental illness. Neglect may be a repeated course of conduct or a single incident . Review of the facility's policy titled, Resident Rights, dated 12/2016, revealed, .Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: Be free from abuse, neglect, misappropriation, of property and exfoliation . Review of the facility's policy titled, Elopements, dated 12/2007, revealed, .Staff shall investigate and report all cases of missing residents .If an employee discovers that a resident is missing from the facility, he/she shall: a. Determine if the resident is out on an authorized leave or pass; b. If the resident was not authorized to leave, initiate a search of the building(s) and premises, If the resident is not located, notify the Administrator and the Director of Nursing Services, the resident's legal representative, the Provider, law enforcement officials, and (as necessary), volunteer agencies; d. Provide search teams with resident identification information, and e. Initiate search of the surrounding area . Review of the facility's undated Emergency Preparedness Program titled, Code Adventure Club Alert, Missing Resident, revealed, .Definition: A resident's location cannot be determined. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing .If an employee discovers that a resident is missing from the facility, he/she shall: a. Determine if the resident is out on an authorized leave or pass; b. If the resident was not authorized to leave, initiate a search of the building(s) and premises, If the resident is not located, notify the Administrator and the Director of Nursing Services, the resident's legal representative, the Provider, law enforcement officials, and (as necessary), volunteer agencies; d. Provide search teams with resident identification information, and e. Initiate search of the surrounding area . Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses which included Altered Mental Status, Alzheimer's Disease, Difficulty in Walking, Post-Traumatic Stress Disorder, Major Depressive Disorder, Bipolar Disorder, Generalized Anxiety Disorder, and Muscle Weakness. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] to the secured unit. On 7/28/2022 she was moved to an Unsecured Unit. Continued review revealed Resident #4 tested positive for COVID-19 on 8/24/2022 and was moved to the Covid unit, which an unfamiliar environment. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment. Continued review revealed the resident required limited assistance with one-person physical assistance with walking. Review of Resident #4's hospital record prior to admitted d 6/16/2022 revealed, .70 yo [year old] F [female] with dementia found on the road and admitted with AMS [Altered Mental Status] .brought to the ED [Emergency Department] by EMS [Emergency Medical Services] after reportedly being found outside on the road, confused, and altered . Review of Resident #4's elopement risk assessment dated [DATE], revealed a score of 25, which indicated high risk for elopement. Review of Resident #4's Order Summary Report dated 9/1/2022, revealed the resident had an order for monitoring of wandering behavior beginning on 6/16/2022. Review of Resident #4's Treatment Administration Record (TAR) dated June 2022 through August 2022, revealed the resident was monitored for wandering every shift. Review of Resident #4's nursing progress note dated 8/24/2022, revealed, .Rapid covid is positive .Will move to room [ROOM NUMBER] . Review of Resident #4's nursing progress note dated 8/27/2022, revealed, .This supervisor alerted by staff of inability to locate resident. Immediate Adventure Club Alert called overhead throughout building. Search of building completed, and resident not located. Call placed to [named local Police Department] to request assistance. [Named local Police Department] located resident and transported her to [NAME] Regional out of precaution for medical clearance. Conservator aware . Review of Resident #4's hospital record dated 6/16/2022 revealed, .70 yo [year old] F [female] with dementia found on the road and admitted with AMS [Altered Mental Status] .brought to the ED [Emergency Department] by EMS [Emergency Medical Services] after reportedly being found outside on the road, confused, and altered . Review of Resident #4's hospital record dated 8/27/2022 revealed, .This [AGE] year-old female who was found by local police at a gas station and brought to ER [emergency room ] for evaluation . Review of Resident #4's nursing progress note dated 8/27/2022, revealed, .BIMS completed today. BIMS Score is 3.0. Category is Severe Impairment . Review of the Incident Report for Resident #4 dated 8/27/2022, revealed, .Patient seen on camera exiting door at 11:51 [a.m.] and turning right. [Named] Police Department called to assist in locating patient. Patient located by police department at 1:05 pm. Out of precaution, patient taken to [named hospital]. [Named nurse at named hospital] notified facility that patient is stable and having preliminary tests run. Notified conservator of incident .She does request that patient be 1:1 [one on one] or placed on 2A upon return . Review of Registered Nurse (RN) #2's verbal statement dated 8/27/2022, revealed, .she was in the break room, eating her lunch when she heard the door alarm. She got up and went to investigate the alarm. the double doors on unit 4 were alarming. [named RN #1] stated there was no one near the doors so she went outside and looked around, didn't see anyone. She came back inside and looked down the halls and no one was in sight. She then went back outside and looked again without seeing anyone before coming back in and turning off the alarm. She then went and found the other nurse for the unit [named LPN #5], and told her about the door alarming and that she looked outside and didn't see anyone . Review of Licensed Practical Nurse (LPN) #5's written statement dated 8/27/2022, revealed, .I was working on hall 400 which is the COVID unit. I heard an alarm sounding, but at the time I was in a resident's room in the middle of a tube feeding procedure. I did hear the alarm stop. The other nurse on the floor [named RN #2] came into the room I was in within the next minute or so. I had completed what I was doing in the room, so stepped out, and she told me that she had gone to the alarm, didn't see anyone inside or outside when she looked, and had turned the alarm off. I went then to check on the residents on our floor. This was when I realized that [named Resident #4] was not in her room. At this time, I notified the supervisor, and an Adventure Club code was called for Missing Persons . During an observation of the 400 Hall exit door on 9/1/2022 at 1:35 PM, with the Maintenance Director and Maintenance employee #1 revealed signage on the door, Push until alarm sounds door can be opened in 15 seconds. Continued observation the Maintenance Director demonstrated by holding the door for 15 seconds, the door opened, and the alarm sounded. During an interview on 9/1/2022 at 12:00 PM, by phone with local police officer involved in elopement for Resident #4 revealed, I didn't find the lady, a state trooper that was helping us with covering our calls found her. She was found at a gas station [Named Gas Station] approximately 1 1/2 to 2 miles away from the facility. The trooper called EMS [Emergency Medical Services] to transport her to the local hospital. He didn't know who she was other than an elderly lady wandering around the [Named Gas Station and Street Name]. He alerted the local police station of this incident. I went to the hospital to check and see if it was the missing Resident, we had been looking for that walked away from a nursing home. She had identified herself by name to hospital staff and they verified it with the nursing home. We were getting ready to call out our team that has blood hounds to find this lady. During an interview on 9/1/2022 at 1:25 PM, the Maintenance Director and Maintenance employee #1 stated Resident #4 eloped from the facility on 8/27/2022. Maintenance employee #1 stated, I was called to the facility to check all the exit doors for proper functioning. He stated, The doors were working properly, but I changed the codes to all the doors for safety measures. Continued interview the Maintenance Director stated, The unit she's [Resident #4] on is not a secured unit, so the doors are not locked. The door she went out is a Delayed Egress door, meaning the door releases after so many seconds. Continued interview he stated, I watched the video footage from 8/27/2022 and [named Resident #4] walked up to the door, read the sign, pushed the door until it released, and walked out. She had already reached the tree line when the nursing staff looked outside the exit door. During an interview on 9/1/2022 at 2:37 PM, Licensed Practical Nurse (LPN) #5 stated she was assigned to Resident #4 on 8/27/2022. She stated, I was in another resident's room when I heard the door alarm. The other nurse back here [named RN #1] came to the door of the room I was in and said she had gone outside and looked around and didn't see anyone outside, so she came back in and didn't see anyone in the hall, so she disabled the alarm. I left the resident room I was in and immediately went to the door to see if I could see anyone, and I didn't. I came back inside and started looking for [named Resident #4]. I was afraid it was her because she had been walking in the hall earlier and I didn't know her that well, and I knew everyone else back here. We did a head count and [named Resident #4] was missing. I notified my supervisor that [named Resident #4] was missing and she paged overhead 'Adventure Club' [the code for a missing resident], called the police and the Administrator. During an interview on 9/1/2022 at 3:25 PM, the Administrator confirmed Resident #4 eloped the facility on 8/27/2022. She stated, They [the staff] notified me they couldn't find [named Resident #4], they had already searched inside and outside the facility and didn't locate her. Continued interview she stated the staff called the local police and the police came to the facility and got a description of the resident. She stated, A State Trooper found her at [named gas station] and she was transported to the emergency room for an evaluation. Continued interview she stated, I watched the video footage, and you can see [named Resident #4] reading the signs on the door and pushing the door until it opened. Once the door opened, she went out the door and was walking very fast. The surveyors verified the acceptable Immediate Action Removal Plan on 9/1/2022 at by: 1. The surveyors verified the facility placed Resident #4 on 1:1 supervision until she can be placed on the secured unit. 2. The surveyors verified the facility assessed all residents in the facility for elopement risk and updated the elopement book. 3. The surveyors verified the facility educated licensed nursing staff on Elopement risk management. 4. The surveyors verified the facility placed signs on every exit door which stated, If alarm sounds, staff must investigate immediately. Do not turn off alarm without investigating. 5. The surveyors verified the facility held an Ad hoc QAPI (Quality Assurance Performance Improvement) meeting on 8/27/2022 related to Resident #4's elopement from the facility. The facility is required to submit a Plan of Correction for F-(Tag).

Based on facility policy review, medical record review, and interviews, the facility failed to identify and provide needed care and services that are resident centered in accordance with professional standards of practice that resulted in a harm for 1 of 9 sampled residents (Resident #7) reviewed. The finding include: Review of the undated facility policy titled Abuse, Neglect and Exploitation of Residents, revealed .it is the policy of the facility that acts of physical, verbal, mental and financial abuse including neglect and exploitation directed against residents are absolutely prohibited. Each resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, mistreatment, neglect, exploitation, and misappropriation of property . Review of the undated facility policy titled, Resident's Rights- Federal, revealed, .The facility shall protect and promote the rights of each Resident . Review of undated facility policy titled, Resident's Rights-Tennessee, revealed, .The nursing home shall establish and implement written policies and procedures setting forth the rights of residents for the protection and preservation of dignity, individually and, to the extent medically feasible, independence . Review of the facility's undated policy titled, Medication Therapy, revealed, .Each residents' medication regimen shall include only those medications necessary to treat existing conditions and address significant risks .All medications will be supported by appropriate care processes and practices .2. f. Any concern for residents with known history of drug addiction/abuse .e. Potential or suspected drug seeking behavior for any residents with known history of drug addiction/abuse .5. D. Where possible questionable medications have been obtained and ingested by a resident with a known history or drug addiction/abuse .e. Evaluation for need of urine drug screening for concerning behavior or clinical presentation of a resident, for example a resident with a known history of drug addiction/abuse . Review of the facility's undated policy titled, Accidents and Incidents- Investigating and Reporting, revealed, .Accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator .The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall initiate and document investigation of the accident or incident .The Nurse Supervisor/Charge Nurse and or the department director or supervisor shall complete an Incident/Accident form and submit the original to the IDT [Interdisciplinary Team] . Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses which included Other Psychoactive Substance Abuse, Paraplegia, and Limitation Of Activities Due To Disability. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #7 scored 13 on the BIMS which indicated high cognitive functioning. The MDS also revealed Resident #7 required supervision with transfer, locomotion on and off the unit, extensive assistance with bed mobility, dressing, toilet use, and personal hygiene. Use of wheelchair indicated. Review of the Comprehensive Care Plan dated [DATE] for Resident #7 revealed the care plan was revised [DATE] to include supervised smoking by staff member, the care plan was revised on [DATE] for exhibiting drug seeking behaviors and observe for s/s (signs/symptoms) of over self-medicating, lethargy, cognitive changes, and changes in respiratory status. Review of the Safety Check Flow-Sheet starting [DATE] and ending [DATE] at 9:00PM revealed Resident #7 was on every 15-minute checks. Review of the Nursing Progress Note dated [DATE] for Resident #7 revealed This nurse was approached by 2A nurse to call supervisor and come down to room [ROOM NUMBER]B upon entering the room I seen a black fanny pack sitting on residents electric wheel chair, the black fanny pack was unzipped, supervisor came into the room, we wore gloves there was brownish looking powder in a plastic wrap supervisor notified director of nursing and administrator night shift supervisor locked up bag of powder in the DONs office so they can get it tested by authorities. Review of the Change in Condition Note-SBAR dated [DATE] on Resident #7 revealed Situation: residents roommate came to nurse and nursing assistant to come to resident's room resident was sitting in a upright position in bed head slumped over touching his feet with head laying on his legs resident was not breathing and had no pulse called code blue and started CPR other nurse came from other units to help with CPR 911 called 9:20PM EMS arrived and take over CPR Ems Narcan resident X4 times. EMS was able to obtain a pulse and transported resident to {Named Hospital} for evaluation and treatment. {Named Facility Doctor} on call and Resident's family notified. Background: resident had a history of drug abuse and had been caught by administration dealing drugs to other residents at the facility, prior to this. Review of the ER Physician Documentation on Resident #7 dated [DATE] revealed .This [AGE] year-old male white male presents to ER via EMS with complaints of CPR. Preceding the arrest, the patient was found down by nursing home staff. The arrest occurred at the nursing home. Pre-hospital course: The arrest was not witnessed by others. Bystanders at the scene performed CPR. EMS care prior to arrival: initiation of ACLS (Advanced Cardiac Life Support) .initial rhythm was asystole .response to therapy: Continued arrest .Patient had a history of paraplegia, presently in the nursing home for rehab (Rehabilitation) .by second hand reports he has a history of drug abuse, he had recently gone out with some friends .he had CPR for over half an hour, despite this he remained on asystole, further resuscitation efforts were deemed futile .Time of death 11:26PM [DATE] .Cardiac Arrest, cause unspecified . Review of four handwritten notes signed and dated [DATE], two undated handwritten notes and two signed and dated [DATE] handwritten notes revealed staff was familiar with Resident #7 and that he was under suspicion for bringing in drugs to the facility. During an interview on [DATE] at 1:30 PM with Certified Nursing Assistant (CNA) #1 revealed she works full time for the facility. CNA #1 was asked if she had ever cared for Resident #7 and she stated, I cared for him 2 days before his death. I had been out for a week prior to this and when I came back, I was told he could not go out to smoke unless he was supervised. CNA #1 stated, He was smoking by himself prior to that, and he had told me that he had history of an overdose. CNA #1 stated, I noticed a couple of days before his death he started sleeping more, I asked him if he was ok, and he said yes. During an interview with the facility Administrator and the facility DON on [DATE] at 2:30PM in the conference room revealed they were both familiar with Resident #7. The Administrator stated, I was made aware that Resident #7 was possibly getting drugs into the facility. We did a search of his room and found nothing. Around [DATE] Resident #7 had visitors come in to visit for about 10 minutes. After that we put him on 1:1 supervision with smoking and later added 15-minute checks. Any packages that were brought in the facility after that we inspected in front of the Resident. Resident #7 denied having illegal drugs brought into the facility. At that point we could not prove anything. Resident #7 was here at the facility before, and we never had any issues. Administraor and DON were asked about a CNA statement on Resdient #7's that a couple days before his death he was sleeping more. The administrator and DON both denied hearing those concerns from the CNA. The Administrator also denied having any results back relating to the ongoing death investigation on Resident #7 or results of the powder substance found in Resident #7's fanny pack. During an interview with LPN #1 and RN #2 on [DATE] at 10:05 AM, LPN #1 was asked if she had ever cared for Resident #7, she stated Yes, I took care of him before he came back this last time. LPN #1 stated, I did have an issue with this resident one weekend that I was the supervisor. LPN #1 and RN #2 reported that Resident #9 was not acting right, pupils were dilated, and she reported Resident #7 gave her a Suboxone pill. LPN #1 stated, I had to give her Narcan. LPN #1 and RN #2 confirmed the date of the incident was [DATE] and pulled up the nurse note and read the note to this surveyor. LPN #1 further stated, [Named Resident #9] stayed at the facility after she received the Narcan, Emergency Medical System [EMS] was called but [Named Resident #9] refused to go to the hospital. The [NAME] police came to the facility and talked to the [Named Resident #9]. LPN #1 stated, The Director of Nursing (DON) was aware of the incident. During an interview on [DATE] at 10:45 AM, Resident #9 was asked about an incident she had while in the facility during the month of [DATE]. Resident #9 stated, Are you talking about the Suboxone I took, yea [Named Resident #7] gave it to me. Now he is dead with an overdose, he was depressed. She stated, I knew it was Suboxone because I have taken that medicine before. I bought the pill from him, but I never got to pay him for it. Resident #9 was asked where Resident #7 obtained the suboxone when he gave it to her and she stated, He kept them in his fanny pack on his wheelchair, he had a bunch of suboxone tablets left. He sold them to other residents, I know [Resident #4] bought some from him because I seen her buy them. We bought them from him when we were outside in the courtyard smoking. I heard him talking to his roommate about the drugs. Resident #9 stated, The suboxone caused my oxygen sats [saturation] to go down, it affected me differently since I have had a stroke, I got really bad. The supervisor [LPN #1] gave me the Narcan, I don't think it really helped any. They [LPN #1] called the ambulance but I refused to go to the hospital. The hospital called the [NAME] police, and they came out to talk with me. I promised the Director of Nursing [DON] that I would never do that again. He [Resident #7] died of a heroin overdose, I know another resident bought heroin from him. Resident #9 was asked who was the resident that was buying heroin from him. She stated, I can't tell you that, but the resident is not here anymore. During an interview on [DATE] at 4:00PM in the conference room with the facility Administrator and DON revealed after being asked about an investigation being completed on Resident #7 giving Resident #9 a suboxone tablet, the Administrator provided signed statements about the incident only. No other investigation reports were acknowledged The Administrator denied having a copy of the police report or any reports as to what the powder substance was that was found in Residet #7's fanny pack. The Administrator stated Resident #9 did have the other half of the unknown tablet that was given to police. The Administrator stated the officer gave it back to the nurse to destroy. The Administrator denied documenting an investigation on the description of the tablet found or that the tablet was destroyed with two nurses. The Administrator was asked if Resident #7 was ever drug tested , provided any psychiatric evaluation, or sent out for evaluation due to suspected drug use and the Administrator stated no.

Based on facility policy review, medical record review, facility video footage review, and interview the facility failed to ensure 1 resident (Resident #2) of 3 residents reviewed was treated with respect, dignity, and quality of life when restrained with a gait belt to his wheelchair. The findings include: Review of the facility policy, Abuse, Neglect and Exploitation of Residents, undated, revealed .It is the policy of the facility that the acts of abuse directed against residents are absolutely prohibited .unlawful restraint is intentionally or knowingly using a physical or chemical restraint . Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed a Significant Change Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 had a Brief Interview for Mental Status (BIMS) of 01, indicating severe cognitive impairment. Further review revealed no restraints were used for Resident #2. Medical record review of Resident #2's (MONTH) 2019 Order Summary Reports revealed no order for a restraint. Review of the facility's video footage on 5/2/19 and interview with the Administrator on 6/11/19 at 11:52 AM in the conference room confirmed the Alleged Perpretrator (AP) restrained Resident #2 to his wheelchair by putting a gait belt around his chest and fastening the gait belt to the back of the wheelchair, restraining Resident #2 in his wheelchair. Interview with the Administrator revealed the AP, Certified Nursing Assistant (CNA) #3 and CNA #4 were identified by the Administrator on the video footage. Further review of the facility's video footage revealed CNA #4 was standing at the nurses station facing the AP and Resident #2 and it appeared that CNA #3, wearing a pink shirt, was in the sideline of the camera then CNA #3 walked by the AP and Resident #2 after the gait belt was applied. Further review revealed the facility's video footage did not show removal of the gait belt. Interview with the Administrator revealed the video footage containing conversation between the Respiratory Therapist (RT) and Resident #2 was unavailable due to the system rolls over video footage after 14 days, and some video footage is self-erased. Interview with the Director of Nursing (DON) on 6/11/19 at 8:00 AM in the conference room revealed the DON was informed of the abuse on 5/2/19 around 9:00 AM by Licensed Practical Nurse (LPN) #5. Continued interview revealed by the time the DON informed the Administrator, the Respiratory Therapist (RT) had already reported it to the Administrator. Continued interview revealed when asked when staff were to report abuse the DON confirmed all staff were expected to report suspected or witnessed abuse immediately. Interview with the Administrator on 6/11/19 at 8:15 AM in the conference room revealed the Administrator was notified on 5/2/19 around 10:00 AM by RT #1 of Resident #2 being restrained in his wheelchair with a gait belt around his chest. Continued interview revealed the Administrator reported the allegation to the State Agency as soon as he was aware of the allegation. Further interview when asked when staff were to report abuse the Administrator stated, Immediately, I expect them to notify me as soon as it happens. Interview on 6/11/19 at 1:45 PM with LPN #5 at nurses station 2A revealed she reported for work on 5/2/19 at 7:30 AM. Continued interview revealed she stated, RT (#1) reported to me that (Resident #2 ) was sitting in his wheelchair at the nurses station with a gait belt around his chest, secured to the wheelchair; I went immediately and assessed Resident #2 and he was in the bed with no restraint on and no injuries noted. Continued interview with LPN #5 stated, I reported to the Director of Nursing around 8:30 AM the RT witnessed Resident #2 being in a wheelchair with a gait belt around his chest, secured (restrained) to the wheelchair. Interview with RT #1 on 6/11/19 at 1:15 PM in the conference room revealed on arrival to the facility on [DATE] around 5:30 AM she observed Resident #2 sitting in a wheelchair yelling come here. and look what that [***] did to me. RT #1 stated the resident had a gait belt around the upper part of the chest, attached to the wheelchair, and fitted snugly against the resident's chest. Continued interview revealed RT #1 reported what she saw to the Administrator around 9:00 to 9:30 AM on 5/2/19. She stated, I guess I should have called someone and reported it sooner, I don't know, I just told (LPN #5) as soon as she got here. Validation of the IJ removal plan was completed on 6/12/19 through review of the facility documentation, observations and interviews. Surveyor verified the IJ removal plan by: 1. Review of the personnel file for the AP revealed abuse training was appropriately provided at orientation and as needed. Continued review revealed the facility obtained background checks and reference checks with no negative findings. Immediately following the incident on 5/2/19 the AP was suspended pending investigation. Further review revealed the AP was terminated on 5/2/19 following review of video footage confirming application of a gait belt as a restraint by the AP to Resident #2. 2. Review of resident audits for all the residents on the secured unit. 3. Review of the restraint policy and abuse policy was completed and the policies were appropriate. In-service education was completed for all staff on 5/3/19 to 5/6/19 as evidenced by sign-in rosters and staff interviews. Verification through interviews of internal audits initiated 6/12/19 to ongoing every 2 weeks then weekly for 3 months to assess for restraint use. 4. Presentation of all audits to the Quality Assurance Committee (QAC) monthly for 3 months; with the first presentation at the 6/12/19 meeting.

Based on policy review, review of the facility investigation, medical record review, facility video footage review and interview the facility failed to ensure 1 resident (Resident #2) of 3 residents was free from the use of restraints related to Resident #2 being restrained with a gait belt to his wheelchair. The findings include: Review of the facility policy, Use of Restraints, undated, revealed .Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted . Review of facility policy, Gait Belts, undated, revealed .Gait belts must be used by all Therapy Rehabilitation staff during balance activities, transfers, and gait training of patients to promote safety during therapeutic activities, unless contraindicated . Review of the facility investigation revealed an investigation was started on 5/2/19 related to allegation of abuse by the alleged perpertrator (AP) to Resident #2. Continued review revealed initial written statements were obtained from the Respiratory Therapist (RT #1) Certified Nurse Aide (CNA) #3 and CNA #4. Further review revealed RT #1's initial written statement revealed I walked over to 2A's nsg (nursing) station at approximately 04:45 to discuss this [MEDICAL CONDITION] Care. As I arrived in the common area, I saw the Resident (#2) sitting in his wheelchair. He was secured (restrained) to the chair with a pink and grey gait belt. The belt was wrapped around the Resident (#2's) chest and the wheelchair. I talked briefly with him. He said the word [***] and motioned his hand as he pointed to the nurses station. When I looked at the nursing station the AP was the only person sitting there. The gait belt was obviously tightly secured because he could not lift his back off of the back of the wheelchair. Continued review of CNA #4's statement revealed I would like to see the video footage because I don't remember seeing any resident being abused while I was working 2A on 5/2/19. Further review revealed CNA #3's statement revealed I don't know really when I came out (of) the room (Resident #2) was already in the chair strapped in. Continued review revealed the initial statement for the AP dated 5/6/19 revealed .there was no intent of abuse .it was placed for his safety . Further review revealed the AP received abuse training upon employment with the facility on 8/22/18. Continued review revealed the AP's employment was terminated on 5/6/19. Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed a Significant Change Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 had a Brief Interview for Mental Status (BIMS) of 01, indicating severe cognitive impairment. Further review revealed no restraints were used for Resident #2. Medical record review of Resident #2's Order Summary Report dated (MONTH) 2019 revealed no order for a restraint. Review of the facility's video footage on 5/2/19 with the Administrator on 6/11/19 at 11:52 AM in the conference room confirmed the AP restrained Resident #2 to his wheelchair at approximately 4:39 AM by putting a gait belt around his chest and fastening the gait belt to the back of the wheelchair, restraining Resident #2 in his wheelchair. Interview with the Administrator revealed the AP, CNA #3 and CNA #4 were identified by the Administrator on the video footage. Further review of the facility's video footage revealed CNA #4 was standing at the nurses station facing the AP and Resident #2 and it appeared that CNA #3, wearing a pink shirt, was in the sideline of the camera then CNA #3 walked by the AP and Resident #2 after the gait belt was applied. Further review revealed video footage did not show removal of the gait belt. Interview with the Administrator revealed the video footage containing conversation between RT #1 and Resident #2 was unavailable due to the system rolls over video footage after 14 days, and some video footage is self-erased. Interview with the Director of Nursing (DON) on 6/11/19 at 8:00 AM in the conference room revealed she was informed of the alleged abuse on 5/2/19 around 9:00 AM by Licensed Practical Nurse (LPN) #5. Continue interview revealed by the time the DON informed the Administrator, RT #1 had already reported it to the Administrator. Continued interview when asked when staff were to report abuse the DON confirmed all staff were expected to report suspected or witnessed abuse immediately. Interview with the Administrator on 6/11/19 at 8:15 AM in the conference room revealed the Administrator was informed on 5/2/19 around 10:00 AM by RT #1 of Resident #2 being restrained in his wheelchair with a gait belt around his chest. Continued interview revealed the Administrator reported the allegation to the State Agency as soon as he was aware of the allegation. Further interview when asked when staff were to report abuse the Administrator stated, Immediately, I expect them to notify me as soon as it happens. Interview on 6/11/19 at 1:45 PM with LPN #5 at nurses station 2A revealed she reported for work on 5/2/19 at 7:30 AM. Continued interview revealed, she stated, the RT (#1) reported to me that (Resident #2) was sitting in his wheelchair at the nurses station with a gait belt around his chest, secured to the wheelchair; I went immediately and assessed Resident #2 and he was in the bed with no restraint on and no injuries noted. Continued interview with LPN #5 revealed I reported to the DON around 8:30 AM RT #1 witnessed (Resident #2) being in a wheelchair with a gait belt around his chest, secured to the wheelchair. Interview with the RT #1 on 6/11/19 at 1:15 PM in the conference room revealed she reported for work on 5/2/19 around 5:30 AM to educate the night shift nurses on [MEDICAL CONDITION] care. Continued interview revealed when she went to station 2A around 5:45 AM and she observed Resident #2 sitting in a wheelchair with his back facing the nurses station. Resident #2 hollered (yelled) come here and motioned for RT #1 to come over to him. RT #1 went over to Resident #2 and he pointed at a gait belt that was around his chest, and said look what that [***] did to me, pointing toward the nurses station where the AP was sitting. Further interview revealed, when asked how was the gait belt placed on Resident #2 she confirmed the gait belt was around the upper part of Resident #2's chest snugly, and attached to the wheelchair. When asked to explain snuggly, RT #1 replied, he could not raise his back off the back of the wheelchair. Continued interview revealed RT #1 went inside the nurses station and spoke to the AP related to the training she was doing and the AP spoke hatefully saying, I don't have time to do the training. RT #1 left nurses station 2A and went to the 400 hall. Further interview revealed RT #1 reported her observation of Resident #2 with a gait belt around his chest restraining Resident #2 to his wheelchair to LPN #5 (Unit Manager for 200 Hall) when she (LPN #5) arrived at the facility at 7:30 AM. Continued interview revealed RT #1 reported her observation of Resident #2 in his wheelchair with a gait belt around his chest to the Administrator during the morning stand up meeting around 9:00 to 9:30 AM on 5/2/19. She stated, I guess I should have called someone and reported it sooner, I don't know, I just told ( LPN #5) as soon as she got here. Telephone interview with CNA #3 on 6/12/19 at 7:25 AM revealed she has been employed with the facility since (MONTH) (YEAR) and usually worked station 2A, the secured unit. Continued interview revealed CNA #3 was trained on abuse upon hire and quarterly. Further interview revealed CNA #3 named the types of abuse and had never suspected or witnessed abuse and would report suspected or witnessed abuse immediately to the supervisor and the DON. Continued interview when asked if she ever witnessed abuse, stated No I've never witnessed abuse, when they (Administrator and DON) called me and asked me about the (AP) securing (restraining) (Resident #2), I told them that I didn't know what they were talking about and I never seen anything, I even wrote a statement saying I never seen nothing. Further interview revealed CNA #3 was again questioned about observing abusive behavior toward residents, CNA #3 stated, I have never seen nobody being abused when I've worked. Telephone interview with CNA #4 on 6/12/19 at 8:17 AM revealed she has been employed with the facility for one year and usually worked on station 2A, the secured unit. Continued interview revealed CNA #4 received training on abuse upon hire during orientation and every month. CNA #4 named the types of abuse and would report suspected or witnessed abuse immediately to the supervisor. Further interview revealed CNA #4 had never observed any resident being abused while working at the facility. CNA #4 stated she had worked with the AP and had never observed her abuse any resident. Continued interview when asked if she recalled Resident #2 being restrained by the AP she stated I never saw him (Resident #2) with a gait belt on him, I only saw him sitting in the wheelchair. Further interview revealed CNA #4 was again questioned about observing abusive behavior toward residents with same answer given as stated above. Validation of the IJ removal plan was completed on 6/12/19 through review of the facility documentation, observations and interviews. Surveyor verified the IJ removal plan by: 1. Review of the personnel file for the AP revealed abuse training was appropriately provided at orientation and as needed. Continued review revealed the facility obtained background checks and reference checks with no negative findings. Immediately following the incident of 5/2/19 the AP was suspended pending investigation. Further review revealed the AP was terminated on 5/2/19 following review of video footage confirming application of a gait belt as a restraint by the AP to Resident #2. The disciplinary action was completed on 5/6/19. 2. Review of resident audits for all the residents on the secured unit. 3. Review of the restraint policy and abuse policy was done and the policies were appropriate. In-service education was completed for all staff on 5/3/19 to 5/6/19 as evidenced by sign-in rosters and staff interviews. Verification through interviews of internal audits initiated 6/12/19 to ongoing every 2 weeks then weekly for 3 months to assess for restraint use. 4. Presentation of all audits to the Quality Assurance Committee (QAC) monthly for 3 months; with the first presentation at the 6/12/19 meeting.

Based on facility policy review, medical record review, facility investigation, employee files and interviews the facility failed to follow the facility policy related to reporting abuse immediately to the supervisor. The findings include: Review of the facility policy, Abuse, Neglect and Exploitation of Residents, undated, revealed .It is the policy of the facility that acts of abuse directed against residents are absolutely prohibited .All personnel (including volunteers) in all departments will be alert to indicators of suspected or actual abuse, neglect and exploitation. The resident is assisted to safety and is protected against (further) harm, and if abuse is suspected, personnel will report their observations to their supervisor immediately and without delay . Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed a Significant Change Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 had a Brief Interview for Mental Status (BIMS) of 01, indicating severe cognitive impairment. Further review revealed no restraints were used for Resident #2. Review of the facility investigation and a Respiratory Therapist (RT #1) initial written statement dated 5/2/19 revealed I walked over to 2A's nsg (nursing) station at approximately 4:45 AM to discuss this [MEDICAL CONDITION] Care. As I arrived in the common area, I saw (Resident #2) sitting in his wheelchair. He was secured (restrained) to the chair with a pink and grey gait belt. The belt was wrapped around (Resident #2's) chest and the wheelchair. I talked briefly with him. He said the word '[***] ' and motioned his hand as to point to the nurses station. When I looked at the nsg station the (AP) was the only person sitting there. The gait belt was obviously tightly secured because he could not lift his back off of the back of the wheel chair. Review of the RT #1's employee file on 6/12/19 revealed RT #1 received training on abuse and reporting abuse upon hire in (MONTH) 2019. Interview with the Director of Nursing (DON) on 6/11/19 at 8:00 AM in the conference room revealed the DON was informed of the alleged abuse on 5/2/19 around 9:00 AM by Licensed Practical Nurse (LPN) #5. Continued interview revealed by the time the DON informed the Administrator, the RT #1 had already reported it to the Administrator. Continued interview when asked when staff are to report abuse the DON confirmed all staff were expected to report suspected or witnessed abuse immediately. Interview with the Administrator on 6/11/19 at 8:15 AM in the conference room revealed the Administrator was informed on 5/2/19 around 10:00 AM by RT #1 of Resident #2 being secured (restrained) in his wheelchair with a gait belt around his chest. Continued interview revealed the Administrator reported the allegation to the State Agency as soon as he was aware of the allegation. Further interview when asked when staff were to report abuse the Administrator stated, Immediately, I expect them to notify me as soon as it happens. Interview with the RT #1 on 6/11/19 at 1:15 PM in the conference room revealed she reported for work on 5/2/19 around 5:30 AM to educate the night shift nurses on [MEDICAL CONDITION] care. Continued interview revealed when she went to station 2A around 5:45 AM and she observed Resident #2 sitting in a wheelchair with his back facing the nurses station. Resident #2 hollered (yelled) come here and motioned for the RT (#1) to come over to him. RT #1 went over to Resident #2 and he pointed at a gait belt that was around his chest, and said look what that [***] did to me, pointing toward the nurses station where the (AP) was sitting. Further interview, when asked how was the gait belt placed on Resident #2 she confirmed the gait belt was around the upper part of Resident #2's chest snuggly, and attached to the wheelchair. When asked to explain snugly, RT #1 replied, he could not raise his back off the back of the wheelchair. Continued interview revealed RT #1 went inside the nurses station and spoke to the AP related to the training she was doing and the AP spoke hatefully saying, I don't have time to do the training. The RT left nurses station 2A and went to the 400 hall. Further interview revealed the RT reported her observation of Resident #2 with a gait belt around his chest securing (restraining) Resident #2 to his wheelchair to LPN #5 (Unit Manager for 200 Hall) when she (LPN #5) arrived at the facility at 7:30 AM. Continued interview revealed RT #1 reported her observation of Resident #2 in his wheelchair with a gait belt around his chest to the Administrator during the morning stand up meeting around 9:00 to 9:30 AM on 5/2/19. She stated, I guess I should have called someone and reported it sooner, I don't know, I just told (LPN #5) as soon as she got here. Interview on 6/11/19 at 1:45 PM with LPN #5 at nurses station 2A revealed she reported for work on 5/2/19 at 7:30 AM. Continued interview revealed she stated, the (RT #1) reported to me that (Resident #2) was sitting in his wheelchair at the nurses station with a gait belt around his chest, secured (restrained) to the wheelchair; I went immediately and assessed (Resident #2) and he was in the bed with no restraint on and no injuries noted. Continued interview with LPN #5 revealed I reported to the DON around 8:30 AM (RT #1) witnessed (Resident #2) being in a wheelchair with a gait belt around his chest, secured to the wheelchair. Validation of the IJ removal plan to remove the IJ was completed on 6/12/19 through review of the facility documentation, observations and interviews. Surveyor verified the IJ removal by: 1. Review of the personnel file for the AP revealed abuse training was appropriately provided at orientation and as needed. Continued review revealed the facility obtained background checks and reference checks with no negative findings. Immediately following the incident of 5/2/19 the AP was suspended pending investigation. Further review revealed the AP was terminated on 5/2/19 following review of video footage confirming application of a gait belt as a restraint by the AP to Resident #2. 2. Review of resident audits for all the residents on the secured unit. 3. Review of the restraint policy and abuse policy was done and the policies were appropriate. In-service education was completed for all staff on 5/3/19 to 5/6/19 as evidenced by sign-in rosters and staff interviews. Verification through interviews of internal audits initiated 6/12/19 to ongoing every 2 weeks then weekly for 3 months to assess for restraint use. 4. Presentation of all audits to the Quality Assurance Committee (QAC) monthly for 3 months; with the first presentation at the 6/12/19 meeting.

Based on review of facility policy, medical record review, and interview the facility failed to prevent elopement from the facility to the facility parking lot for 1 resident (Resident #1) of 3 residents reviewed. The findings include: Review of facility policy, Elopements, revealed .when a departing individual returns to the facility the Director of Nursing Services or Charge Nurse shall .complete and file Report of Incident /Accident . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an annual Minimum (MDS) data set [DATE] revealed a Brief Interview for Mental Status score of 8 indicating moderate cognitive impairment. Medical record review of an elopement risk evaluation dated 4/22/19 revealed a score of 9 (9 or greater indicated a risk of elopement). Continued medical record review of an elopement risk evaluation dated 5/18/19 revealed a score of 21. Further review of the medical record revealed Resident #1 was care planned for wandering and exit seeking. Interview with the Director of Nursing (DON) on 6/11/19 at 8:40 AM in the conference room revealed video footage of Resident #1's elopement on 5/17/19 was reviewed. Continued interview confirmed the DON stated the video showed the resident pushing open the door (key pad coded) and self-propelling from inside the facility to outside the facility. Further interview revealed the video footage was no longer available due to the facility video system auto-erasing every 14 days. The DON confirmed an investigation was not done for Resident #1's elopement on 5/17/19. Interview with Licensed Practical Nurse (LPN) #1 on 6/11/19 at 12:10 PM in the Unit Manager's office revealed Resident #1 self-propelled from the resident's room to the rehabilitation (rehab) unit as he desired. Continued interview with LPN #1 revealed the resident had a pattern of going to the rehab unit most everyday. Further interview with the LPN revealed when the station 3 nursing staff could not locate the resident they would look in the rehab unit. LPN #1 confirmed the resident had exit seeking behaviors. Interview with LPN #3 on 6/11/19 at 4:35 PM in the conference room revealed as she was leaving the facility on 5/17/19 at approximately 7:00 PM she observed an empty wheelchair with a person sitting by a truck, on his butt, on the asphalt and touching the truck. Continued interview revealed she observed the person as was Resident #1. Further interview revealed the resident stated he was working on this truck; I've been meaning to get to it all day. LPN #3 did a quick assessment of Resident #1 for injuries as she used her cellular phone to call the nursing staff for assistance with the resident. Continued interview revealed LPN #3 was told by Resident #1 he was unsure how he got outside. Interview with the Administrator on 6/12/19 at 9:05 AM in the conference room revealed the video footage from 5/17/19 was auto-erased by the video program system. Continued interview revealed the Administrator gave a description of the video to this surveyor. Further interview revealed the Administrator stated Resident #1 was seen rounding the corner of the hall into the area in front of the door #13 (key pad coded). The Administrator confirmed the resident was seen on the video to push open the door and self-propel himself outside. Continued interview confirmed Resident #1 was unable to be seen on the video in the parking lot. Further interview confirmed the video monitor for the facility was not watched 24/7. The Administrator confirmed the time frame Resident #1 was out of the building was unknown. Validation of the IJ removal plan was completed on 6/12/19 through review of the facility documentation, observations and interviews. Surveyor verified the IJ removal plan by: 1. Resident #1 was returned to the facility and the facility policy for elopement appropriately followed as evidenced by nursing progress notes, event notes and staff interviews. The resident was checked every hour by physician's orders [REDACTED]. 2. In-service education was provided 5/20/19 for wandering and elopement as evidenced from sign-in rosters and staff interviews. Daily door audits were initiated 5/20/19 and performed by the department heads. Audits were ongoing every shift for 2 weeks then weekly for 3 months. Key pad coded doors (4) in the rehab unit were scheduled for installation of alarms the week of 6/17/19. 3. Resident assessments were checked for current status to match condition on 6/12/19 and performed by the DON and nursing staff. The maintenance director will continue daily door audits for proper operation for an additional 2 weeks and then resume daily audits. 4. Presentation of all audits by the DON and maintenance director to the Quality Assurance Committee (QAC) monthly for 3 months; with the first presentation at the 6/12/19 meeting.

Based on medical record review, observation, and interview the facility failed to follow the resident care plan interventions related to nutrition and dignity for 2 of 22 (Resident #30 and 25) sampled residents reviewed for care planning of the 41 residents included in the Stage 2 review. Failure of the facility to follow care plan interventions for nutrition resulted in actual harm to Resident #30 who suffered significant weight loss. The findings included: 1. Medical record review revealed Resident #30, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The [MEDICAL CONDITIONS], Constipation and Dietary Calcium were acquired after admission to the facility. The care plan dated 9/14/16 revealed, .PROBLEM .POTENTIAL FOR WEIGHT LOSS .INTERVENTIONS .DINING ASSIST (Assistance): LIMITED TO EXT (EXTENSIVE) ASSIST .OFFER SUBSTITUTES IF RESIDENT CONSUMES LESS THAN 50% OF MEALS .OBSERVE AND RECORD ALL INTAKE . Review of the monthly and weekly weight records revealed the following: On 3/6/17 the resident weighed 171 pounds (lbs). On 4/13/17 the resident weighed 166 lbs. On 4/17/17 the resident weighed 166 lbs. On 4/24/17 the resident weighed 163 lbs. On 5/1/17 the resident weighed 160 lbs. There were no weights documented for the week of 5/8/17. A physician's telephone order dated 5/12/17 documented. .House Supplement BID . The resident's care plan was revised on 5/12/17 and included an intervention to administer supplements per order and observe for intake. Review of the weight records revealed on 5/17/17 the resident weighed 160 lbs. The quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #30 had a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment, and required supervision such as encouragement or cueing with eating. On 5/24/17 the resident weighed 155 lbs, revealing a 16 pound, 9.3 percent (%) severe and significant weight loss since 3/6/17. Review of the 5/31/17 Bedside Care Plan (used by the Certified Nursing Assistants (CNAs) to provide care for the resident) documented, .Feed self after set up . Limit distractions during meals No TV (television) during meals . Review of the resident's written plan of care revealed the plan was revised on 6/2/17 and reflected to continue to assist with meals. The CNAs bedside care plan was not updated with the revision to assist with meals. Observations in Resident #30's room on 5/31/17 at 5:38 PM, revealed Resident #30 lying in bed with her supper set up on her bedside table in a divided plate that contained Salisbury steak, lima beans, potatoes, Angel Food cake, and a glass of tea. There was no house supplement on Resident #30's tray. There were no staff in the room assisting, cueing or encouraging the resident with eating and the television was on. Observations in Resident #30's room on 6/1/17 at 8:20 AM, revealed Resident #30 lying in bed with a half-eaten piece of toast and had a carton of 2% milk, instead of whole milk. Toast was the only finger food the resident was served, as the resident preferred finger foods. Observations on 6/1/17, in Resident #30's room, revealed the following: At 11:47 AM- Resident #30 was sitting in a Broda chair. A lunch tray was delivered to Resident #30 by Certified Nursing Assistant (CNA) #4, who set the tray up on the bedside table, left the roll in the paper wrapper, and walked out of the room. At 11:55 AM- Resident #30 was holding her fork and was starring off. At 12:08 PM- No staff had assisted the resident with her meal. At 12:49 PM- Resident #30 had finished her tea and poured her House Supplement into her tea glass. Resident #30 had not eaten any of the food on the tray. At 12:52 PM- CNA #4 entered the room, stood in front of Resident #30, and stated, Are you through with your lunch and did you get full? Well, that's all that matters. Let me take your clothes protector off. CNA #4 took the clothes protector off and laid it over the top of Resident #30's plate and glass of house supplement and walked out of the room. The television was on. The lunch tray was in Resident #30's room for over 1 hour and no staff came in the room to supervise, cue, assist or encourage her to eat her lunch. Observations in Resident's #30's room on 6/1/17 at 6:04 PM, revealed Resident #30 lying in the bed with the supper tray on the bedside table. The plate had not been taken off the tray and set up for Resident #30. The tray had a meal ticket which documented that gravy should have been served on her supper tray. No gravy was served with the supper meal and the television was on. Observations in Resident #30's room on 6/2/17 at 9:30 AM, revealed Resident #30 lying in bed asleep with the breakfast tray on the bedside table. The plate had not been set up for Resident #30. The tray had a meal ticket which documented that toast as one of her breakfast foods. Resident #30's breakfast tray contained ground sausage, a biscuit, gravy, Rice Krispies, and orange juice. There was no toast on the tray, the resident had only eaten the Rice Krispies and the television was on. Interview with Occupational Therapist (OT) #1 on 6/2/17 at 9:42 AM, in the Rehabilitation Office, OT #1 was asked if she had seen the CNA's provide cueing and encouragement for Resident #30. OT #1 stated, No, I have not . Interview with the Speech Pathologist on 6/2/17 at 9:56 AM, in the Rehabilitation office, the Speech Pathologist was asked what type of therapy was provided for Resident #30. The Speech Pathologist stated, .received a referral from nursing and the dietician regarding weight loss .she consumed consistently under 50%, she was very distractible. The Speech Pathologist was asked what her recommendations were for Resident #30. The Speech Pathologist stated, That her meal was set up very accessible .She preferred finger foods . The Speech Pathologist was asked, since there was an attention issue with Resident #30, would having someone assist or encourage her help her with eating. The Speech Pathologist stated, Yes . Interview with the interim Director of Nursing (DON) on 6/2/17 beginning at 10:23 AM, in the interim DON office, The interim DON was asked to look at the care plan which indicated to assist with meal intake thru 6/2/17. The interim DON was then asked if she thought Resident #30 was encouraged, cued, or assisted when a CNA delivered the meal, set it up, and was out of the room in a minute and never returned for over an hour. The interim DON stated, No. The interim DON confirmed that Resident #30 should have received assistance with eating all along. Interview with the Registered Dietician (RD) #1 on 6/2/17 at 11:45 AM, in the Conference Room, RD #1 was asked if she had done a caloric needs assessment for Resident #30's weight loss. RD#1 stated, No . RD #1 was asked about doing a caloric needs assessment when Resident #30 had significant weight loss. RD #1 stated, I will, moving forward. But, no, that has not been my practice. RD#1 was asked if gravy was listed on the meal ticket should the resident have gravy with the meal. The RD #1 stated, Yes. RD #1 was asked if the meal ticket listed toast, should the resident have toast on the tray. RD #1 stated, Yes. RD #1 was asked if Resident #30 should receive 2% milk or whole. RD #1 stated the resident should have received Whole milk. RD #1 was asked if there should have been a house supplement on Resident #30's supper tray. RD #1 stated, We will have to educate our staff. Resident #30 sustained severe and significant weight loss and the facility failed to implement the care plan interventions to prevent weight loss. 2. Medical record review revealed Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan dated 6/22/16 documented, .PROBLEM .SEVERELY COGNITIVELY IMPAIRED .RESIDENT IS NON VERBAL AND COMMUNICATES ONLY BY NODDING HER HEAD .INTERVENTIONS .INTRODUCE SELF AND EXPLAIN CARE PRIOR TO BEGINNING, TALK TO RESIDENT DURING CARE . Observations in Resident #25's room on 6/1/17 at 8:18 AM revealed LPN #7 checked placement of Resident #25's Percutaneous Endoscopic Gastrostomy (PEG) tube, administered medications through the PEG tube, administered eye drops to both eyes, administered insulin by subcutaneous injection into Resident #25's left arm, turned Resident #25 on her side in the bed and applied a medicated patch to Resident #25's back. LPN #7 did not introduce self or explain the procedures prior to beginning the treatments and did not talk to the resident during the care. Interview with Licensed Practical Nurse (LPN) #7 on 6/02/17 at 5:06 PM, at the Station 1 Nurse's station, LPN #7 was reminded about the care plan intervention to introduce themselves and explain care prior to beginning and talk with the resident during care. LPN #7 was then asked if she followed that intervention during her care of Resident #25. LPN #7 stated, I don't remember. LPN #7 was asked if it was acceptable to provide care to a nonverbal resident or any resident without informing the resident what is being done. LPN #7 stated, Absolutely not. LPN #7 was asked if a resident should be informed before they are given an injection or turned. LPN #7 stated, Yes. Interview with the interim DON on 6/3/17 at 12:29 PM, in the conference room, the interim DON was asked if it was acceptable to provide care, give injections, administer eye drops, or turn a resident without explaining what is being done to the resident. The interim DON stated, No, it doesn't matter whether they are cognitively impaired, aphasic or whatever, you introduce yourself to the patient and explain what you are doing.

Based on policy review, medical record review, observation and interview, the facility failed to ensure an effective Quality Assurance (QA) program that recognized an ongoing concern with weight loss, identified the root cause of the problems, developed appropriate plans and ensured systems and processes were in place and consistently followed by staff to address quality concerns. Failure of the facility to implement and/or provide interventions for residents with significant weight loss resulted in actual harm to Resident #30. The findings included: 1. The QA program failed to identify and develop interventions to prevent significant and severe weight loss resulting in actual harm to Resident #30. Refer to F325. 2. The QA program failed to ensure the Registered Dietitian or a Nutritional Professional reassessed the nutritional intervention implementation for all residents. Resident #30 had a severe and significant weight loss and the nutritional interventions were not implemented. Refer to F361. 3. Interview with the interim Director of Nursing (DON) and the Administrator on 6/03/17 11:10 PM, the DON stated, I think it falls under both of our realms (DON and Administrator) for the QA responsibility. The only QA information provided by the DON or Administrator related to nutritional concerns was that the DON stated, .I went out and put it on the ADL sheets and did an in-service related to nutritional supplements. The DON stated this was conducted today on 6/3/17, after the survey team identified the nutritional concerns.

Based on job description, medical record review, and interview, the Registered Dietitian (RD) or a Nutritional Professional failed to ensure interventions were implemented to maintain nutritional status for 3 of 5 (Resident #30, 113, and 277) sampled residents reviewed for nutrition of the 41 included in the Stage 2 review. The failure to provide accurate assessments and effective nutritional interventions for residents with significant and severe weight loss resulted in actual harm to Resident #30. The findings included: 1. The facility's Dietician job description documented, .The primary purpose of your job position is to plan, organize, develop and direct the overall operation of the Food Services Department .As Dietitian, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties .Ensure that charted food service progress notes are informative and descriptive of the services provided and of the resident's response to the service .Review the dietary requirements of each resident admitted to the facility and assist the attending physician in planning for the resident's prescribed diet plan .Encourage the resident/family to participate in the development and review of the resident's assessment and plan of care .Review nurses' notes to determine if the dietary care plan is being followed .Discuss problem areas with the Director of Nursing Services .Be sure that substitute foods of similar nutritive value are provided to residents who refuse foods served . 2. The facility's Weight Assessment and Intervention policy statement documented, .The multidisciplinary team will strive to prevent, monitor .and intervene for undesirable weight loss for our residents . The facility's High Calorie/High Protein Supplements policy documented, .The nursing staff will supervise the delivery and consumption of all supplements and record appropriately in the medical record and/or the medication administration record .Individual acceptance of supplements will be monitored and adjustments will be made as needed . 3. Medical record review revealed Resident #30 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The [MEDICAL CONDITIONS], Constipation and Dietary Calcium Deficiency were acquired after admission to the facility. The resident's care plan dated 9/14/16 identified the resident was at risk for weight loss and revealed the interventions to provide dining assistance, substitutes and dietary to assess the resident's nutritional status/needs. Review of Occupational Therapy Evaluation and Plan of Treatment report dated 4/21/17 revealed the resident has had a decline in the ability to feed herself. A physician's telephone order dated 5/12/17 documented. .House Supplement BID (twice a day) with snack cart . The care plan was updated on 5/12/17 to include supplement administration per the physician's orders [REDACTED]. The Nutritional Evaluation dated 5/18/17 documented. .MP (Med Pass) BID House supp (supplement) with lunch and dinner . There was no documentation a Nutritional Professional or RD conducted an assessment to determine if the resident was receiving the supplements as ordered. The quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had severe cognitive impairment, and should have supervision with eating. There was no documentation a Nutritional Professional or the RD conducted an assessment to determine if the resident was receiving needed assistance for eating and implement interventions to address assistance. Review of the weight records revealed the resident weighed 171 pounds (lbs) on 3/6/17. The resident continued to loose weight and on 5/24/17 the resident weighed 155 lbs, a 9.3 % severe and significant weight loss in less than 3 months. Review of the Nutritionally at Risk (NAR) report dated the week of 5/26/17, documented the daughter requested that the resident not be fed. The daughter also requested that the resident's plate be taken off the tray to prevent the plate from spinning. There was no documentation a Nutritional Professional or RD conducted an assessment to determine why the daughter did not want the resident to be fed, if the plate was being taken off the tray to allow easier handling of the plate and implement interventions to address these issues. Observations in Resident #30's room revealed the following: On 5/31/17 at 5:38 PM, revealed the resident did not receive the house supplement on her her tray. On 6/1/17 at 8:20 AM, revealed this resident with severe weight loss received a carton of 2% milk instead of whole milk, on her breakfast tray. On 6/1/17 at 6:04 PM, revealed the resident should have received gravy on her supper tray and the gravy was not served to the resident. On 6/2/17 at 9:30 AM, revealed the resident had a meal ticket which documented toast was a breakfast food she liked. Resident #30's breakfast tray did not contain toast on the tray. Interview with the interim Director of Nursing (DON) on 6/2/17 beginning at 10:23 AM, in the interim DON's office, the interim DON was asked if she was aware that Resident #30 had a significant weight loss. The interim DON stated, We talk about her .in NAR meetings on Fridays . The interim DON was asked if she knew that the daughter did not want Resident #30 to be fed. The interim DON stated, No, I do not . The interim DON was asked if she thought loss of independence was a valid reason not to feed a resident with significant weight loss. The interim DON stated, .I would say no .we need to help and the patient should be helped first. Interview with RD #1 on 6/2/17 at 11:45 AM, in the conference room, RD #1 was asked if she had done a caloric needs assessment for Resident #30's weight loss. RD #1 stated, No . RD #1 was asked about doing a caloric needs assessment when Resident #30 had significant weight loss. RD #1 stated, I will, moving forward. But, no, that has not been my practice. RD #1 was asked if gravy was listed on the meal ticket should the resident have gravy with the meal. RD #1 stated, Yes. RD #1 was asked if the meal ticket listed toast, should the resident have toast on the tray. RD #1 stated, Yes. RD #1 was asked if Resident #30 should receive 2% milk or whole. RD #1 stated, Whole. RD #1 was informed that there was 2% milk on Resident #30's breakfast tray on 6/1/17. RD #1 stated, That was just us trying to rotate our stock. RD #1 was informed that on 5/31/17, there was not a house supplement on Resident #30's supper tray. RD #1 was asked if there should there have been a house supplement on the supper tray. RD #1 stated, We will have to educate our staff. The RD or other Nutritional Professional failed to ensure all recommended and ordered interventions were implemented and effective for this resident with a severe and significant weight loss, resulting in actual harm. 3. Medical record review revealed Resident #113 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the weekly weight records revealed the on 2/7/17 the resident weighed 121 lbs, on 2/20/17 the resident weighed 116 lbs (which is a 4.13% loss in 2 weeks), on 3/14/17 the resident weighed 111 lbs (which is an 8.26% significant weight loss in 4 weeks), on 4/18/17 the resident weighed 104 lbs (which is a 14% severe weight loss in 9 week), and on 5/24/17 the resident weighed 100 lbs (which is a 17.3% severe weight loss in 13 weeks). Review of the 3/10/17 physician's orders [REDACTED]. Review of the intake sheet for March 2017 revealed that the supplement was not administered with breakfast or lunch 3/10-3/24, and 3/27-3/31, and was not administered with supper 3/10-3/31. On 3/31/17 the physician ordered that the house supplement be discontinued and to start a Nutritional Juice Drink (NJD) supplement every day with breakfast. Review of the intake sheets for April, May, and June 2017 revealed the following: Breakfast - Supplement not administered 4/1-4/31, 5/1-5/15, 5/18, 5/21, 5/23 -5/31, 6/1 and 6/2. Lunch - Supplement was not administered 4/1-4/31, 5/1-5/31, 6/1 and 6/2. Supper - Supplement was not administered 4/1-4/13, 4/15-4/31, 5/1-5/26, 5/28-5/31, 6/1 and 6/2. The Nutritional Progress Notes dated 4/27/17 documented, .Resident (with) continued (decreased) weight .Resident has been tried on multiple supplements (with) poor intake .Resident unavoidable wt. (weight) loss R/T (related to) poor PO (by mouth) intake .potential for further unavoidable wt. loss . Review of the Nutritional Progress Notes dated 5/5/17 revealed there was no documentation a Nutritional Professional or RD conducted an assessment to determine why the supplements were not being consumed by the resident and implemented other interventions. Telephone interview with RD #1 on 6/3/17 at 9:42 AM, RD #1 was asked if the nutritional juice drink is considered a supplement. RD #1 stated, Yes. RD #1 was asked if she expected the CNAs to chart the supplement on the intake sheet. RD #1 stated, Yes. RD #1 was asked how often she reviews the intake logs. RD #1 stated, When I do an assessment. RD #1 confirmed her notes for March, April and May, and confirmed she also reviewed the intake sheets for those months. The RD was asked if it was acceptable that the supplement had not been documented consistently. RD #1 stated, No . RD #1 was asked if, when she reviewed the March intake log and realized the supplement was not being documented, she had addressed it with the Administrator or the Director of Nursing (DON). RD #1 stated, No. RD #1 was asked how she was able to adequately assess the residents' nutritional status without periodically doing a thorough assessment with nutritional needs and calculations. She stated, I use the intakes and the weights and talk with the staff. Interview with the interim DON on 6/03/17 at 10:01 AM, in the conference room, the interim DON was asked if the supplement had been documented on the April, May and June intake sheets for Resident #113. The DON stated, Inconsistently in May, no, no, it's not been charted. The interim DON was asked how the RD could do a thorough nutritional evaluation without documentation of supplement intake. The interim DON stated, I don't see how she could. Review of an RD note dated 6/5/17, faxed to the State office on 6/5/17, after the survey revealed the RD documented, .Most recent CT scan of the abdomen recommends colonoscopy due to underlying malignancy (potential per CT scan) in the ascending colon. Family declined work-up due to patient not wanting treatment . 4. Medical record review revealed Resident #277 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's telephone order dated 5/1/17 documented, .med pass 3 oz (ounces) BID .record % (percent) consumed in MAR (Medication Administration Records) . A physician's telephone order dated 5/10/17 documented, .Ensure (chocolate) po TID . Review of the weight records revealed on 4/26/17 the resident weighed 105 lbs, on 5/3/17 the resident weighed 98 lbs, a 6.67% significant weight loss in 1 week and on 5/8/17 the resident weighed 93 lbs, an 11.4% severe weight loss in 2 weeks Review of the May and June 2017 MARs revealed that there was no documentation that Resident #277 was receiving the Ensure or the Med Pass as ordered. Review of the intake sheets for May and June 2017 revealed the following: Breakfast - Supplement was not administered 5/1-5/8, 5/10-5/31, and 6/1. Lunch - Supplement was not administered 5/1, 5/3, 5/5-5/25, 5/27, 5/28, 5/30, 5/31, and 6/1. Supper - Supplement was not administered 5/1-5/10, 5/13-5/23, 5/25, 5/26, and 5/29-5/31. Interview with the interim DON on 6/3/17 at 9:12 AM, in the conference room, the interim DON stated, The Med Pass would be documented on the MAR. The interim DON was asked if the Med Pass was documented on the May and June MARs. The interim DON stated, No . The interim DON was asked if it was acceptable to not follow physician's orders [REDACTED]. Interview with the interim DON on 6/3/17 at 9:58 AM, in the conference room, the interim DON was asked where the Ensure supplement should be documented. The interim DON stated, On the ADL sheet. The interim DON was asked if the supplement had been documented for May and June. The interim DON stated, I don't see it .it's not consistently documented .no. The interim DON was asked if it was acceptable to not document the supplements according to the physician's orders [REDACTED]. The interim DON stated, No, it should be documented. Telephone interview with RD #1 on 6/3/17 at 10:30 AM, RD #1 was asked if Resident #277 had a significant weight loss. RD #1 stated, Yes. RD #1 was asked if she reviewed supplement documentation. RD #1 stated, I look at them to see how they are taking the Med Pass and the percent. RD #1 was asked whether Resident #277 was getting her supplements. RD#1 stated, I don't remember if I looked at her MARs or ADL sheets .No. RD #1 was asked if it was acceptable that Resident #277's supplements were not documented. RD #1 stated, No, that is not our practice .

Based on policy review, medical record review, observation, and interview, the facility failed to follow physician orders [REDACTED].#30, 113, and 277) sampled residents reviewed for nutrition of the 31 included in the stage 2 review. The failure to provide nutritional interventions resulted in an severe and significant weight loss and actual harm to Resident #30. The findings included: 1. The facility's Weight Assessment and Intervention policy statement documented, .The multidisciplinary team will strive to prevent, monitor .and intervene for undesirable weight loss for our residents . The facility's High Calorie/High Protein Supplements policy documented, .The nursing staff will supervise the delivery and consumption of all supplements and record appropriately in the medical record and/or the medication administration record .Individual acceptance of supplements will be monitored and adjustments will be made as needed . 2. Medical record review revealed Resident #30 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The [MEDICAL CONDITIONS], Constipation and Dietary Calcium Deficiency were acquired after admission to the facility. The care plan dated 9/14/16 documented, .PROBLEM .POTENTIAL FOR WEIGHT LOSS .WILL CONTINUE TO ASSIST WITH MEAL INTAKE THRU 6/2/17 .INTERVENTIONS .DINING ASSIST (ASSISTANCE) .LIMITED TO EXT. ASSIST .OFFER SUBSTITUTES IF RESIDENT CONSUMES LESS THAN 50% OF MEALS .DIETARY WILL ASSESS NUTRITIONAL STATUS/NEEDS . Review of the weight records revealed on 3/6/17 the resident weighed 171 pounds (lbs) and on 4/17/17 the resident weighed 166 lbs. Review of Occupational Therapy .Evaluation & Plan of Treatment report dated 4/21/17 revealed, .Clinical impressions indicate that (Resident #30) has had a decline with self feeding . The Nutritional Progress Notes dated 4/24/17 documented, .Resident with gradual decrease wt (weight) Noted ST (Speech Therapy) note on 4/20 regarding Resident's daughter not wanting staff to provide any assistance . Review of the weight records revealed on 4/24/17 the resident weighed 163 lbs, on 5/1/17 the resident weighed 160 lbs, there were no weights documented for the week of 5/8/17 A physician's telephone order dated 5/12/17 documented. .House Supplement BID with snack cart . The care plan was updated on 5/12/17 to include supplement administration per the physician's orders [REDACTED]. Review of the weight records revealed on 5/17/17 the resident weighed 160 lbs. The quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #30 had a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment, and and required supervision such as encouragement or cueing with eating. The NUTRITIONAL EVALUATION/RE-EVALUATION dated 5/18/17 documented. .MP (Med Pass) BID (twice a day) House supp (supplement) with lunch and dinner . Review of the weight records revealed on 5/24/17 the resident weighed 155 lbs, resulting in a severe and significant weight loss of 9.3 % since 3/6/17. Review of the NAR (Nutritionally at Risk) report dated the week of 5/26/17, documented, .Nutrition Interventions and Comments .Daughter does not want resident fed .Daughter wants plate taken off of tray and base and placed directly on table so it won't spin . Review of the 5/31/17 Bedside Care Plan used by the Certified Nursing Assistants (CNAs) to care for Resident #30, documented, .Feed self after set up . Limit distractions during meals No TV (television) during meals . The CNA bedside care plan did not reflect the nursing care plan intervention for staff to assist Resident #30 with eating. Observations in Resident #30's room on 5/31/17 at 5:38 PM, revealed Resident #30 lying in bed with her supper set up on her bedside table. There was no house supplement on Resident #30's tray. There were no staff in the room assisting, cueing or encouraging the resident with eating and the television was on. Observations in Resident #30's room on 6/1/17 at 8:20 AM, revealed Resident #30 was lying in bed and had been served a carton of 2% milk, instead of whole milk, on her breakfast tray. Observations on 6/1/17, in Resident #30's room, revealed the following: At 11:47 AM- Resident #30 was sitting in a Broda chair. CNA #4 delivered and set up the lunch tray on the bedside table, left the roll in the paper wrapper, and walked out of the room. At 11:55 AM- Resident #30 was holding her fork and just staring into space. At 12:08 PM- Staff had not come back in Resident #30's room to check on her progress with eating or to supervise, cue or encourage her to eat. At 12:49 PM- Resident #30 had finished her tea but had not eaten any of the food on the tray. At 12:52 PM- CNA #4 entered the room, stood in front of Resident #30, and stated, Are you through with your lunch . CNA #4 removed the clothing protector, laid it over Resident #30's plate, and walked out of the room. The television was on. CNA #4 did not offer Resident #30 a substitute. The lunch tray was in Resident #30's room for over 1 hour and no staff came in the room to supervise, cue or encourage her to eat her lunch and the resident's television was on. Observations in Resident's #30's room on 6/1/17 at 6:04 PM, revealed Resident #30 lying in the bed with the supper tray on the bedside table. The plate had not been taken off the tray and set up for Resident #30. The tray had a meal ticket which documented that gravy should be on her supper tray. No gravy was served with the supper meal. The television was on. Observations in Resident #30's room on 6/2/17 at 9:30 AM, revealed Resident #30 lying in bed asleep with the breakfast tray on the bedside table. The plate had not been set up for Resident #30. The tray had a meal ticket which documented toast was one of her favorite breakfast foods. Resident #30's breakfast tray contained ground sausage, a biscuit, gravy, Rice Krispies, and orange juice. There was no toast on the tray and the television was on. Interview with Occupational Therapist (OT) #1 on 6/2/17 at 9:42 AM, in the Rehabilitation Office, OT #1 was asked if she was aware of a significant weight loss for Resident #30. OT #1 stated, Yes . OT #1 confirmed that the CNAs were to give her supervision, and provide cueing and encouragement. OT #1 was asked if she ever saw the CNAs doing that. OT #1 stated, No, I have not. Interview with the Speech Pathologist on 6/2/17 at 9:56 AM, in the Rehabilitation office, the Speech Pathologist was asked what type of therapy was provided for Resident #30. The Speech Pathologist stated, .received a referral from nursing and the dietician regarding weight loss .she consumed consistently under 50%, she was very distractible. The Speech Pathologist was asked what her recommendations were for Resident #30. The Speech Pathologist stated, That her meal was set up very accessible, feed her out in the 300 Dining Room .She preferred finger foods . The Speech Pathologist was asked, since there was an attention issue with Resident #30, would having someone assist or encourage her help her with eating. The Speech Pathologist stated, Yes . Interview with the interim Director of Nursing (DON) on 6/2/17 beginning at 10:23 AM, in the interim DON's office, the interim DON was asked if she was aware that Resident #30 had a significant weight loss. The interim DON stated, We talk about her .in NAR meetings on Fridays . The interim DON was asked if she knew that the daughter did not want Resident #30 to be fed. The interim DON stated, No, I do not . The interim DON was asked if she thought loss of independence was a valid reason not to feed a resident with significant weight loss. The interim DON stated, In my professional opinion, I would say no .we need to help and the patient should be helped first. The interim DON was asked if she thought Resident #30 was encouraged, cued, or assisted when a CNA delivered the meal, set it up, and was out of the room in a minute, and didn't return for over an hour. The interim DON stated, No. The interim DON was asked if she thought assistance should be provided for Resident #30 for eating. The interim DON stated, Yes . Interview with the Registered Dietician (RD) #1 on 6/2/17 at 11:45 AM, in the Conference Room, RD #1 was asked if she had done a caloric needs assessment for Resident #30's weight loss. RD #1 stated, No . RD #1 was asked about doing a caloric needs assessment when Resident #30 had significant weight loss. RD #1 stated, I will, moving forward. But, no, that has not been my practice. RD#1 was asked if gravy was listed on the meal ticket should the resident have gravy with the meal. The RD #1 stated, Yes. RD #1 was asked if the meal ticket listed toast, should the resident have toast on the tray. RD #1 stated, Yes. RD #1 was asked if Resident #30 should receive 2% milk or whole. RD #1 stated, Whole. RD #1 was informed that there was 2% milk on Resident #30's breakfast tray on 6/1/17. The RD #1 stated, That was just us trying to rotate our stock. RD #1 was asked if there should have been a house supplement on Resident #30's supper tray. RD #1 stated, We will have to educate our staff. There was no documentation the facility reassessed the resident's continued weight loss to determine why the interventions were not effective. The failure of the facility to follow physician orders [REDACTED].#30. 3. Medical record review revealed Resident #113 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the weight records revealed on 2/7/17 the resident weighed 121 pounds, on 2/13/17 the resident weighed 119 lbs, on 2/20/17 the resident weighed 116 lbs (a 4.13% weight loss in 2 weeks) and on 3/6/17 the resident weighed 114 lbs (a 5.7% severe and significant weight loss in 1 month). A PHYSICIAN'S TELEPHONE ORDERS dated 3/10/17 documented, .House Supplement TID (3 times a day) (with) meals . Review of the weight records revealed on 3/14/17 the resident weighed 111 lbs (a 8.26% significant weight loss in 4 weeks. Review of the intake sheet for March 2017 revealed that the supplement was not administered with breakfast or lunch 3/10-3/24, and 3/27-3/31, and was not administered with supper 3/10-3/31. Review of the Nutritional Progress Note dated 3/31/17 documented, .Resident does not like house supplement so will D/C (discontinue) it .Resident agreeable to ice cream: will try NJD (with) breakfast . A PHYSICIAN'S TELEPHONE ORDERS dated 3/31/17 documented, .D/C (discontinue) House Supplement .NJD (nutritional juice drink) QD (with) Bkft (Breakfast) . There was no documentation the facility reassessed the resident's dislike for the supplement and that the resident was not taking the supplement for the month of March 2017 until 3/31/17. Review of the weight records revealed on 4/12/17 the resident weighed 106 lbs. (a 12.4% severe and significant weight loss in 8 weeks) and on 4/18/17 the resident weighed 104 lbs. which is a 14% severe weight loss in 9 weeks. Review of a Computed Tomography (CT) scan dated 4/18/17 documented, .Reason for Exam: Chronic Nausea, Epigastric Pain .Impression .There is persistent distention .Again, direct visualization (colonoscopy) is recommended to exclude an underlying malignancy in this location . Review of the weight records revealed on 4/24/17 the resident weighed 103 lbs. which is a 14.9% severe weight loss in 10 weeks. The Nutritional Progress Notes dated 4/27/17 documented, .Resident (with) continued (decreased) weight .Resident has been tried on multiple supplements (with) poor intake .Resident unavoidable wt. (weight) loss R/T (related to) poor PO intake .potential for further unavoidable wt. loss . Review of the weight records revealed on 5/2/17 the resident weighed 101 lbs which is a 16.5% severe weight loss in 11 weeks. Review of the Nutritional Progress Notes dated 5/5/17 revealed no documentation that additional interventions were implemented to address the continued severe weight loss. Review of the weight records revealed on 5/24/17 the resident weighed 100 lbs which is a 17.3% severe weight loss in 13 weeks. Review of the intake sheets for April, May, and June 2017 revealed the following: Breakfast - Supplement not administered 4/1-4/17, 4/19-4/31, 5/1-5/15, 5/18, 5/21, 5/23 -5/31, 6/1 and 6/2. Lunch - Supplement was not administered 4/1-4/31, 5/1-5/31, 6/1 and 6/2. Supper - Supplement was not administered 4/1-4/13, 4/15-4/31, 5/1-5/26, 5/28-5/31, 6/1 and 6/2. Review of an RD note dated 6/5/17, faxed to the State office on 6/5/17, after the survey revealed the RD documented, .Most recent CT scan of the abdomen recommends colonoscopy due to underlying malignancy (potential per CT scan) in the ascending colon. Family declined work-up due to patient not wanting treatment . Interview with Licensed Practical Nurse (LPN) #4 on 6/03/17 at 9:21 AM at the Station 2B nurses station, LPN #4 was asked how she ensured that residents get their supplements. LPN #4 stated, They (CNAs) chart it on their ADL (activities of daily living) intake sheets. LPN #4 was asked if the supplement was documented. LPN #4 stated, They didn't chart .I don't understand why it's not charted . Telephone interview with RD #1 on 6/3/17 at 9:42 AM, RD#1 was asked if the nutritional juice drink is considered a supplement. RD #1 stated, Yes. RD #1 was asked if she expected the CNAs to chart the supplement on the intake sheet. RD #1 stated, Yes. RD #1 was asked how often she reviews the intake logs. RD #1 stated, When I do an assessment. RD #1 confirmed her notes for March, April and May, and confirmed she also reviewed the intake sheets for those months. RD #1 was asked if it was acceptable that the supplement had not been documented consistently. RD #1 stated, No . RD #1 was asked if, when she reviewed the March intake log and realized the supplement was not being documented, she had addressed it with the Administrator or the Director of Nursing (DON). RD #1 stated, No. RD #1 was asked how she was able to adequately assess nutritional status without periodically doing a thorough assessment with nutritional needs and calculations. She stated, I use the intakes and the weights and talk with the staff. Interview with the interim DON on 6/03/17 at 10:01 AM, in the conference room, the interim DON was asked if the supplement had been documented on the April, May and June intake sheets for Resident #113. The interim DON stated, Inconsistently in May, no, no, it's not been charted. The interim DON was asked how the RD could do a thorough nutritional evaluation without documentation of supplement intake. The interim DON stated, I don't see how she could. 4. Medical record review revealed Resident #277 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the weight records revealed on 4/26/17 the resident weighed 105 lbs, on 5/3/17 the resident weighed 98 lbs (a 6.67% severe and significant weight loss in 1 week). A physician's telephone order dated 5/1/17 documented, .med pass 3 oz (ounces) BID .record % consumed in MAR (Medication Administration Records) . Review of the weight records revealed on 5/8/17 the resident weighed 93 lbs (a 11.4% severe weight loss in 2 weeks). A physician's telephone order dated 5/10/17 documented, .Ensure (chocolate) po TID . Review of the May and June 2017 MARs revealed that there was no documentation that Resident #277 was receiving the Med Pass as ordered. Review of the intake sheets for May and June 2017 revealed the following: Breakfast - Supplement was not administered 5/1-5/8, 5/10-5/31, and 6/1 Lunch - Supplement was not administered 5/1, 5/3, 5/5-5/25, 5/27, 5/28, 5/30, 5/31, and 6/1 Supper - Supplement was not administered 5/1-5/10, 5/13-5/23, 5/25, 5/26, and 5/29-5/31. The facility failed to follow the physician's orders [REDACTED]. Interview with the CNA #5 on 6/3/17 at 8:45 AM, on the Station 4B Nurse's station, CNA #5 was asked where CNAs documented supplements for residents. The CNA stated, We document it on the CNA ADL (activities of daily living) sheet under supplement. Interview with LPN #1 on 6/3/17 at 8:48 AM, on the Station 4B Nurse's station, LPN #1 was asked where she documented supplements for residents. LPN #1 stated, On the MAR (medication administration record). LPN #1 was asked where the percent consumed for the Med Pass should be documented. LPN #1 stated, On the MAR. LPN #1 looked at the May and June 2017 MARs. LPN #1 confirmed there was no documentation of percent consumed on the MARs. LPN #1 was asked if it was acceptable to not follow doctor's orders for supplements. LPN #1 stated, No, we have to do what the doctor tells us to do. Interview with the interim DON on 6/3/17 at 9:12 AM, in the conference room, the interim DON was asked where the Med Pass supplement should be documented. The interim DON stated, The Med Pass would be documented on the MAR. The interim DON was asked if the Med Pass was documented on the May and June MARs. The interim DON stated, No . The interim DON was asked if it was acceptable to not follow physician's orders [REDACTED]. Interview with the interim DON on 6/3/17 at 9:58 AM, in the conference room, the interim DON was asked where the Ensure supplement should be documented. The interim DON stated, On the ADL sheet. The interim DON was asked if the supplement had been documented for May and June. The interim DON stated, I don't see it .it's not consistently documented .no. The interim DON was asked if it was acceptable to not document the supplements according to the physician's orders [REDACTED]. The interim DON stated, No, it should be documented. Telephone interview with the RD #1 on 6/3/17 at 10:30 AM, RD #1 was asked if Resident #277 had a significant weight loss. RD #1 stated, Yes. RD #1 was asked how she made sure residents received their supplements. RD #1 stated, .I ' m in the kitchen a lot I serve on the tray line .I know what we are providing to each resident. RD #1 was asked if she reviewed supplement documentation. RD #1 stated, I look at them to see how they are taking the Med Pass and the percent. RD #1 was asked whether Resident #277 was getting her supplements. RD #1 stated, I don't remember if I looked at her MARs or ADL sheets .No. RD #1 was asked if it was acceptable that Resident #277's supplements were not documented. RD #1 stated, No, that is not our practice .