Every finding on record at Good Samaritan-Olathe

The facility identified a census of 123 residents with one kitchen. Based on observation, record review, and interviews, the facility failed to maintain sanitary dietary standards related to food storage and food temperature checks. This deficient practice placed the residents at risk related to foodborne illnesses and food safety concerns.Findings included:- On 07/21/24 at 07:00 AM, a walkthrough of the facility's secured 100 Hall was completed. An inspection of the unit's kitchenette refrigerator revealed uncovered and labeled food plates from the previous evening's dinner on the top two shelves. The refrigerator had food residue on the inside of the walls. An inspection of the Juice machine area revealed a cup caked in pink drink mix residue in a drawer directly under the juice fountain.On 07/21/25 at 07:28 AM, an observation in the kitchen's dry food storage room revealed a bread storage cart. The bread storage car had a sign that documented when bread was pulled from the freezer, staff were to mark it with a date and use that bread within seven days, no exceptions.On 07/21/25 at 07:29 AM, an observation in the kitchen's dry food storage room, on the bread storage cart, revealed one opened package of hamburger buns. The bag was not dated. On 07/21/25 at 07:29 AM, an observation in the kitchen's dry food storage room, on the bread storage cart, revealed one opened loaf of bread. The bag was not dated. On 07/21/25 at 07:30 AM, an observation in the kitchen's dry food storage room, on the bread storage cart, revealed one bag of hot dog buns. The bag contained six hot dog buns. Three of the buns had visible mold on them.On 07/21/25 at 07:31 AM, an observation in the kitchen's dry food storage room, on the bread storage cart, revealed two open bags of hot dog buns. The bags were not dated.On 07/21/25 at 07:35 AM, an observation in the kitchen's dry food storage room revealed two opened bags of noodles. One bag was wrapped with plastic wrap, and one bag was open to the air. The bags were not dated.On 07/21/25 at 07:37 AM, an observation in the kitchen's dry food storage room revealed one opened bag of yellow cake mix. The bag did not have a date.On 07/21/25 at 07:51 AM, an observation in the main kitchen area revealed a refrigerator labeled as refrigerator three. A plastic container was observed inside of refrigerator three. The plastic container contained two hard-boiled eggs. The container was not labeled or dated.On 07/21/25 at 07:52 AM, an observation in the main kitchen area revealed a refrigerator labeled as refrigerator two. Refrigerator two contained 10 unopened bags of French toast and one unopened bag of pancakes. The bags were unlabeled, had no manufacturer information on the packaging, and had no date.On 07/21/25 at 08:00 AM, an observation in the Walk-In refrigerator unit revealed two half-gallons of 2% milk. The two half-gallons of milk were opened and had no date.On 07/21/25 at 08:01 AM, an observation in the Walk-In refrigerator unit revealed one opened bag of red grapes. The bag had no date.On 07/21/25 at 08:05 AM, an observation in the Walk-In freezer unit revealed one bag of frozen tater tots. The bag was opened and had no date.On 07/21/25 at 08:05 AM, an observation in the Walk-In freezer unit revealed one bag of frozen onion rings. The bag was open to air and had no date.On 07/21/25 at 11:07 AM, Dietary CC checked the temperatures for food as it was taken from the oven and moved to the steam table. Dietary CC took a dish towel and ran it under the water from the sink. Dietary CC was not observed performing hand hygiene prior to wetting the dish towel. Dietary CC wrung the excess water out with his hand and brought the towel to the prep table. Dietary CC placed the towel on the table and used it to wipe the thermometer off between checking each food item taken from the oven. Dietary CC placed the thermometer on the food prep table, where the probe would touch the table. Dietary CC also checked food temperatures for food being served from the steam table for lunch. Dietary CC took the dish towel to the steam table and continued to use it to wipe the thermometer probes between food items. On 07/22/25 at 07:54 AM, on the facility's secured 100 Hall CNA N labeled and placed breakfast plates for R2, R71, R102, and R104 directly in the refrigerator on the unit's kitchenette. CNA N placed the plates in the refrigerator briefly, without covers, and closed the refrigerator.On 07/21/25 at 11:25 PM, Dietary BB stated he had only been at the facility for a week so far. Dietary BB stated that any food items that had been opened should have been covered, labeled, and dated. Dietary BB stated bags should not have been left open, and he would use a resealable bag for food items like that. He further stated that when items were taken out of a box, they would need to be labeled. Dietary BB further stated that any blank manufacturer bags should have dates placed on them. Dietary BB stated that when temping food, staff should have wiped the thermometer probes with disposable sanitation wipes they had in the kitchen and not a towel. Dietary BB stated staff should wash their hands between tasks, touching other items, and moving to different locations.The facility's Food-Supply Storage- Food and Nutrition Services policy, with a reviewed/revised date of 03/07/25, documented the use of the principle of First-In, First-Out (FIFO) in all areas of food and drink storage for the rotation of food items. Foods that have been opened or prepared are placed in an enclosed container, dated, labeled, and stored properly. Stock items are individually dated with the delivery date if removed from the original container.

The facility had a census of 123 residents. The sample included 24 residents. Based on observation, record review, and interview, the facility failed to secure chemicals in a safe, locked area, and out of reach of the twelve cognitively impaired, independently mobile residents. This placed the affected residents at risk for preventable accidents.Finding included:- On 07/21/25 at 07:05 AM, an initial walkthrough of the facility revealed an unsecured exam room on the 300 Hall. An inspection of the exam room revealed a container of purple disinfectant wipes on the counter. The label on the wipes contained the warning, Keep out of reach of children, hazardous to humans, can cause eye irritation, harmful if swallowed.On 07/21/25 at 10:00 AM, an inspection of the facility's secured 100 Hall revealed a kitchenette area. An inspection of the kitchenette revealed a container of purple disinfecting wipes in the cabinet underneath the sink. The label on the wipes contained the warning, Keep out of reach of children, hazardous to humans, can cause eye irritation, harmful if swallowed. Certified Nurse Aid (CNA) N stated the wipes were to be in a locked closet and moved them to the nurse's station.On 07/23/25 at 01:09 PM, Licensed Nurse (LN) G stated that staff were expected to lock up cleaning products and ensure they remained out of reach for the residents.On 07/23/25 at 01:30 PM, Administrative Nurse D stated that cleaning products and areas with potential hazards should always be locked.The facility's Accidents policy, revised 04/2025, stated the facility would ensure a safe environment for all residents. The policy indicated staff would assess each resident's potential risks, including functional abilities, potential falls, assistive devices, and environment, to ensure resident safety.

The facility identified a census of 123 residents. The sample included 24 residents, with one resident reviewed for dignity. Based on observation, record review, and interviews, the facility failed to provide services in a dignified manner for Resident (R) 31 when staff stood over R31 while feeding her a yogurt cup. This deficient practice placed R31 at risk for impaired dignity and decreased psychosocial well-being.Findings included:- R31's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of hypertension (high blood pressure), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), bradycardia (low heart rate, less than 60 beats per minute), difficulty walking, and abnormalities of gait and mobility.The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 12, which indicated moderately impaired cognition. The MDS documented R31 needed set up or cleanup for eating, set up or cleanup for oral hygiene, substantial to maximal assistance with toileting, and dependent on staff for bathing and personal hygiene. R31's Functional Abilities (self-care mobility) Care Area Assessment (CAA) dated 11/06/24 documented R31 needs assistance with activities of daily living (ADL).R31's Care Plan dated 04/20/25 documented R31 had an ADL self-care performance deficit related to dementia and needed assistance with ADLs. R31's plan of care documented that the staff were to assist with bedtime cares, offer a wheelchair if R31 was weak, and toilet her before going to bed. The plan of care documented staff were to ensure R31 got from the dining room to her room after meals.On 07/21/24 at 08:11 AM, R31 was sitting in her wheelchair in her room. The CNA O was in her room, standing over her bedside table, feeding R31 yogurt. The CNA O stated she was told to help her with her meal, that R31 had difficulty eating by herself.On 07/23/25 at 12:48 PM, Certified Nursing Aide (CNA) M stated that staff could stand or sit to help residents needing assistance to eat. She stated it was better to sit down and talk to the resident if they were feeding them.On 07/23/25 at 01:00 PM, Licensed Nurse (LN) G stated that staff should sit next to the resident if they fed that resident. She stated CNA O should never stand over a resident to feed them.On 07/23/25 at 01:48 PM, the Administrative Nurse D staff should sit next to the resident and talk to the resident. Staff should never tower over a resident while they are feeding them.The facility's Resident Dignity policy dated 12/11/24 documented that the location would promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality.

The facility identified a census of 123 residents. The sample included 24 residents. One resident was sampled for reasonable accommodations of the resident's needs. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 38's call light was within his reach. This deficient practice left R38 vulnerable to unmet care needs due to the inability to call for staff assistance.Findings included:- R38's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), psychotic disturbance (a loss of touch with reality characterized by altered thinking, perceptions, and behavior), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), bradycardia (low heart rate, less than 60 beats per minute), repeated falls, need for assistance with personal care, lack of coordination, neuromuscular dysfunction of the bladder (the muscles that control the flow of urine out of the body do not relax and prevent the bladder from fully emptying), muscle weakness, dysphagia (swallowing difficulty), pain, and major depressive disorder (major mood disorder that causes persistent feelings of sadness).The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of zero, which indicated severely impaired cognition. The MDS documented R38 was dependent on staff for toileting, bathing, and dressing, and required partial to moderate assistance from staff for eating.R38's Cognitive/Loss Dementia Care Area Assessment (CAA) dated 09/11/24 documented R38 was unable to complete a BIMS score. The CAA documented R38 had reported short-term and long-term memory problems. The CAA documented R38 could not make decisions regarding daily life. The CAA documented R38 was severely impaired and had physical and verbal behaviors toward others.R38's Care Plan dated 09/04/24 documented R38 had a communication problem related to hearing deficit, dementia, and rarely speaks. R38's plan of care documented that the staff were to encourage R38 to continue stating thoughts even if he was having difficulty. R38's plan of care documented that the staff were to encourage verbalizing frustrations versus physical action. R38's plan of care lacked staff direction regarding his call light placement.On 07/21/25 at 07:35 AM, R35 sat in her room in his Broda chair (specialized wheelchair with the ability to tilt and recline). R38's call light laid on the floor between his bed and his Broda chair. R38 was unable to reach his call light.On 07/23/25 at 12:48 PM, Certified Nurse's Aide (CNA) M stated that call lights should always be within the resident's reach.On 07/23/25 at 01:00 PM, Licensed Nurse (LN) G stated that call lights should be in the resident's reach. LN G stated that placing call lights was the last thing the CNAs were trained to do before walking out of a resident's room.On 07/23/25 at 01:38 PM, Administrative Nurse D stated the resident's call light should be placed anywhere the resident can reach the light. Administrative D stated that some residents can knock their call lights on the floor, out of their reach.The facility's Call light policy dated 07/08/25 documents ensure residents always have a method of calling for assistance, and staff promptly answer residents' call lights. When the facility has a new admission, explain and demonstrate the use of the call light system. When a resident's call light is observed/heard, go to the resident's room promptly and respond to the request as soon as possible. Turn the call light off and inquire about the resident's request. When leaving the room, place the call light within easy reach of the resident. For residents unable to use the call light, care plan appropriate interventions, and provide an adaptive call light if applicable.

The facility identified a census of 123 residents. The sample included 24 residents, with one resident reviewed for abuse and neglect. Based on observation, record review, and interviews, the facility failed to report an unwitnessed injury fall of Resident (R) 58 (severely cognitively impaired), resulting in emergency medical treatment to the state investigative agency. This placed the residents at risk for potentially unidentified and ongoing abuse and /or neglect.Findings included:- The Medical Diagnosis section within R58's Electronic Medical Records (EMR) included diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), insomnia (difficulty sleeping), muscle weakness, and abnormal gait/mobility.R58's Significant Change Minimum Data Set (MDS) completed 06/06/25 noted a Brief Interview for Mental Status (BIMS) score of three, indicating severe cognitive impairment. The MDS noted she required substantial to maximal assistance with dressing, toileting, footwear, and personal hygiene, but could transfer and ambulate with supervision. The MDS indicated she was a fall risk and had a history of falls. R58's Cognitive Impairment Care Area Assessment (CAA) completed 06/12/25 indicated she had severe cognitive impairment related to her medical diagnoses, and a care plan would provide interventions to minimize the risks associated with her impairment.R58's Falls CAA completed 06/12/25 indicated she was at risk for falls related to her cognitive impairment, unsteady balance, and history of fracture (broken bone) related falls. The CAA noted she was not able to recognize her physical limitation and postural instability. The CAA noted that a care plan would provide interventions to minimize the risks associated with her impairment.R58's Care Plan initiated 11/08/24 indicated she was at risk for falls, impaired communication, a decrease of activities of daily living (ADL), and elopement due to her medical diagnoses. The plan noted she required staff assistance for bathing, toileting, and dressing. The plan noted she could ambulate (walk) and transfer without assistive devices or staff assistance. The plan noted she had fallen on 05/31/25, resulting in a maxillary/sinus (left facial fracture) while walking down the hallway. The plan instructed staff to remind R58 of her limitations during walking and offer breaks while ambulating around the unit. The plan indicated R58 had non-slip strips applied to her floor on 06/26/25 after an injury fall.R58's EMR under Progress Notes revealed she had an unwitnessed fall in her room on 06/26/25 at 01:10 PM. The note revealed that staff heard R58 yelling for help in her room. The note revealed that staff found R58 on the floor, partially on her back. The note revealed R58 had a contusion (bruising under skin) on the right side of her forehead and bleeding. The note revealed R58 could not communicate to the staff what happened or how her injuries occurred. The note revealed she was sent out to an acute medical facility for treatment.R58's EMR under Progress Notes revealed an Interdisciplinary Team (IDT) note dated 06/27/25, which revealed she received two staples at the top of her head and returned to the facility with no new fractures.A facility investigation completed on 06/06/25 revealed a root cause analysis noted R58 probably tried to get out of bed and slipped on the hardwood floor. The investigation indicated non-slip strips were added to the floor next to her bed to prevent future falls. The report lacked an indication that the unwitnessed injury fall was reported to the state investigating agency for review.R58's EMR revealed no documentation showing prior injuries to R58's forehead, scalp, or top of her head prior to her fall on 06/26/25.On 07/22/25 at 09:01 AM, an inspection of R58's room revealed her bed in the low position. Non-slip strip around her bed and toileting area. R58's toilet had grab bars installed to prevent toileting falls. On 07/23/25 at 09:14 AM, Administrative Nurse D stated the facility did not report the incident because she felt it was just a fall. She stated the facility was required to report injuries of unknown origin, but didn't think the fall was reportable. She stated the facility holds annual and periodic trainings related to reporting abuse, neglect, and exploitation for cognitively impaired residents.The facility's Abuse and Neglect policy, revised 07/2024, would educate, prevent, identify, and report all potential abuse, neglect, and exploitation allegations within the guidelines set by the facility, state investigatory agency, and federal guidelines.

The facility identified a census of 123 residents. The sample included 24 residents. Based on observation, record review, and interview, the facility failed to ensure a bed hold and notification was provided to Resident (R) 1, and her representative was provided with a bed hold policy that included the facility's per diem rate to hold a bed. The facility failed to ensure R1 and her representative were provided a written notification of transfer upon her transfer to the hospital. This placed R1 at risk of miscommunication between the facility and the resident's representative, and the possible missed opportunity for healthcare services.Findings included:- R1's Electronic Medical Record (EMR) documented diagnoses of hypertension (elevated blood pressure), atrial fibrillation (rapid, irregular heartbeat), cerebrovascular disease (CVA- stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), and dementia (a progressive mental disorder characterized by failing memory and confusion).R1's Discharge Minimum Data Set (MDS) dated 10/08/24 documented an unplanned discharge to an acute hospital with a return anticipated.R1's Entry MDS dated 10/14/24 documented a re-entry to the facility from an acute hospital.R1's Discharge MDS dated 04/08/25 documented an unplanned discharge to an acute hospital with a return anticipated.R1's Entry MDS dated 04/11/25 documented a re-entry to the facility from an acute hospital.R1's Significant Change MDS dated 04/18/25 documented she had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R1 required partial to substantial assistance from staff for her activities of daily living (ADL). The MDS documented R1 was dependent on staff for toileting, and R1 required the use of a walker and a wheelchair for mobility. R1's Functional Abilities Care Area Assessment (CAA) dated 04/25/25 documented she needed assistance with ADLs.R1's Care Plan, last revised on 03/25/25, directed staff that she wished to remain at the facility for long-term care. The Care Plan directed staff to encourage her to discuss her feelings and concerns regarding R1's advanced directives. The facility failed to provide a written notification of transfer and a bed hold policy to R1 and her representative before her transfer to the hospital on [DATE].The facility failed to provide a written notification of transfer and a bed hold policy to R1 and her representative before her transfer to the hospital on [DATE].On 07/22/25 at 08:15 AM, R1 sat in her wheelchair in the dining room eating breakfast. R1 stated she had not received the bed hold policy before she went to the hospital.On 07/23/25 at 02:30 PM, Administrative Staff A stated that he was unable to locate the bed hold and notification of transfer for R1's transfer to the hospital on [DATE] and 04/08/25.On 07/23/25 at 01:38 PM, Administrative Nurse D stated that initially, the nurse should complete the bed hold and notification of transfer paperwork before a resident was sent to the hospital. Administrative Nurse D stated that social services was responsible for notifying the representative and following up on the bed hold and notification of transfer.The facility's Bed-Hold Rehab/Skilled policy, revised on 12/19/24, documented at the time of admission, transfer or therapeutic leave, the location would provide written information to the resident or resident representative that specified the duration of the state bed-hold policy, if any, during which a resident was permitted to return and resume residence. The reserve bed payment policy in the state plan. The location's policies regarding bed-hold periods permit a resident to return. The resident's copy of the Notice of Bed-Hold Policy was sent with the other papers accompanying the resident to the hospital. The family member or resident representative, if any, is provided with the Notice of Bed-Hold Policy within 24 hours of the transfer. The Notice of Bed-Hold Policy should be mailed if the family or the resident representative did not come to the facility to receive a copy. The charge nurse was responsible for the completion of notification procedures if the transfer occurred at a time when the social worker was not at the location. The social worker or designated individual will contact the resident/resident representative to inquire regarding their decision to hold a bed. In cases where the facility was unable to notify the resident representative, the social worker or designated individual will document multiple attempts to reach the resident's representative.The facility's Notification of Change policy, revised on 12/23/24, documented a facility must immediately inform the resident, consult with the resident's physician and notify, consistent with his or her authority, the resident representative(s) when there was: A decision to transfer or discharge the resident from the facility for one of the following reasons: The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility. When the facility transfers or discharges a resident under any of the circumstances specified, the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving healthcare institution or provider.

The facility identified a census of 123 residents. The sample included 24 residents, with four residents reviewed for activities of daily living (ADL) for dependent residents. Based on observation, record review, and interviews, the facility failed to ensure a shower/bath was provided for Resident (R) 52, who was dependent on staff assistance with ADLs. This deficient practice had the potential to cause skin breakdown and/or skin complications due to poor personal hygiene and impaired psychosocial well-being.Findings included:- R52's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of muscle weakness, need for assistance with personal care, abnormalities of mobility, and cancer of the endometrium (mucous membrane that lines the uterus).The Significant Change Minimum Data Set (MDS) dated 05/30/25 documented a Brief Interview of Mental Status (BIMS) score of 12 which indicated moderately impaired cognition. The MDS documented R52 required substantial to maximum staff assistance with bathing, transfers, bed mobility, and personal hygiene during the observation period.R52's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA), dated 05/31/25 documented she required assistance with her ADLs.R52's Care Plan, last revised on 10/01/24 documented she required assistance with bathing and would offer to assist her with shaving.R52's EMR under the Reports tab and Bathing task was reviewed for the following dates: 05/01/25 to 07/21/25 (81 days). The EMR documented three non-facility staff provided (NF) on 05/07/25, 05/14/25, and 06/08/25, three Whirlpool (W) were documented on 05/29/25, 06/04/25, and 06/11/25, one Sponge Bath (Sp) on 06/21/25, and one Shower (SH) on 06/18/25. The EMR documented Not Applicable (97 not applicable) on 05/28/25 and 06/07/25, one Did Not Occur (DO) onmn06/22/25, and four Resident Refused (98 resident refused) on 06/11/25, 06/14/25, 06/28/25, and 07/16/25. The facility provided a bath log for R52, which was not part of her EMR. The facility provided a printed report from the Tasks tab for the past 30 days, which documented on 06/25/25 R52 refused her bath, on 07/16/25 R52 refused her bath, on 07/19/25 non-facility staff provided R52 a bath, and on 07/23/25 R52 was provided a sponge bath.On 07/21/2025 at 11:03 AM, R52 sat in her wheelchair in her room. R52's room had an odor of urine.On 07/22/25 07:43 AM, R52 was asleep on her bed. R52's room had an odor of urine noted next to the bed and wheelchair.On 07/23/25 at 07:22 AM, R52 was asleep on her bed in the low position, and an odor of urine was not next to the bed.On 07/23/25 at 08:50 AM, Certified Nurse Aide (CNA) P stated R52 did not usually refuse her baths/showers. CNA P stated R52 was incontinent of bladder. CNA P stated her room had a urine smell in the carpet and on the bed, because she removed her soiled incontinent brief, placed it on the floor in the mornings, and then was incontinent of her bladder on the mattress.On 07/23/25 at 09:10 AM, Licensed Nurse (LN) H stated R52 was incontinent of bladder. LN H stated she was aware that R52 would remove her soiled incontinent brief at times and place the brief on the floor. LN H stated R52's room had a urine odor from her bed and carpet. LN H stated R52's room should have the carpet removed. LN H stated R52 seldomly refused her bath. LN H stated CNA P was usually the staff member that R52 wanted to provide her bathing activity.On 07/23/25 at 01:40 PM, Administrative Nurse D stated that each resident had an assigned bath day. Administrative Nurse D stated that the list was located on the Kardex (a nursing tool that gives a brief overview of the care needs of each resident), on the resident's plan of care, and there was a master list kept at the nurse's station. Administrative Nurse D stated she would expect the nursing staff to offer a resident a bath several times if they had refused. Administrative Nurse D stated that the staff should notify the charge nurse when a resident refused their bath. Administrative Nurse D stated that the charge nurse should attempt to find out why the resident had refused their bath, and the refusal of a bath should be documented in the resident's EMR.The facility's Activities of Daily Living policy dated 12/23/24 documented that any resident who was unable to carry out activities of daily living would receive necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Based on the resident's comprehensive assessment, the center would ensure the resident's ability in activities of daily living (ADL) does not decline except when unavoidable for reasons of disease progression, deterioration of physical condition associated with disability, or refusal of care/treatment by the resident or legal representative. Evidence of any of these reasons would be reflected in the medical record.

The facility identified a census of 123 residents. The sample included 24 residents, with one resident reviewed for quality of care. Based on observation, record review, and interview, the facility failed to complete weekly wound assessments, including wound measurements, for Resident (R) 11's right knee wound. This placed R11 at increased risk for worsening pressure or skin injuries and delayed wound recovery. Findings included:- R11's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of muscle weakness, need for assistance with personal care, diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), and open wound on right knee.The Significant Change Minimum Data Set (MDS) dated 12/18/24 documented a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R11 required substantial to maximum staff assistance for dressing upper body and mobility. The MDS documented R11 required partial to moderate staff assistance for personal hygiene. The MDS documented R11 was dependent for staff assistance for transfers, toileting, and lower body dressing. The MDS documented R11 was at risk for development of pressure related injuries. The MDS documented R11 had an open lesion during the observation period. The MDS documented the facility provided a pressure reducing device for her bed and chair. The Quarterly MDS dated [DATE] documented a BIMS score of 15, which indicated intact cognition. The MDS documented that R11 was dependent on staff assistance for transfers, bathing, bed mobility, dressing, and toileting. The MDS documented R11 was at risk for development of pressure related injuries and the facility would provide pressure reducing devices on her bed and chair. The MDS documented R11 had application of nonsurgical dressings and applications of ointments/medications other than to feet during the observation period.R11's Pressure Ulcer Care Area Assessment (CAA), dated 12/26/24 documented she was at risk for pressure ulcers.R11's Care Plan with an initiated date of 07/29/24, documented R11 had actual impairment to skin integrity to peri area (the region of the body between the anus and the external genitals) and buttocks. The Care Plan with an initiated date of 07/22/24, documented R11 had potential for pressure ulcer development related to decreased mobility.Review of the assessment tab of R11's EMR documented the following:Two entries for Wound Register Nurse (RN) assessment dated 12/14/24 and 01/07/25. The listed type for the two assessments were documented as coccyx (area at the base of the spine). No other Wound RN Assessments were documented in R11's EMR after 01/07/25. Two entries for Wound Data Collection dated 12/13/24 and 12/16/24. The listed type for the two assessments were documented as coccyx. No other Wound Data Collection assessments were documented in R11's EMR after 12/16/24.A Skin Observation assessment dated [DATE], documented a skin check was completed with no skin conditions observed or skin condition resolved. A note in the assessment documented no new skin observations. The assessment lacked any documentation related to R11's right knee wound.A Skin Observation assessment dated [DATE], documented all other skin observations noted with a note box that documented top of R11's left foot had a superficial skin abrasion noted by Physical Therapy (PT) staff. The assessment note further documented there was no redness or open skin noted. The assessment lacked any documentation related to R11's right knee wound.There were no further Skin Observation assessments documented after 05/09/25, in R11's EMR.Review of R11's Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated 06/01/25 to 06/30/25 documented right knee skin prep every day and evening shift for area. Start date 06/10/25 and discontinue date of 07/01/25. The order was documented as done each shift starting the evening of 06/10/25 to the evening of 06/22/25. Entries starting 06/23/25 to 06/30/25 were documented as R11 being hospitalized .Review of R11's MAR and TAR dated 07/01/25 to 07/31/25 documented to right knee: cleanse with normal saline (NS- saline water solution for medical use), apply medihoney (used in wound care to promote healing) and cover with bordered foam (a type of wound dressing that combines a highly absorbent foam layer with an adhesive border). Change every other day and as needed, with a start date of 07/02/25. The order was documented as done each shift starting on 07/02/25 day shift to 07/22/25 on evening shift.R11's EMR lacked evidence that wound assessments or measurements were done for R11's right knee wound from 06/10/25 to 06/22/25 prior to her hospitalization. R11's EMR lacked evidence wound assessments or wound measurements were done for R11's right knee wound from 07/02/25 to 07/22/25 after she had returned to the facility from the hospital.A Provider/Practitioner note with an effective date of 07/21/25 and a created date of 07/23/25 was marked as a late entry. The note documented R11 had a chronic wound to her right knee that remained stable or unchanged. The note further documented the wound had been present without complete healing for greater than one year and prior to initial admission at the facility. The note documented R11's abrasion (scraping or rubbing away of skin) to her right knee had not healed. The note further documented current dressing protected area and the writer documented they did not expect the area to close. The note documented R11 was followed by outpatient wound center and released. The note further documented continue to monitor to assure stability and no infection.The note lacked any wound measurements.On 07/24/25 the facility provided an untitled document, from R11's hospital stay, dated 06/23/25 that documented wound measurements to R11's right knee. The document recorded a wound length of 2.7 centimeters (cm), wound width 2.2 cm, and a wound depth of 0.1 cm.On 07/21/25 at 10:00 AM, R11 rested in her bed. R11 stated she had a wound to her right knee. R11 stated she had the wound so long she did not remember where it came from. She stated she thought it rubbed on the Hoyer (full body mechanical lift) sling and that may have kept it from healing.On 07/23/25 at 11:28 AM, Licensed Nurse (LN) J stated measurements, and wound assessment should have been documented under the Wound Data Collection assessment every time her wound was assessed. LN J stated there should have been measurements documented for R11's knee wound. On 07/23/25 at 01:03 PM, LN G stated weekly skin assessments was documented on the resident's TAR and the only time a skin assessment would have been documented in further detail would be if a new skin condition was found. LN G stated LN J normally does the wound assessment and measurements for the facility, but she has recently switched her hours to part time and another nurse had taken over her role. LN G stated wound measurements should have been documented in the Wound Data Collection assessments. LN G sated she thought since the wound doctor was not following R11's knee wound weekly, that the wound measurements were not being done. She was not sure how often the wound nurse measured the wounds. LN G stated R11 has had the wound for a long time. LN G stated in the past, the facility would get the wound to close; however, R11's wound would often reopen after she returned to the facility from a hospital stay. LN G stated she believed R11's knee wound has been opened for at least the last month. LN G stated she believed R11's doctor was monitoring her knee wound.On 07/23/25 at 01:38 PM, Administrative Nurse D stated resident's skin and pain assessments were documented on the TAR and documented in further detail if a new wound was found. Administrative Nurse D stated wound measurements and assessment were done weekly. Administrative Nurse D stated LN J had to change her hours to as needed and another nurse was assuming her role. She stated some of the transition had occurred during the time R11's wound measurements were not documented. Administrative Nurse D stated the wound assessments and measurements were supposed to be done even if the wound doctor was not following the wound directly. Administrative Nurse D stated R11 should have had measurements documented for her knee wound. The facility's Skin Assessment Pressure Ulcer Prevention policy dated 04/06/25 documented the purpose of the policy was to systematically assess residents regarding risk of skin breakdown. Nursing was to accurately document observations and assessments of residents. Nursing was to appropriately use prevention techniques and pressure redistribution surfaces on those residents at risk for pressure ulcers. Assessment and documentation of bruises, contusion (bruise), skin tears, or abrasion (scraping or rubbing away of skin). A bruise or contusion was an injury when the skin was not broken. Pain, swelling, and discoloration was characteristic. A skin tear was a traumatic injury to the skin that results in separation of outer layers of the skin. An abrasion was a wound caused by superficial damage to the skin, no deeper than the epidermis (superficial layers of the skin). If a bruise, contusion, abrasion, or skin tear was observed on a resident, this should be reported to the nurse immediately. The bruise/contusion/skin tear/abrasion should be monitored weekly and any changes and/or progress toward healing should be documented on the Skin Observation user Defined Assessment (UDA) and on the resident's care plan. The nurse should also document a Braden Scale UDA for predicting pressure sore risk Positioning Assessment and Evaluation UDA, Skin Observation UDA, Wound Data Collection UDA, and Wound Registered Nurse Assessment UDA.

The facility identified a census of 123 residents. The sample included 24 residents, with three residents reviewed for treatment and services to prevent or heal pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interviews, the facility failed to effectively implement interventions to reduce the risk or promote healing of pressure injuries for Resident (R) 74 and R31, the facility further failed to ensure R3's offloading boots were placed on his heels. This placed R74, R31, and R3 at increased risk for pressure ulcer development.Findings included:- R74's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), dementia (a progressive mental disorder characterized by failing memory and confusion), history of falls, major depressive disorder (major mood disorder that causes persistent feelings of sadness), need for assistance with personal care, communication deficit, urge incontinence (involuntary passage of urine occurring soon after a strong sense of urgency to void), and Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness). The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of seven, which indicated severely impaired cognition. The MDS documented that R74 was at risk for developing pressure ulcers. The MDS documented R74 had a pressure-reducing cushion in her chair and bed, and a turning repositioning program. The MDS documented R74 had an unstageable wound due to a non-removable dressing. The Pressure Ulcer/Injury Care Area Assessment (CAA) dated 04/09/25 documented R25 was incontinent of bowel and bladder. The CAA documented that R74 had a cushion on her wheelchair and a pressure relief mattress on her bed. The CAA documented that R74 would not wear boots because she walks and transfers herself. R74's Care Plan dated 05/07/25 documented R74 had an unstageable pressure area on the left heel related to decline. The plan of care documented that the staff were to assess, record, and monitor the healing weekly. The plan of care documented staff were to report improvements and declines to the health care provider. The plan of care for R74 documented facility was to provide a cushion for her wheelchair, a pressure relief mattress on her bed, and a pillow under her feet at night. The plan of care for R74 documented that the facility was to provide supplemental protein, and staff were to notify the nurse immediately of any new area of skin breakdown. R74's Wound Data Collection Assessment dated 07/21/25 documented R74 had 0.5 centimeters (cm) in length and 0.9 cm in width area of eschar (dead tissue) to the left heel. Skin-prep (liquid skin protectant) would be applied to the heel. R74's Braden Scale for Prediction Pressure Sore Risk dated 07/01/25 documented 15, which indicated a mild risk for pressure ulcer. R74's EMR under the Orders tab revealed the following physician orders: R74 offload heels in bed with a pillow-no heel boots/protectors due to fall risk every shift for unstageable pressure ulcer, dated 04/14/25. Complete daily wound data for the left heel (wound nurse will do weekly measurement) every evening shift for the unstageable pressure ulcer, dated 04/15/25. On 07/21/25 at 07:36 AM, R74 lay in her bed, on her back. R74's heels lay directly on her mattress. On 07/22/25 at 08:05 AM, R74 lay in her bed on her back. R74's heels lay directly on her mattress. On 07/23/25 at 12:48 PM, Certified Nurse's Aide (CNA) M stated that if a resident needed their heels floated, nurses were to ensure that heels were floated. CNA M stated that the floating of a resident's heel was on the Treatment Administration Record, and she stated that it was a nursing duty. On 07/23/25 at 01:00 PM, Licensed Nurse (LN) G stated the CNAs and nursing staff were to ensure the residents' heels were floated. LN G stated that the floating of heels was on the nursing TAR but was also on the Kardex (a nursing tool that gives a brief overview of the care needs of each resident). She stated that all nursing staff are responsible for ensuring the residents are taken care of. On 07/23/25 at 01:38 PM, Administrative Nurse D stated it was all the nursing staff's responsibility to ensure heels were floated. Administrative Nurse D stated that floating of heels was on the Kardex for CNAs to see and was on the TAR as a second check. The facility's Skin Assessment Pressure Ulcer Prevention policy dated 04/06/25 documented that the purpose of the policy was to systematically assess residents regarding risk of skin breakdown. Nursing was to accurately document observations and assessments of residents. Nursing was to appropriately use prevention techniques and pressure redistribution surfaces on those residents at risk for pressure ulcers. - R31's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of hypertension (high blood pressure), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), bradycardia (low heart rate, less than 60 beats per minute), difficulty walking, and abnormalities of gait and mobility. The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 12, which indicated moderately impaired cognition. The MDS documented R31 was at risk for pressure ulcer/injury. The MDS documented R31 had a pressure-reducing device for her chair and bed. The MDS documented R31 had a turning/reposition program, nutrition and hydration, and pressure ulcer injury care. R31's Pressure Ulcer/Injury Care Area Assessment (CAA) dated 11/06/24 documented R31 had a new Stage 2 (partial-thickness skin loss into but no deeper than the dermis, including intact or ruptured blisters). The CAA documented R31 declined offloading boots, and staff were to elevate her legs. R31 had a cushion on her wheelchair and a pressure relief mattress on her bed. R31's Care Plan dated 06/10/25 documented R31 had a Stage 3 (full-thickness pressure injury extending through the skin into the tissue below) pressure ulcer related to a decrease in mobility. The plan of care for R31 documented she had a history of an open area on her left heel, currently had an area on her sacrum, an open area on her left great toe, and an open area on her right knee. The plan of care for R31 documented staff would reposition her every two hours, encourage her to shift in her wheelchair, and encourage her to lay down in the afternoon. The plan of care documented staff were to provide a low air loss mattress with bolsters and heel protectors as tolerated, R31 preferred pillows for offloading her heels in bed, and a cushion for her wheelchair. R31s Braden Scale for Prediction Pressure Sore Risk dated 07/15/25 documented a score of 13, indicating a moderate risk for pressure ulcers. R31's Weekly Wound Assessment dated 07/21/25 documented R31 had wounds to the right and left great toes and sacrum. R31's physician's orders under the Orders tab revealed the following orders: Left heel: Cleanse with normal saline and apply Skin-prep (liquid skin protectant) to the surrounding area, then apply a bordered foam (foam dressing), change every day shift, every Monday and Thursday, to maintain skin integrity, dated 05/05/25. On 07/21/25 at 08:25 AM, R31 lay on her bed; R31's heels lay directly on her mattress. On 07/23/25 at 12:48 PM, Certified Nurse's Aide (CNA) M stated that if a resident needed their heels floated, nurses were to ensure that heels were floated. CNA M stated that the floating of a resident's heel was on the Treatment Administration Record, and she stated that it was a nursing duty. On 07/23/25 at 01:00 PM, Licensed Nurse (LN) G stated the CNAs and nursing staff were to ensure the residents' heels were floated. LN G stated that the floating of heels was on the nursing TAR but was also on the Kardex (a nursing tool that gives a brief overview of the care needs of each resident). She stated that all nursing staff are responsible for ensuring the residents are taken care of. On 07/23/25 at 01:38 PM, Administrative Nurse D stated it was all the nursing staff's responsibility to ensure heels are floated. Administrative Nurse D stated that floating of heels was on the Kardex for CNAs to see and was on the TAR as a second check. The facility's Skin Assessment Pressure Ulcer Prevention policy dated 04/06/25 documented the purpose of the policy was to systematically assess residents regarding risk of skin breakdown. Nursing was to accurately document observations and assessments of residents. Nursing was to appropriately use prevention techniques and pressure redistribution surfaces on those residents at risk for pressure ulcers. - R3's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), muscle weakness, and pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) on right heel. The admission Minimum Data Set (MDS) dated 03/05/25 documented a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R3 required substantial to maximum staff assistance with personal hygiene, partial to moderate staff assistance with bed mobility, and was dependent on staff assistance with transfers. The MDS documented R3 was at risk for pressure-related injuries. The MDS documented that R3 had an unhealed pressure ulcer during the observation period. The MDS documented R3 had pressure-reducing devices on the bed and in the chair. The Quarterly MDS dated [DATE] documented a BIMS score of 13, which indicated intact cognition. The MDS documented that R3 required substantial to maximum staff assistance for personal hygiene and transfers, and partial to moderate staff assistance with bed mobility. The MDS documented R3 was at risk of pressure-related injuries and had an unhealed pressure ulcer during the observation period. The MDS documented R3 had a pressure-reducing device on the bed and in the chair. R3's Pressure Ulcer Care Area Assessment (CAA), dated 03/13/25, documented that he had a pressure ulcer on his right heel. R3's Care Plan, last revised 03/18/25, documented that the facility would provide a low-air-loss mattress on his bed, a cushion in his wheelchair, and offloading boots as tolerated. On 07/23/25 at 09:32 AM, R3 lay on the bed, head of bed elevated with his bedside table across the bed. R3's right heel rested directly on the mattress, and a pressure-reducing boot was on the floor at the floor next to the bed. On 07/23/25 at 12:48 PM, Certified Nurse's Aide (CNA) M stated that if a resident needed their heels floated, nurses were to ensure that heels were floated. CNA M stated that the floating of a resident's heel was on the Treatment Administration Record, and she stated that it was a nursing duty. On 07/23/25 at 01:00 PM, Licensed Nurse (LN) G stated the CNAs and nursing staff were to ensure the residents' heels were floated. LN G stated that the floating of heels was on the nursing TAR but was also on the Kardex (a nursing tool that gives a brief overview of the care needs of each resident). She stated that all nursing staff are responsible for ensuring the residents are taken care of. On 07/23/25 at 01:38 PM, Administrative Nurse D stated it was all the nursing staff's responsibility to ensure heels are floated. Administrative Nurse D stated that floating of heels was on the Kardex for CNAs to see and was on the TAR as a second check. The facility's Skin Assessment Pressure Ulcer Prevention policy dated 04/06/25 documented the purpose of the policy was to systematically assess residents regarding risk of skin breakdown. Nursing was to accurately document observations and assessments of residents. Nursing was to appropriately use prevention techniques and pressure redistribution surfaces on those residents at risk for pressure ulcers.

The facility identified a census of 123 residents. The sample included 24 residents, with two residents reviewed for respiratory care. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 45's continuous positive airway pressure (CPAP- ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep), and nasal oxygen tubing (medical device used to deliver supplemental oxygen therapy to individuals with low oxygen levels) were stored in a sanitary manner. This placed R45 at an increased risk for respiratory infection and complications.Findings included:- R45's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of hallucination (sensing things while awake that appear to be real, but the mind created), metabolic encephalopathy (a condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body), obesity (due to excessive calories), sleep apnea (a disorder of sleep characterized by periods without respirations), hypertension (high blood pressure), muscle weakness, abnormalities of gait and mobility, and diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin).The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 13, which indicated intact cognition. The MDS documented R45 had an impairment on both sides of her body and needed partial to moderate assistance with dressing and was dependent on staff for toileting. The MDS documented R45 needed to set up and clean up for eating and oral hygiene. The MDS documented R45 used a CPAP and continues oxygen use.R45's Functional Abilities (Self-Care Mobility) Care Area Assessment (CAA) dated 06/14/25 documented R45 was alert and oriented, had a BIMS score of 13. R45 had a new internal feeding and was trying to maintain her weight.R45's Care Plan dated 09/05/25 documented R45 would have no signs of poor oxygen absorption. Nursing staff were to monitor changes in the normal breathing pattern. The plan of care for R45 documented staff should report to nursing any difficulties R45 would have with using her CPAP.R45's EMR under the Orders tab revealed the following physician orders:Three liters of oxygen per nasal canula can be weaned based on oxygen saturation reading, dated 04/15/25.Wash CPAP tubing and mask in the morning in warm, soapy water. Rinse and dry. Place in a large baggie after the CPAP was dried in the morning for sleep apnea, dated 05/22/25. Replace air filter as needed (PRN) for holes or blockage, dated 05/21/25.Assist with putting on CPAP at 12 midnight, make sure the water tub was filled to the line with distilled water. Make sure the mask was sealed at bedtime related to sleep apnea, dated 05/21/25.Replace the air filter on the CPAP at bedtime every 180 days, related to sleep apnea dated 06/01/25.On 07/21/25 at 08:33 AM, R45 laid in her bed. R45's CPAP laid on the bedside table, and R45's nasal oxygen tubing was placed on the handle of her oxygen cannister. R45's CPAP mask and nasal cannula were not stored in a sanitary manner.On 07/22/25 at 08:26 AM, R45's CPAP mask laid on her bedside table, and her nasal oxygen tubing was behind her bed on the bed frame. R45's nasal cannula and CPAP mask were not stored in a sanitary manner.On 07/23/25 at 12:48 PM, Certified Nurse's Aide (CNA) M stated she was not sure where the CPAP should be stored. She stated the nurses take care of the CPAP mask. CNA M stated that the oxygen nasal tubing should be placed in a bag when not in use.On 07/23/25 at 01:00 PM, Licensed Nurse (LN) G stated that the CPAP mask was washed after use and placed on a towel to dry; the mask should be covered. LNG stated when the mask was dry, the mask was placed in a sanitary bag for storage. LN G stated nasal oxygen tubing not in use was placed in a bag for storage. On 07/23/25 at 01:48 PM, Administrative Nurse D stated all respiratory equipment should be placed in a mesh bag when not in use.The facility's Oxygen Administration, Safety, Mask Types policy dated 07/28/24 documented that Oxygen administration is carried out only with a medical provider order. A licensed nurse or other employee trained according to state regulations in the use of oxygen would be on duty and is responsible for the proper administration of oxygen to the resident. Continuing education would be provided annually on safety, handling, and usage requirements for employees who handle medical gas (oxygen). Any employee that had the potential to handle oxygen must take the online course in the Success Center annually.

The facility identified a census of 123 residents. The sample included 24 residents, with six sampled residents reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported when Resident (R) 54's hypotension (a medication that treats low blood pressure) medication Midodrine order lacked a diagnosis. The CP failed to identify and report when R54's Midodrine was administered by facility staff outside of the physician-ordered parameters. This placed R54 at risk of unnecessary medication administration and related complications. Findings included:- R54's Electronic Medical Record (EMR) documented diagnoses of orthostatic hypotension (blood pressure dropping with change of position), atrial fibrillation (rapid, irregular heartbeat), and syncope (fainting or passing out). R54's Annual Minimum Data Set (MDS) dated 01/22/25 documented she had a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. R54 required setup to supervision assistance from staff. R54 received an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) and an anticoagulant (a class of medications used to prevent the blood from clotting) medication regularly.R54's Functional Abilities Care Area Assessment (CAA) dated 01/23/25 documented she required minimal staff assistance with activities of daily living (ADL). R54's Care Plan, last revised on 04/24/25, directed staff to encourage the resident to get up slowly, sit on the side of the bed before standing. Staff were directed to apply compression stockings (specially made socks that fit tighter than normal that gently squeezed your legs and helped improve blood flow and reduce pain and swelling in your legs) as ordered. The Care Plan directed staff to monitor, document, and report to the health care provider as needed any signs and symptoms of hypotension.R54's Order Summary Report in the EMR documented a physician's order dated 04/24/25 for Midodrine hydrochloride (HCl) tablet 2.5 milligrams (mg) to give two tablets by mouth three times a day; hold if the systolic blood pressure (SBP - top number, the force your heart exerts on the walls of your arteries each time it beats) was greater than 120. This order lacked a diagnosis for use.A review of R54's Medication Administration Record (MAR) in the EMR for May 2025 revealed that R54's Midodrine was administered outside of the physician's ordered parameter on 10 of 93 opportunities.A review of R54's MAR in the EMR for June 2025 revealed that R54's Midodrine was administered outside of the physician's ordered parameter on three of 90 opportunities.A review of R54's MAR in the EMR for July 2025 revealed that R54's Midodrine was administered outside of the physician's ordered parameter on nine of 63 opportunities.A review of the CP's monthly Medication Reviews from May 2025 to July 2025 revealed the CP failed to identify and report that R54's Midodrine order lacked a diagnosis for use. The CP failed to identify and report when R54 was administered her Midodrine when her SBP was greater than 120.On 07/23/25 at 09:00 AM, Licensed Nurse (LN) I stated that the parameters should be followed when administering medications. R54 has a parameter to hold her Midodrine when her SBP is greater than 120.On 07/23/25 at 01:38 PM, Administrative Nurse D stated the physician ordered parameters should be followed when administering medications. Administrative Nurse D stated she expected the CP to identify and report any irregularities found. The facility's Medication: Drug Regimen Review policy dated 12/23/24 documented to ensure each medication order includes the date, route, dosage, frequency, strength, and reason for administration. The drug regimen review (DRR) would identify the following: Review of medications to assure that doses and duration are appropriate to each resident's clinical condition, age, and comorbidities; Monitoring of medications for efficacy and adverse consequences; Potential medication irregularities and response to these irregularities; Medication-related errors; and gradual dose reduction. The pharmacist would complete a written report noting any drug irregularities or issues of concern for each resident reviewed.

The facility identified a census of 123 residents. The sample included 24 residents, with six sampled residents reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 54's hypotension (a medication that treats low blood pressure) medication order, Midodrine, included a diagnosis for use. The facility failed to ensure R54's physician-ordered parameter for Midodrine was followed before the medication was administered. This placed R54 at risk of unnecessary medication administration and related complications. Findings included:- R54's Electronic Medical Record (EMR) documented diagnoses of orthostatic hypotension (blood pressure dropping with change of position), atrial fibrillation (rapid, irregular heartbeat), and syncope (fainting or passing out). R54's Annual Minimum Data Set (MDS) dated 01/22/25 documented she had a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. R54 required setup to supervision assistance from staff. R54 received an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) and an anticoagulant (a class of medications used to prevent the blood from clotting) medication regularly.R54's Functional Abilities Care Area Assessment (CAA) dated 01/23/25 documented she required minimal staff assistance with activities of daily living (ADL). R54's Care Plan, last revised on 04/24/25, directed staff to encourage the resident to get up slowly, sit on the side of the bed before standing. Staff were directed to apply compression stockings (specially made socks that fit tighter than normal that gently squeeze your legs and helped improve blood flow and reduce pain and swelling in your legs) as ordered. The Care Plan directed staff to monitor, document, and report to the health care provider as needed any signs and symptoms of hypotension.R54's Order Summary Report in the EMR documented a physician's order dated 04/24/25 for Midodrine hydrochloride (HCl) tablet 2.5 milligrams (mg) to give two tablets by mouth three times a day; hold if the systolic blood pressure (SBP - top number, the force your heart exerts on the walls of your arteries each time it beats) was greater than 120. This order lacked a diagnosis for use.A review of R54's Medication Administration Record (MAR) in the EMR for May 2025 revealed that R54's Midodrine was administered outside of the physician's ordered parameter on 10 of 93 opportunities.A review of R54's MAR in the EMR for June 2025 revealed that R54's Midodrine was administered outside of the physician's ordered parameter on three of 90 opportunities.A review of R54's MAR in the EMR for July 2025 revealed that R54's Midodrine was administered outside of the physician's ordered parameter on nine of 63 opportunities.On 07/23/25 at 09:00 AM, Licensed Nurse (LN) I stated that the parameters should be followed when administering medications. R54 has a parameter to hold her Midodrine when her SBP was greater than 120.On 07/23/25 at 01:38 PM, Administrative Nurse D stated the physician-ordered parameters should be followed when administering medications. The facility's Medication: Unnecessary-R/S, LTC policy dated 10/15/24 documented each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used: In excessive dose (including duplicate therapy); For excessive duration; Without adequate monitoring; Without adequate indications for its use; In the presence of adverse consequences which indicate the dose should be reduced or discontinued; Any combination of the reasons above.

The facility identified a census of 123 residents. The sample included 24 residents, with five reviewed for nutritious diets. Based on observation, record review, and interviews, the facility failed to ensure meals were served at a palatable, safe, and appetizing temperature for Residents (R) 80 and R104. This deficient practice placed the residents at risk for risks related to impaired nutrition and weight loss.Findings included:- On 07/21/24 at 07:00 AM, a walkthrough of the facility's secured 100 Hall was completed. An inspection of the unit's kitchenette revealed that the kitchen had an oven, and a microwave included in the kitchenette. The microwave had signage that noted When heating foods in the microwave, please make use of the thermometers provided to ensure that your food reaches the safe temperature of 165 degrees. An inspection of the cabinet to the right of the microwave revealed a thermometer and a box of disposable thermometer covers. An inspection of the refrigerator revealed uncovered and labeled food plates from the previous evening's dinner on the top two shelves. The refrigerator had food residue on the inside of the walls. On 07/22/25 at 07:30 AM, Certified Nurse Aide (CNA) N assisted the kitchen staff with serving food during breakfast. CNA N received a plate for R80 from the portable serving station. CNA N carried the plate over to the microwave and put the food plate in it, and cooked it for one minute. CNAN then brought the plate back to the portable serving station, placed syrup on the pancakes, and gave the food plate to R80 at the table. The food temperature was never checked after being microwaved and served to ensure a safe temperature. On 07/22/25 at 07:54 AM, CNA N labeled and placed breakfast plates for R2, R71, R102, and R104 directly in the refrigerator briefly without covers and closed the refrigerator. CNA N then asked the kitchen staff to retrieve four dome covers for the plates placed in the refrigerator. The plates were covered within five minutes. On 07/22/25 at 09:13 AM, R104 was escorted to the dining area by staff. CNA N retrieved R104's breakfast plate from the refrigerator and placed it in the microwave for one minute and thirty seconds. CNA N delivered R104's breakfast plate to her at the dining room table next to the juice machine. The food temperature was never checked after being microwaved and served to ensure a safe temperature. On 07/23/25 at 12:49 PM, CNA M stated food should always be placed in the fridge with a cover or plastic barrier to prevent contamination. She stated that staff were expected to check the temperature of food after microwaving. She stated each kitchenette had thermometers available. On 07/23/25 at 01:03 PM, Licensed Nurse G stated that staff were expected to use the microwaves to warm up food sometimes. She stated that each kitchen had thermometers to ensure the food was heated to safe temperatures. On 07/23/25 at 01:40 PM, Administrative Nurse D stated staff were expected to use the thermometers each time food was heated in the microwave ovens. The facility's Texture- Modified Diets- Food and Nutrition Services policy, revised 05/2025, indicated residents will receive food that is nourishing, attractive, and palatable. The policy indicated that resident meals would maintain the appropriate texture, consistency, and safe serving temperatures.

The facility identified a census of 123 residents. The sample included 24 residents, with two residents reviewed for hospice services. Based on observation, record review, and interviews, the facility failed to update Resident (R) 49's plan of care to reflect the services, medication, and equipment provided to R49 by hospice. This deficient practice created a risk for missed opportunities for services and delayed physical, mental, and psychosocial needs for R49. Findings included:- R49's electronic medical record (EMR) documented diagnoses of Atherosclerotic heart disease of native coronary artery (plaque buildup in and on the walls of the heart arteries) and cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). The admission Minimum Data Set (MDS) dated 06/25/25 documented a Brief Interview of Mental Status (BIMS) score of nine, which indicated moderate cognitive impairment. The MDS documented R49 required partial to moderate assistance for showers or bathing, and dressing. The MDS documented R49 was independent for moving from seated to lying position, lying to sitting on side of the bed, sit to stand, and transfers from chair or bed.R49's Cognitive Loss/Dementia Care Area Assessment (CAA), dated 06/25/25, documented R49 had scored a nine on his BIMS, had a diagnosis of heart disease, hemiplegia (paralysis on one side of the body), and hemiparesis (weakness on one side of the body) following cerebral infarction. The CAA documented R49 received Hospice services.R49's Care Plan, dated 06/19/25, documented R49 had a terminal prognosis and was being followed by hospice. An intervention dated 06/19/25 documented a consult with a health care provider and Social Services to have Hospice care for the resident in the facility. An intervention dated 06/19/25 documented reviewing the resident's advanced care planning choices and assisting others to respect choices. An intervention dated 06/19/25 documented staff were to encourage R49 to express feelings. An intervention dated 06/19/25 documented the adjustment of the provision of Activities of Daily Living (ADL) to compensate for the resident's changing abilities and encourage participation to the extent the resident wishes to participate. An intervention dated 06/19/25 documented managing restlessness through environmental manipulation or pharmacological intervention and using the least sedating pharmacological means possible to control restlessness. An Intervention with an initiated date of 06/19/25 documented R49 required the assistance of one Certified Nurse Aide (CNA) for bathing, and to assist with shaving, and nail care as needed. The Intervention further documented that hospice also assisted with bathing.R49's Care Plan lacked documentation related to which days baths were provided by hospice. R49's Care Plan lacked documentation related to any medications, medical equipment, or supplies provided by hospice.The Hospice Plan of Care provided by hospice for R49 documented the following under the Durable Medical Equipment (DME) and supplies section, which included a shower chair, walker, wheelchair, wheelchair cushion, barrier cream, bed pads, briefs, gloves, underwear (pull-ups), urinal, wash basin, and wipes.R49's EMR under the Orders tab revealed the following physician order: Admit to hospice with diagnosis of Atherosclerotic heart disease of native coronary artery. The order was dated 06/20/25.An observation on 07/22/25 at 08:47 AM revealed R49 rested on his bed in his room.On 07/23/25 at 12:48 PM, CNA M stated that CNAs can review the Kardex (a nursing tool that gives a brief overview of the care needs of each resident) to find out what services hospice provides for the residents, or they can review the hospice book. CNA M stated that hospice visits and bathing days will usually be listed on the Kardex. CNA M stated that staff were to complete baths on the opposite days that hospice provides them.On 07/23/25 at 01:03 PM, Licensed Nurse (LN) G stated that staff can check the resident's profile on the EMR to find out who is on hospice and the phone number of the hospice company. LN G stated the hospice books show resident shower days, and the hospice aides have assigned shower days when they come out. LN G stated nurse visitation varies unless the resident was actively dying. LN G stated she believed the nurses charted in the hospice book when they came to the facility. LN G stated the facility provides showers on the opposite days that hospice provides them. She stated that information should be on the care plan. LN G further stated that the care plan for the facility and the care plan hospice provides should align and show what supplies, services, and equipment were provided.On 07/23/25 at 01:38 PM, Administrative Nurse D stated the facility's care plan should line up with the care plan hospice provides. Administrative Nurse D stated that staff and hospice staff should document when bathing was done. Administrative Nurse D stated she was unsure if things such as wheelchairs, pads, briefs, or other supplies provided by hospice should be on the facility's care plan. Administrative Nurse D stated she wasn't sure if that information was only kept in the hospice binders or if it should have been on the facility care plan as well.The facility's undated Delineation of Nursing and Aide Services policy documented facility responsibilities to oversee the provision of room and board services as indicated by the patient's level of care, including coordination with hospice staff in implementation and update of the joint plan of care.

The facility identified a census of 120 residents. The sample included three residents. Based on observation, record review, and interviews, the facility failed to notify Resident (R) 1's representative of care plan changes and/or results. This deficient practice had the risk of miscommunication between R1, their representative, and the facility. Findings included: - R1's Electronic Medical Record (EMR) documented diagnoses of heart failure (HF-a condition with low heart output and the body becomes congested with fluid), hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body) following cerebral infarction (cerebrovascular accident [CVA]/stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) affecting the right dominant side, and seizures. The Significant Change Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status was not conducted due to R1 rarely or never understood. R1 had coughing or choking during meals or when swallowing medications. R1 had weight loss. The Cognitive Loss/Dementia (progressive mental disorder characterized by failing memory, confusion) Care Area Assessment (CAA) dated 11/11/24, documented R1 experienced strokes and seizures and other medical and physical complications including dysphasia (a condition that affects your ability to produce and understand spoken language). The Nutrition CAA dated 11/12/24, documented R1 had impaired nutrition related to weight loss and poor appetite. R1 needed set-up assistance and cueing and staff placed items in reach of R1's left hand. R1's Care Plan dated 03/22/19, documented R1 had impaired cognitive function related to CVA and directed the facility to communicate with R1 and her representative regarding R1's capabilities and needs. R1's EMR revealed the following: A Communication/Visit with Physician note on 09/06/24 at 05:04 PM, documented that staff notified R1's provider of her seizure activity. The provider gave a new order to restart Lacosamide (medication used to treat seizures) 250 milligrams (mg) daily. R1's clinical record lacked evidence the facility notified R1's representative of her seizure activity and new medication order. A Health Status note on 09/07/24 at 01:08 PM, documented R1 had two short seizures that shift. R1 came out of the seizures quickly and seemed to return to her normal self shortly after. R1's clinical record lacked evidence the facility notified R1's representative of her seizure activity. A Provider/Practitioner note on 10/21/24 at 06:49 PM, documented R1 had diffuse (throughout) wheezing (breathing with a whistling or rattling sound in the chest) in all lung fields. R1 had a chest x-ray completed and the results were pending at the time of the visit. The provider ordered levofloxacin 500 mg daily if the chest x-ray showed pneumonia (inflammation of the lungs). R1's clinical record lacked evidence that the facility notified R1's representative of the order for a chest x-ray or the plan of care in case of pneumonia. A Health Status note on 10/22/24 at 09:13 AM, documented R1's provider ordered a chest x-ray on 10/21/24 due to respiratory symptoms. The x-ray results showed R1's lungs were free of infiltrates (substances that are not normally present in the lungs, but instead build up in the lung tissue) with no pleural effusion (abnormal accumulation of fluid in the lungs) or pneumothorax (accumulation of air and blood in the area around the lungs). R1's clinical record lacked evidence the facility notified R1's representative of the chest x-ray results. A Communication/Visit with Physician note on 10/23/24 at 09:27 AM, documented R1 had an open area to her sacrum (large triangular bone/area between the two hip bones) from shearing/pressure. R1 had weight loss and the facility placed R1 in a different wheelchair with a new cushion. The facility notified the registered dietitian and R1's provider. R1's clinical record lacked evidence the facility notified R1's representative of the open area to her sacrum, weight loss, and the new wheelchair. A Health Status note on 10/26/24 at 10:34 AM, documented R1 had a mild seizure episode and staff noted R1 stared for a couple of seconds then responded to her name. R1's clinical record lacked evidence the facility notified R1's representative of R1's seizure activity. A Provider/Practitioner note on 11/01/24 at 11:53 PM, documented the provider discussed R1's weight loss and sacral wound with her representative. On 11/19/24 at 12:07 PM, R1 sat in a Broda (specialized wheelchair with the ability to tilt and recline) at a dining room table and ate spaghetti. On 11/19/24 at 10:52 AM, R1's representative stated the facility did not notify her about changes. She stated she found out in a provider visit a few weeks ago that the facility treated R1 for pneumonia. R1's representative stated the facility did not notify her about the Broda chair. On 11/19/24 at 01:42 PM, Administrative Nurse E stated as a nursing intervention, the facility changed R1 to a new wheelchair for her weight loss and open sacral area. She stated R1's provider talked to her representative about the new wheelchair and documented it in a provider note. On 11/19/24 at 01:46 PM, Licensed Nurse (LN) G stated she notified families and representatives of medication changes, physical changes such as sickness, or any new orders for testing such as x-rays then again with the results. LN G stated most of R1's seizures lasted less than a minute, but the facility sent her out for significant seizures. She stated she did not notify R1's representative after each seizure but she might if R1 had more than one per day. LN G stated she notified representative notifications in the progress notes including attempts to call the representative. She stated the facility notified resident representatives if a resident changed to a Broda chair. On 11/19/24 at 02:09 PM, LN G stated she notified a resident's representative before the end of her shift except for emergencies then she notified their representative right away. On 11/19/24 at 02:26 PM, Administrative Nurse D stated the facility notified the resident's representative for weight loss and medication changes. She stated she expected staff to notify the resident's representative of any changes, as soon as possible that day. Administrative Nurse D stated staff documented notifications in the progress notes, and she expected staff to document attempts at notifying representatives. She stated staff should have notified R1's representative about the Broda chair. She stated R1's representative responded better when talking to the provider and R1's provider notified R1's representative about the Broda chair. Administrative Nurse D stated she expected staff to notify the resident's representative and provider after seizures and document the notification in the progress notes. The facility's Notification of Changes policy, last revised 12/04/23, directed the facility to immediately inform the resident, their physician, and their representative of a significant change in the resident's physical, mental, or psychosocial status and a need to alter treatment significantly. The facility failed to notify R1's representative of the plan of care changes and/or results. This deficient practice had the risk of miscommunication between R1, their representative, and the facility.

The facility identified a census of 114 residents. The sample included 23 residents with eight reviewed for nutrition. Based on observation, record review, and interviews, the facility failed to provide consistent weight monitoring per the professional standards of practice after admission, failed to obtain weekly weights as ordered by the physician, and failed to provide cueing for meals as needed for Resident (R) 38. The facility further failed to implement nonpharmacological interventions to prevent weight loss for R38 until after a significant unplanned loss occurred. These deficient practices resulted in a loss of 12.15% in three months. Findings Included: - The Medical Diagnosis section within R38's Electronic Medical Records (EMR) included diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), muscle weakness, chronic kidney disease, type two diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), cerebral infarction (CVA-stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), and major depressive disorder (major mood disorder). A review of R38's Admission Minimum Data Set (MDS) completed 08/23/23 noted a Brief Interview for Mental Status (BIMS) score of four, indicating severe cognitive impairment. The MDS noted she ate independently but required set-up assistance from staff. The MDS noted she weighed 171 pounds (lbs.) with no known weight loss. No dental or swallowing concerns were noted in the MDS. R38's Significant Change MDS completed 11/15/23 indicated her weight was 151 lbs. The MDS noted she had significant weight loss but was not on a prescribed weight loss regimen. No dental or swallowing concerns were noted in the MDS and R38 received an antidepressant (class of medications used to treat mood disorders and relieve symptoms of depression) medication. The MDS indicated she required supervision or touch assistance while eating. The MDS noted the staff provided verbal cues or touching/steadying assistance as resident completed activity. R38's Nutritional Care Area Assessment (CAA) completed 08/29/23 indicated she had actual nutritional impairment. The CAA noted she needed occasional cueing for meals and chose to eat in her room. The CAA noted she could communicate her needs but had difficulty finding the words. The CAA noted her goal to maintain weight within five percent of her admitting weight. R38's Nutritional CAA completed 11/17/23 indicated she had unplanned weight loss. The CAA noted she did not have an order for nutritional supplements and Boost supplements would be added. The resident often said no to meals due to confusion from her dementia. The CAA instructed staff to anticipate her needs. The resident was started on Remeron (antidepressant medication often used to stimulate appetite) on 10/20/23. The CAA indicated she would benefit from eating in the assisted area but preferred to eat in her room. The CAA further noted Hopefully she will gain or at least not lose more weight. Staff were to weigh the resident weekly and the Registered Dietician (RD) would see her for weight loss. R38's Care Plan initiated 08/16/23 indicated she had nutritional problems related to her medical diagnoses, poor appetite, and new admission. The plan noted staff were to weigh her weekly and R38 would be followed in nutritional risk group (08/16/23). The plan noted R38 would maintain a weight goal within five pounds of 150 lbs. (08/16/23). The plan instructed staff to provide a calm, quiet setting at mealtimes with adequate mealtime (08/16/23). The plan noted she preferred to dine in her room but often refused lunch (11/21/23). The plan indicated medical nutritional supplements were ordered (11/21/23). The care plan lacked interventions regarding R38's level of assistance and supervision required during meals per her 11/15/23 Significant Change MDS. R38's Physician Orders recorded an order dated 08/16/23 for a regular diet with regular texture and thin consistency. R38's EMR under Weights Report documented her admission weight as 171.2 lbs. on 08/17/23. A Dietician Assessment completed 08/23/23 for R38 indicated she had a history of inadequate nutrient intake related to her medical diagnoses. The note indicated staff assisted the resident with meals and reported meal intake. The report indicated her intake varied and she did not meet the requirement for malnutrition. R38's EMR under Weights Report revealed she weighed 165.6 lbs. on 09/07/23, which indicated a 5.6 lbs. loss from the previous weight, dated 08/17/23. A 09/21/23 Health Status revealed R38 slept through the shift and refused to get up for meals. The note indicated R38's responsible party recommended giving her drinks and noted she drank a Boost supplement drink when offered. R38's Weights Report on 10/11/23 revealed she weighed 155.8 lbs. (a 15.4 lbs. loss since admission to the facility). The report lacked evidence staff obtained a weight between 09/07/23 and 10/11/23. A Communication Note dated 10/15/23 revealed R38's responsible party voiced concern to the facility about R38's continued weight loss and not eating meals. R38's Weights Report indicated on 10/20/23 she weighed 156.4 lbs. R38's Physician Orders documented an order dated 10/20/23 for mirtazapine (antidepressant medication often used to stimulate appetite) at bedtime to increase her appetite and prevent weight loss. R38's Physician Orders documented an order for weekly weights every Friday dated 10/20/23. The 11/10/23 Weights Report revealed R38 weighed 151 lbs., which indicated a total loss of 20.2 lbs. since admission. R38's EMR lacked evidence the staff obtained a weekly weight as ordered on Friday 10/27/23 and 11/03/23. A Mini-Nutritional Assessment completed on 11/15/23 indicated R38 had a moderate decrease in food intake and a weight loss greater than 6.6 lbs. The assessment scored her at six, indicating she was malnourished. The assessment recommended a referral to the dietician. R38's Physician Orders indicated she received diabetic house supplements twice daily starting on 11/17/23. A review of a Dietician Note completed 11/22/23 indicated the resident weighed 150.4 lbs. and she received a regular diet. The note indicated she was on diabetic house supplements twice daily and she recommended Nutren (nutritional supplement) 1.5 supplement, three times daily. R38's Physician Orders indicated she received Nutren Protein three times daily starting on 11/24/23. On 12/06/23 at 08:00 AM R38 lay flat in her bed with her head and shoulders propped up by her pillows. R38 had her bedside table pulled over the bed and she attempted to eat her breakfast. R38 reported she did not want to eat her breakfast but needed to. She struggled to express why she did not want to eat her meal. She stated she chose to eat in her room. Staff were not in her room during the resident breakfast to provide assist. R38 only ate 25 percent of her meal. R38 refused lunch but drank her supplement. On 12/07/23 at 08:15 AM R83 sat up in her bed while eating her breakfast. R38 consumed 80 percent of her meal and 100 percent of her supplement. Staff were not present while R38 ate her meal. On 12/06/23 at 11:45 AM R38's responsible party stated R38 struggled with appetite and weight loss in the past few months. She stated R38 chose to eat in her room and often refused to eat meals. She stated she talked to the facility about her concerns with R38's decreased appetite. She stated R38 received medication to help with her weight but wondered if providing more supplement options or meal assistance would be more helpful. On 12/12/23 at 11:50 AM Licensed Nurse (LN) J stated R38 struggled with weight loss due to her poor appetite and refusals for meals. She stated R38 often would not eat lunch but ate breakfast in her room. She stated R38 was recently started on supplements to help her maintain weight. She stated any resident with noticeable weight loss would be reported to the RD for review. She stated the RD was onsite weekly to provide consults. She stated the resident were weighed based on their orders and if a resident refused weights, it would be noted in the EMR. On 12/12/23 at 02:20PM Administrative Nurse D stated every resident received nutritional assessments upon admission. She stated residents with identified weight loss or nutritional risks received interventions that included specialized diets, supplements, and review for meal assistance. She stated the interdisciplinary team reviewed at-risk residents for potential losses and provided interventions. She stated the nursing staff were expected to report weight losses and the RD was onsite weekly to see the residents. On 12/13/23 at 10:14AM Consultant HH was unavailable for interview. A review of the facility's Weight policy revised 09/18/23 indicated residents with nutritional risk were weighed weekly. The policy indicated the medical provider and registered dietician will be notified upon significant weight loss. The policy noted interventions will be placed to address weight loss and prevent potential losses. The facility failed to provide consistent weight monitoring per the professional standards of practice after admission, failed to obtain weekly weights as ordered by the physician, and failed to provide cueing for meals as needed for R38. The facility further failed to implement nonpharmacological interventions to prevent weight loss until after a significant unplanned loss occurred for R38. These deficient practices resulted in a loss of 12.15% in three months for R38.

The facility identified a census of 114 residents with one kitchen and two main dining rooms. Based on observation, record review, and interviews, the facility failed to follow sanitary dietary standards related to cleanliness of the kitchen/dining room equipment, clean ventilation, equipment storage, hygienic serving practices, and food storage. This placed the residents at risk for food borne illness. Finding Included- - On 12/06/23 at 07:02AM an initial walkthrough of the kitchen was completed. An inspection of the air conditioning vents above the food warming station, stove/grill, food prep table, sink, and clean plates storage revealed layered debris/dust covering the vents. An inspection of the spice storage shelf revealed spilled spice particles covering the bottle and shelf. An inspection of the wet condiment shelf revealed sticky residue underneath the honey, vanilla, and vinegar bottles. An inspection of the storage area outside the kitchen revealed a buffet table with piles of clean cloth napkins covering the top of the buffet table exposed to the environment. An inspection of refrigerator number two revealed a package of opened pancakes with no opened date. An inspection of refrigerator number three revealed a measuring container with slimy yellowish liquid substance with no label or date. An inspection of the clean bowel/plate storage rack revealed them to be stored upward with nothing covering them. An inspection of the 300 Hall nutrition fridge revealed an unlabeled/undated paper plate wrapped in a plastic bag, an open container of apple juice with no open date, a brown square unidentifiable food item with no label or date and an opened small container of milk which lacked a date opened or name. On 12/06/23 at 11:45AM an inspection of lunch service revealed multiple staff repeatedly adjusting their face masks during meal service without completing hand hygiene. Dietary Staff CC carried drinks while touching the drinking surface of the glass with her bare hands. Further observation revealed a white PVC storage bin heavily soiled with old food and debris. An uncovered, wheeled bin contained clean place mats and napkins was pushed against the trash can and touched the soiled storage bin. Dietary Staff CC wore her mask with her mouth exposed. On 12/06/23 at 12:03PM Dietary staff CC stated clean surfaces should not be in contact with soiled surfaces. She stated the trash can should not touch the clean linen carts but was not sure if the clean linen should have been covered. On 12/06/23 at 12:30PM Dietary Staff BB stated staff were expected to clean and wipe down the storage bin and cart after use or when they became soiled. She stated all food and items stored should be labeled and dated in the refrigerators. She stated maintenance was coming to clean the vents above to kitchen area and they were responsible for maintaining them. She stated staff were expected to complete hand hygiene during meal service and should not be touching their masks. She stated the bowl and plate cart was usually covered with a dome when not in use. A review of the facility's Food Services and Nutrition policy 11/27/23 indicated the facility would promote a system that identified proper service, cleaning, and food storage. The policy noted all surfaces within the dining room and kitchen were to be cleaned and sanitized per professional standards. The policy indicated food would be label/dated and stored in a manner that is safe and maintains nutrition value. The policy indicated staff were to ensure safe food handling practices to prevent cross-contamination and food-borne illness. The policy indicated staff should complete hand hygiene in between touching surfaces related to direct food preparation, handling, and serving. The policy noted all kitchen ad dining equipment be stored in a manner that prevent soiling or contamination of clean items. The facility failed to follow sanitary dietary standards related to cleanliness of the kitchen/dining room equipment, clean ventilation, equipment storage, hygienic serving practices, and food storage. This placed the residents at risk for food borne illness.

The facility reported a census of 114 residents. Five Certified Nurse Aide's (CNA) were sampled for prevention of abuse, neglect, and exploitation training. Based on record review and interview the facility failed to provide evidence of the required prevention of abuse, neglect, and exploitation training for one of the five CNAs that were sampled. This placed the residents at risk for abuse. Findings included: - Employee record review of CNA OO revealed the facility failed to provide evidence that CNA OO received the required abuse, neglect, and exploitation training. On 12/11/12 at 02:24 PM Administrative Nurse D stated she contacted CNA OO and asked him to come in and complete the required education. On 12/12/23 at 02:41 PM Administrative Nurse D stated Consultant II oversaw and tracked the compliance and education requirements/hours for the employees at the facility. Administrative Nurse D stated it was also her responsibility to make sure employees were up to date on required training. An education policy was not provided by the facility. The facility failed to provide evidence of the required prevention of abuse, neglect, and exploitation training for one of the five CNAs that were sampled. This placed the residents at risk for abuse.

The facility had a census of 114 residents. Five Certified Nurse Aides (CNA) were sampled for required in-service training. Based on record review and interview, the facility failed to ensure two of the five CNA staff reviewed had the required 12 hours of in-service education which included dementia (progressive mental disorder characterized by failing memory, confusion) care training. This placed the residents at risk for decreased quality of life and/or inadequate care. Findings included: - Review of the facility's in-service records revealed the following: CNA OO, hired on 11/30/05, had 1.75 hours of in-service in the past 12 months. Review of trainings for CNA OO for past year lacked evidence of the required education on the topic of dementia. CNA QQ, hired on 08/31/16, had 6.59 hours of in-service in the past 12 months. Review of trainings for CNA QQ for past year lacked evidence of the required education on the topic of dementia. On 12/11/12 at 02:24 PM Administrative Nurse D stated she contacted CNA OO and asked him to come in and complete the required education. On 12/12/23 at 02:41 PM Administrative Nurse D stated Consultant II oversaw and tracked the compliance and education requirements/hours for the employees at the facility. Administrative Nurse D stated it was also her responsibility to make sure employees were up to date on required training. Administrative Nurse D stated dementia training was done annually through an online learning center and the facility offered hands on/in-person training as well. An education policy was not provided by the facility. The facility failed to ensure two of the five CNA staff reviewed had the required 12 hours of in-service education and dementia care training. This placed the residents at risk for decreased quality of life and/or inadequate care.

The facility identified a census of 114 residents. The sample include 23 residents. Based on observation, record review, and interviews, the facility failed to provide consistent activities for Resident (R) 7 and the other cognitively impaired residents who resided outside of the locked unit. This deficient practice placed the affected residents at risk for decreased psychosocial wellbeing and boredom. Findings included: - On 12/11/23 at 09:50 a group of cognitively impaired residents sat in the fireplace social area. The residents were not alerted or invited to attend the scheduled 10:00AM. The residents did not attend the planned activity event from 10:00AM to 11:00AM. On 12/11/23 at 10:00AM the facility held a Name that Christmas song activity. The activity provided snacks for the residents as they listened for the mystery Christmas songs played. At 10:33AM R7 () wheeled herself down the hall and into the activities room. R7 wheeled herself around the room and residents attending the event. R7 wheeled herself to the front of the room by the activities staff. Staff did not invite R7 to the game or provide her with a snack. R7 then wheeled herself to the adjoined chapel area and sat in the dark. At 10:45AM R7 wheeled herself out of the activity room and to the vending machine room. R7 sat in the vending machine room until 12:33PM. On 12/11/23 at 01:24PM R84, R41, R66, R100, and R309 (all cognitively impaired residents) sat at the fireplace social area. The listed residents sat in the common area with their eyes closed. They were not asked if they would like to attend the scheduled Bingo game at 02:00 PM. The residents missed the Bingo events. Residents remained in the seated area with minimal interactions or engagement from staff. No activities were offered or provided to the residents. On 12/12/23 at 09:50AM R309 sat by the fireplace common area. Activities Staff Z began escorting residents to the activities room for Christmas Ornament Painting event. R309 was not asked by staff if she wanted to attend the event and was left in the area with several other residents. At 10:10AM the event began and R309 was still at the fireplace sitting area. R309 stated she wanted to attend the event. 12/11/23 at 02:30PM Certified Nurse Aid M stated staff were expected to communicate with the resident the scheduled activities and ask them if they prefer something else. He stated staff should be offering options to the residents like attending activities, social hour, television, and games. He stated cognitively impaired resident should receive sensory activities. On 12/12/23 at 11:22AM Activities Staff Z stated she R7 usually was anxious during the events and would often have to leave due to disruptions. She stated the activities calendars are given out to all the residents and posted on the bulletin board. She stated impaired residents are provided with painting activities on one-one basis. She stated a lot of the more cognitively impaired residents don't like to attend the social events or activities. She stated every should be asked to attend or invited. She stated R7 liked to paint, color, and watch others. She stated the activities provided for each resident was charted in the EMR. On 12/12/23 at 02:30PM Administrative Nurse D stated all resident should be invited to the activity events. She stated it is the resident's choice not to attend but the activities should include everyone. She stated staff should provide engagement and offer activities if the resident did not want to go to the scheduled events. A review of the facility's Activities indicated the facility was responsible for providing beneficial activities that meet each resident's needs, interest, and functional level. The policy noted the activities should build community, spirituality, and cognitive opportunities for the residents. The facility failed to provide consistent activities for the cognitively impaired residents who did not reside on the locked unit. This deficient practice placed the affected residents at risk for decreased psychosocial wellbeing and boredom.

The facility identified a census of 137 residents. The sample included 3 residents reviewed for falls. Based on interview and record review, the facility failed to accurately assess cognitively impaired dependent resident #1 as a fall risk, and he/she fell from a wheelchair and experienced a broken neck. The facility further failed to develop and implement effective interventions to prevent falls for two (#1 and #2) residents. Findings included: - The closed electronic medical record for resident #1 included [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11, which indicated a moderate cognitive impairment. He/she required extensive assistance of 2 staff members for bed mobility and transfers, could only stabilize him/herself with staff assistance with surface to surface transfers, and had a range of motion impairment in both lower extremities. The resident used a wheelchair for mobility, and had a fall in the month prior to admission. The Care Area Assessments (CAA) dated 12/19/17 revealed the resident had some difficulty with short term recall, and required extensive assistance from staff with most of his/her Activities of Daily Living (ADLs). The fall CAA dated 12/19/17 revealed the resident had a history of [REDACTED]. The resident did not attempt to self-transfer, and required a Broda chair (specialized wheelchair with the ability to tilt and recline) for mobility. He/she had stiff knees and deformities to his/her toes, and experienced forgetfulness which impacted his/her judgment and safety awareness. The initial care plan for falls dated 12/12/17 documented staff educated the resident and family about safety reminders, what to do if a fall occurred, causes of falls, and the safe use of assistive devices. Staff reminded the resident to use a grabber to reach objects or ask for assistance, and not bend over to pick up items. Staff monitored the resident for significant changes in gait, mobility, use of positioning devices, standing/sitting balance, and lower extremity joint function. Staff updated the care plan on 12/25/17 to monitor, document, and report signs of pain, bruising, change in mental status, new onset of confusion, sleepiness, and inability to maintain posture and agitation when necessary. Staff updated the care plan on 1/8/18 for the therapy department to evaluate the safety of his/her wheelchair when he/she returned from the hospital. Staff reviewed his/her medical record for medications or combinations of medications that could predispose him/her to falls. The fall risk assessment dated [DATE] documented a score of 12, which indicated a medium risk of falls, the assessment dated [DATE] documented a score of 6, which indicated a low risk for falls, and the assessment on 1/6/18 documented a score of 12. The progress notes dated 12/25/17 at 3:50 A.M. documented staff found the resident lying on the floor beside his/her bed. He/she laid on his/her left side and tried to pull out his/her urinary catheter (tube inserted into the bladder to drain urine into a collection bag). The fall investigation dated 12/25/17 documented staff would check on the resident every hour, with reminders to not pull on the catheter. Staff updated this document on 12/27/17 to include treatment of [REDACTED]. The progress notes dated 1/6/18 at 2:45 P.M. documented staff found the resident on the floor in his/her room. He/she had an abrasion (scraping or rubbing away of a surface, such as skin, by friction) on his/her forehead, the top of his/her head, and a bruise under his/her right eye. The fall investigation dated 1/6/18 documented he/she sustained a moderate injury, which resulted in hospitalization . Staff were to evaluate the safety of his/her wheelchair. The progress notes dated 1/8/18 at 2:40 P.M. documented the resident's family reported he/she had sustained 2 spine fractures (broken bones) from the fall on 1/6/18, and the resident had difficulty swallowing. The resident's family further reported the resident had relayed he/she had flipped himself forward from the wheelchair while he/she reached for something. The progress notes from the hospital dated 1/9/18 documented the resident fell with evidence of a C1-C2 fracture (breaks in the 1st and 2nd cervical vertebrae) and a frontal sinus fracture (a break in the bones of the face which form a cavity above the nose and eyes). On 1/25/18 at 1:35 P.M. administrative nursing staff D stated he/she expected nurses to initiate an immediate intervention after a fall to prevent another fall. Staff D further stated the administrative staff met every morning to review resident falls and update the care plans. On 1/25/18 at 2:40 P.M. licensed nursing staff H stated he/she assessed the resident after the fall on 1/6/18 and remembered the resident had a nose bleed, a bruise under the right eye, and 2 spots on his/her head which bled. Staff H further stated the resident denied pain so staff assisted him/her to bed, but did report a little pain to his/her neck later and vomited. On 1/25/18 at 2:50 P.M. therapy staff P stated the resident received speech therapy for swallowing and cognition difficulties. Staff P said staff assessed the resident on 1/4/18; he/she was comfortable in his/her wheelchair, could propel the wheelchair, and operate the wheelchair brakes. The facility's Fall Prevention and Management Policy, dated 5/16/17, documented the facility identified risk factors and implemented interventions before a fall occurred. Appropriate interventions were care planned, which included personalization of all areas. The facility continued to monitor the condition and the effectiveness of the interventions. The facility failed to accurately assess the resident's fall risk, and develop and implement interventions to prevent falls in this cognitively impaired dependent resident with a history of falls, who fell and experienced a broken neck. - The physician's orders [REDACTED].#2 included [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 7, which indicated severely impaired cognition. The resident required supervision assistance of 1 staff with bed mobility and toileting. The resident required set up help of 1 staff with transfers. The significant change MDS dated [DATE] documented the resident was unable to complete the BIMS assessment. The resident required extensive assistance of 2 staff with bed mobility, toileting, and transfers. The Care Area Assessment (CAA) dated 1/3/2018 for falls indicated the resident was weak and became tired easily. It further indicated the resident spent most of the time in bed, but would get up in a wheelchair when he/she wanted to. Due to an overall decline, the resident primarily used the wheelchair. The care plan dated 10/19/2017 directed staff to monitor the resident for significant changes in gait, mobility, positioning devices, standing/sitting balance, and lower extremity joint function, and to educate the resident as to the cause of the fall. On 12/1/17, staff updated the care plan to monitor the resident after a fall for signs and symptoms of pain, bruising, change in mental status, new onset of confusion, sleepiness, inability to maintain posture, and agitation, and physical therapy would consult for strength and mobility, re-evaluate the resident's footwear and [MEDICAL CONDITION] (swelling). The care plan directed staff to observe the resident for significant changes in cognition, safety awareness, and decision-making capacity; obtain lab tests for increased confusion. Staff updated the care plan on 12/4/2017 to review the status of any medical conditions which predisposed the resident to falls or that could increase the risk of injury from falls, and to evaluate pain medications. The fall investigation documented on 11/30/17 at 7:00 P.M., staff found the resident lying on his/her left side on the floor. The resident sustained [REDACTED]. Staff documented the resident had increased scattered thoughts and jumbled words. The fall investigation documented on 12/1/2017 at 7:15 P.M., staff found the resident on the floor in another resident's room. Staff documented the resident was very confused and not aware of his/her limitations. The resident tried to ambulate when he/she fell . The clinical record lacked evidence of new interventions after this fall. The fall investigation documented on 12/2/17 at 8:20 P.M., staff lowered resident to the floor when he/she tripped over his/her foot. Staff noted the resident hit his/her head and had no apparent injury. The fall investigation documented on 12/3/17 at 10:51 A.M., staff found the resident on the floor in his/her room. The resident complained of pain and could not move his/her right leg. The physician's orders [REDACTED]. The resident underwent [REDACTED]. The hospital's progress note dated 12/16/17 documented a [DIAGNOSES REDACTED]. On 1/25/18 at 1:32 P.M., administrative nursing staff D stated he/she expected staff to alert the licensed nurse when they found a resident on the floor. Staff D said he/she expected the staff on duty to develop new interventions to prevent another fall. On 1/25/18 at 2:40 P.M., licensed nursing staff H reported he/she knew a resident was a fall risk through report and the facility's star system, in which staff identified walkers of residents at risk for a fall with a star. If a resident fell , he/she would assess the resident, notify the resident's representative and physician. Licensed nursing staff H further stated staff completed a fall form, developed new interventions, and documented them on the form. On 1/25/18 at 4:00 P.M., direct care staff Q stated if a resident fell , he/she would send for the nurse to assess the resident. If the nurse suspected a serious injury, the resident would not be moved until the ambulance arrived. The facility's policy Fall Prevention and Management, revised 10/17 documented risk management was completed with each fall, communication with physician was documented in the progress notes, a fall scene huddle worksheet was completed by nursing staff at the time of the fall, and an intervention was put in place the same day of the fall. The facility failed to develop and implement effective interventions after this cognitively impaired resident fell on [DATE], 12/1/17, 12/2/17, and 12/3/17, and sustained a subarachnoid hemorrhage which required hospitalization and treatment.

The facility census totaled 135 residents with 3 residents sampled. Based on observation, interview and record review, the facility failed to provide adequate supervision and appropriate interventions to prevent accidents for 1 of 3 residents (#1) reviewed for accidents. Staff inappropriately transferred the resident with a Hoyer lift. The resident fell from the lift onto the floor, which resulted in a head injury with a laceration (cut), subarachnoid (space around the brain tissue) bleed, and intraparenchymal (tissue inside the brain) hemorrhage (bleeding). Findings included: - Resident #1 ' s Physician order [REDACTED]. The annual Minimum Data Set assessment ((MDS) dated [DATE] documented the resident was rarely and/or never understood. The resident required total dependence of 2 staff members with transfers. The MDS further documented the resident ' s balance was not steady and only able to stabilize with staff assistance. The fall Care Area Assessment (CAA) dated 9/3/15 documented the resident required extensive assistance with activities of daily living. The resident was unable to stand and all transfers were done with a total lift. The resident did not attempt to transfer self. The 11/27/15 revised fall care plan documented the resident was at risk for falls related to history of multiple cerebrovascular accidents (CVA) (stroke) (sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) with left sided weakness. The 11/27/15 revised activities of daily living care plan instructed the nursing staff with transfers to use a total lift with a medium high back sling (a piece of material used as a transfer aid with a mechanical lift, that went from above the resident ' s head to below their thighs) and 2 staff members. The fall risk assessment dated [DATE] scored 10 which indicated the resident was a low risk for falls. The mobility assessment tool dated 9/29/15 documented the resident was totally dependent on 2 staff members, and required a total lift with a high back medium sized sling. The nurses ' noted documented on 1/11/16 at 10:08 P.M. direct care staff O transferred the resident from his/her wheelchair to the bed with a total lift machine and a hygiene sling (a transfer sling that covers only the upper back and thighs). Direct care staff O reported the resident was jiggling his/her leg and fell from the air onto the floor. The resident hit the back of his/her head on the floor. Licensed nursing staff H noted a laceration on the back of the resident ' s head. The resident transferred to the hospital. The nurse ' s notes documented on 1/12/16 at 9:34 A.M. staff called the hospital to check on the resident. The hospital reported the resident had a right frontal bleed (right side of the front of the brain). The resident was responsive and had a moderate amount of pain. The hospital record dated 1/12/16 documented the resident was dropped and sustained a head injury with subarachnoid and intraparenchymal hemorrhage and a head laceration that required stitches. The nursing readmit data collection note dated 1/21/16 at 4:21 P.M. documented the resident required transfer assistance of 2 staff members, he/she did not speak, and had left upper extremity paralysis (the loss of muscle function, sensation, or both). Review of the nursing Kardex (report on the Kiosk) that documented the resident ' s needs included the resident required a total lift with a medium high back sling and 2 staff members with transfers. On 2/10/16 at 8:32 A.M. observed direct care staff P and direct care staff Q prepared the resident to get up in his/her Broda chair (a specialized wheelchair with the ability to tilt and recline). Direct care staff P placed a full body sling (a piece of material placed around and/or under the resident to use with a mechanical lift machine) under the resident. The sling went from above the resident ' s head to just above his/her knees. Staff encompassed the resident in the sling, and then hooked the sling to the Hoyer lift (mechanical lift used for transfers). Staff transferred the resident into the Broda chair with 2 staff controlling the movement of the machine and the resident with the transfer. Staff lowered the resident into the Broda chair and unhooked from the Hoyer lift. Review of direct care staff O ' s notarized statement dated 1/12/16 documented he/she usually asked for help but this time he/she transferred the resident by themselves. The resident had a hygienic sling (covers only the back and wraps around the upper thighs) under him/her. Direct care staff O started to raise the lift to transfer the resident from his/her chair to his/her bed. Direct care staff O documented he/she was close to the resident ' s bed when the resident slipped through the sling. The resident hit his/her head on the floor and his/her left foot was stuck on the sling. Direct care staff O removed the resident ' s foot and the rest of the resident body was on the floor. Direct care staff O then called the nurse. Review of licensed nursing staff H ' s notarized statement dated 1/14/16 documented that direct care staff O notified him/her the resident fell out of the total body lift and was lying on the floor. Direct care staff O told the licensed nursing staff H he/she was transferring the resident by him/herself with the hygiene sling and the resident slipped out of the sling. There was blood on the floor and on the pillow that staff placed under the resident ' s head. Licensed nursing staff H assessed the resident and noted the back of his/her head was bleeding. After assessing the resident, staff placed the resident on a full body sling and assisted him/her into bed. Interview on 2/10/16 at 8:30 A.M. with direct care staff P stated any resident that used a total lift had to have 2 staff members there during the transfer. Interview on 2/10/16 at 8:40 A.M. with direct care staff Q stated that a resident who required the Hoyer lift had to have 2 staff members with the transfers. Interview on 2/10/16 at 12:26 P.M. with direct care staff R stated this resident required a 2 person lift with the Hoyer lift. The resident had a hygiene sling on and not the full body sling that he/she was supposed to use. Direct care staff R told direct care staff O to take the resident to his/her room and direct care staff would be there to help, after he/she answered a call light. Direct care staff O did not wait on him/her. Interview on 2/10/16 at 12:28 P.M. with licensed nursing staff H stated when he/she went to check on the resident, the hygiene sling was still connected to the lift machine and the resident was on the floor. Licensed nursing staff H stated only direct care staff O was with the resident and there should have been 2 staff members with the transfer. The resident should have been on a full body sling for the transfer. Interview on 2/10/16 at 2:20 P.M. with direct care staff O stated he/she transferred the resident by him/herself because we were very busy and everybody wanted to get up. Direct care staff O stated he/she had transferred the resident by him/herself several times. The Kardex did say we should have 2 staff members with the resident but we have to do what we have to do . It was a very busy time and direct care staff O stated he/she just had to transfer the resident by him/herself. Direct care staff O stated the hygiene sling was already under the resident, so he/she raised the lift and he/she slid down through the sling. The resident ' s boot was caught in the sling and he/she landed on his/her head. Direct care staff O stated he/she had to unhook the sling to let the rest of the resident fall. Direct care staff O placed a pillow under the resident ' s head which was bleeding, and then direct care staff O went and got the nurse. Interview with administrative nursing staff D on 2/10/16 at 2:44 P.M. stated the nursing staff should follow the procedures as they were taught. All the nursing staff received training on the different lifts in August. Administrative nursing staff D stated the nursing staff was told then to use 2 staff members with a full body lift. The facility policy dated 7/2015 Fall Prevention and Management instructed the staff to implement interventions, including adequate supervision, consistent with a resident ' s needs, goals, plan of care and current standards of practice in order to reduce the risk of an accident; and/or monitor the effectiveness of the interventions and modify the interventions as necessary, in accordance with current standards of practice. The revised 1/14 facility policy Mechanical Lift instructed the staff to properly use the mechanical lifts. After completing the data collection tool, if a mechanical lift would be used, the staff would document the type of mechanical lift used, the sling type and size, and the number of people needed to assist in the transfer. The facility failed to ensure the nursing staff followed the resident ' s care plan and Kardex which instructed the nursing staff to use 2 staff members and full body sling with transfers. This cognitively impaired, dependent resident was dropped from the air per the Hoyer lift to the floor and his/her head hit the floor first. The resident obtained a laceration to the back of his/her head and was sent to the hospital. The hospital documentation revealed the resident sustained [REDACTED].

The facility identified a census of 138 residents. The sample included 4 residents. Based on observation, record review, and interview, the facility failed to ensure #1 of 4 residents received adequate supervision and assistive devices to prevent a fracture. Findings included: - Resident #1's March 2014 electronic medical record documented the resident had a [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] recorded the resident had a Brief interview for Mental Status (BIMS) score of 5 which indicated severe cognitive impairment. The resident required extensive assistance of 1 staff with transfers and toilet use. The MDS recorded the resident had frequent bladder incontinence and no recent falls. The significant change MDS dated [DATE] recorded a BIMS score of 10 which indicated moderate cognitive impairment. The MDS documented the resident required extensive assistance of 2 persons with transfers and toilet use, was incontinent of bowel and bladder, and had 1 fall since the previous assessment. The 2/27/15 Care Area Assessment (CAA) for falls recorded the following: The resident had two falls on 2/17/15. On 2/17/15 at 6:15 A.M., direct care staff assisted the resident to the bathroom and used the sit- to- stand lift (a mechanical device with a non-restraining harness to assist non-ambulatory resident's with standing and transfers). The resident let go of the lift's hand grasps and slid to the floor. He/she had an abrasion on his/her right shoulder, but the x-ray was negative for a fracture (no break in a bone identified). The second fall on 2/17/15 was at 9:24 P.M. when direct care staff assisted the resident to bed. Staff was instructed to use the total lift (a lift cradling the entire body and not requiring the resident to stand). (Investigative reports revealed a sit-to-stand was used and not a total lift). The resident still complained of right shoulder pain. The resident had a second x-ray on 2/21/15 which revealed an acute fracture of the the right humeral head (a broken right arm bone near the shoulder). An orthopedic physician was following the resident. The resident's care plan dated 2/17/15 directed staff to use a total lift for transfers at all times with assistance of two care givers. The resident did not hold onto the sit-to stand-lift. The care plan lacked documentation regarding the specific time the change from one person assistance and a sit-to-stand lift, to a two person assistance and a total lift was initiated. Review of the direct care staff Kardex (an updated pocket sized care plan) also documented the residents use of a total lift, but lacked documentation of the specific time on 2/17/15 the intervention was initiated. The nurse's progress note dated 2/21/15 at 8:00 P.M. documented the physician ordered a sling (a cloth pouch used to immobilize an arm for healing) and directed staff to make a appointment with an orthopedic physician on 2/23/15. The physician's orders [REDACTED].M. and P.M., and as needed (prn) for pain relief. The medication administration record revealed the resident received additional and/or prn doses of the medication on 2/18/15, 2/19/15 2/20/15, and 2/21/15 to provide relief of his/her right shoulder pain. On 3/18/15 at 8:10 P.M. observation revealed the resident in a motorized wheelchair in his/her room and wearing a sling supporting his/her right arm. On 3/18/15 at 12:20 P.M. observation revealed two direct care staff assisted the resident from his/her motorized wheelchair with a total lift and nestled the resident's right arm inside the lift sling. Interview on 3/18/15 at 8:10 P.M. the resident stated he/she remembered a lift that lifted his/her body, but did not recall the use of a sit-to-stand lift. The resident did not remember the falls. He/she remembered breaking a bone and stated his/her right shoulder hurt from time- to- time but did not hurt at this time. Interview on 3/18/15 at 10:10 P.M. licensed nurse J stated he/she responded to the resident's A.M. fall on 2/17/15. The direct care staff reported the resident's knees buckled during transfer from the bed to this/her motorized chair. Nurse J could not recall if the lift sling was attached to the lift or under the resident and was not sure if the resident fell or slid to the floor. The resident complained of right shoulder pain, the physician ordered an X-ray, and it was negative. Nurse J stated we assessed the resident and began the fall protocol. Interview on 3/18/15 at 1:45 P.M. direct care staff D stated walking rounds (report on resident status) were done at each shift change. If there was a care measure in question staff checked the Kardex for updated status such as a change in lift status. Interview on 3/18/15 at 2:20 P.M. licensed nurse K stated when a change was made to the resident care plan such as new interventions added after a fall, they were immediately placed on the resident's care plan. The electronic program prompted the nurse to make a change to the direct care staff Kardex. Nurse K stated sometimes it does not show up until the next shift. Interview on 3/18/15 at 2:25 P.M. administrative licensed nurse E stated interventions are added to the care plan by the nurses on the unit whenever a change occurs, and then the care plan prompts for the direct care staff Kardex to be updated and that is when it is done (review revealed the updated electronic program does not give a specific time any changes are made). Nurse E stated administrative staff post changes to the care plan and Kardex immediately because they are received in a meeting every A.M.. Interview on 3/18/15 at 2:35 P.M. direct care staff F (witness to fall on 2/17/15 at 9:24 P.M.) stated: he/she did not receive report on the hall at shift change from the day shift and no one mentioned the resident fell in the A.M. Direct care staff F stated the resident wanted to go to bed. Direct care staff F stated he/she got the sit-to- stand lift and when the resident scooted out a little on his/her motorized chair, he/she complained of leg pain. The pain subsided so we tried again and she just raised his/her arms from the lift and fell landing on her right side on the floor. Interview on 3/18/15 at 2:35 P.M. direct care staff G stated (after fall on 2/17/14 at 9:24 P.M.) we used a gait belt to assist the resident to sit in his/her chair and then transfer to bed. At that time the resident did complain of pain to his/her right arm/shoulder. On 3/19/15 at 12:00 A.M. administrative licensed nurse D stated the 2/17/15 day shift nursing staff reported the resident fell in the A.M. to the oncoming shift and along with instruction for the use of a total lift. Administrative licensed nurse D stated the oncoming evening shift nurse on 2/17/15 did not recall if he/she received the information. On 3/19/15 at 12:29 P.M. resident #1's primary care physician commented the resident's second fall on 2/17/15 most likely caused his/her broken arm. The facility's Prevention and Management of Falls Practice Guidelines policy revised September 2012, recorded, shift to shift communication was completed in a number of ways. The 24 hour report in (electronic charting) was available to track changes throughout the shift and share between staff at shift change. The facility failed to timely provide and communicate interventions to prevent a fall with injury for cognitively impaired dependent resident #1 who was at risk for falls.

The facility documented a census of 136 residents. The sample included 4 residents. The facility reported 18 residents received [MEDICATION NAME] (blood thinner medication). Based on observation, record review and interview the facility failed to adequately monitor for 1 of 4 residents (#1) receiving an anticoagulant (blood thinner) medication ([MEDICATION NAME]) per physician's orders [REDACTED]. Findings included: - Resident #1's Physician order [REDACTED]. The quarterly Minimum Data Set 3.0 assessment dated [DATE] documented the Brief Interview for Mental Status (BIMS) score of 3 which indicated severely impaired mental status. The MDS further documented the resident was independent in all activities of daily (ADLs) except dressing for which he/she required limited assistance of 1 staff member. The Care Area Assessment (CAA) related to cognition dated [DATE] documented the resident scored 5 out of 15 on BIMS. The resident had difficulty with dates and recall. The resident did not have [MEDICAL CONDITION] related to disorganize thinking but due to previous stoke, the resident had [MEDICAL CONDITION] and difficulty expressing self. The resident did communicate well; sometimes the resident had to describe what she/he tried to say because he/she could not think of the word. The resident was generally alert and oriented to person, place and time. Resident had periods of mild confusion but none recently. The CAA related to ADLs dated [DATE] documented the resident did most of his/her ADLs independently. The resident toileted and dressed him/herself. The staff helped the resident with showers and making the bed. He/she was able to use the call light appropriately, to make his/her needs known and usually did so. The resident had a [MEDICAL CONDITIONS] prior to admission and had right sided weakness but he/she was able to walk and use his/her right side. He/she was motivated to be as independent as possible. The care plan dated [DATE] documented the resident on anticoagulant (blood thinner) therapy of [MEDICATION NAME] related to a heart condition of [MEDICAL CONDITION] the most common cardiac arrhythmia (irregular heart beat). The interventions included: ? Monitor/document/report to doctor as needed signs and symptoms of anticoagulant complications such as: blood tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, shortness of breath, loss of appetite, sudden changes in mental status, and/or significant or sudden changes in vital signs. ? Review medication list and monitor for adverse interactions. Avoid use of aspirin or non-steroidal anti-[MEDICAL CONDITION] drugs (NSAIDS). BLACK BOX WARNING (a warning that appears on the label of a prescription medication to alert consumers and healthcare providers about safety concerns, such as serious side effects or life-threatening risks). The U.S. Food and Drug Administration (FDA) required a black box warning for the most serious of medication warnings. [MEDICATION NAME] ([MEDICATION NAME]): Observe for major or fatal bleeding. Potential adverse effects included hematuria (blood in the urine) and hemorrhage (bleeding elsewhere). The resident was on platelet drugs related to [MEDICAL CONDITION] and history of [MEDICAL CONDITION]. The interventions included black box warning for aspirin to monitor for signs and symptoms of [MEDICAL CONDITION] and bruising. The nurses notes documented on [DATE] at 2:30 P.M. licensed nursing staff D received the laboratory results of an International Normalized Ratio (INR a test to measure the time it takes for blood to clot and compares it to an average) for resident #1. The laboratory test results documentation revealed a level of 4.8 (which was a high level). The normal INR range is 0.9 - 1.2. Licensed nursing staff D faxed the laboratory results to the resident's primary physician at 2:40 P.M. The Geriatric Dosage Handbook 16th edition documented an INR greater than 4 did not generally add additional therapeutic benefit and was associated with increased risk of bleeding. The nurses notes documented on [DATE] at 5:55 P.M. licensed nursing staff C documented to hold (not give) the [MEDICATION NAME] for 2 days. Licensed nursing staff C wrote a telephone order from the primary physician to hold the [MEDICATION NAME] for 2 days and resume [MEDICATION NAME] 5 milligrams on [DATE]. The telephone order also included an order to recheck the resident's INR on Friday [DATE]. Review of the resident's medication sheet revealed staff held the resident's [MEDICATION NAME] on [DATE] and then resumed on [DATE]. The facility continued to give the [MEDICATION NAME] 5 milligrams daily until [DATE] when the resident went to the hospital. Review of the resident's record revealed the facility had not sent in for INR after [DATE]. On [DATE] at 1:32 P.M. licensed nursing staff E documented the resident complained of his/her stomach hurting and requested to go to the hospital. Staff called the resident's primary physician and he/she gave the order to send the resident to the emergency room . On [DATE] at 6:41 P.M. licensed nursing staff F documented the resident admitted to the hospital with [REDACTED]. Review of the hospital records revealed the resident presented to the emergency room with abdominal pain for 3 days. The resident indicated he/she had abdominal pain, diarrhea and black stools for 3 days. The resident was receiving [MEDICATION NAME] for [MEDICAL CONDITION] and a mechanical heart valve. The hospital's laboratory tests revealed the resident's [MEDICATION NAME] (PT) (used to determine the clotting tendency of blood) was greater than 300 seconds and INR greater than 20.0. The documentation for the laboratory levels were at critical levels. The normal reference range for the PT levels were 9.0 - 12.5 seconds and for the INR 0.9 - 1.2. The resident's hemoglobin (the molecule in red blood cells that carries oxygen) level was 7.1 grams per deciliter (normal range 11.6 - 15.6) and hematocrit (measures the percentage of the volume of whole blood that is made up of red blood cells) level documented at 22.0% (normal range 36.0 - 48.0). The resident received [MEDICATION NAME] (Vitamin K) 10 milligrams in the emergency room , to diminish the anticoagulant effects of the [MEDICATION NAME] the resident had received. The resident admitted to the hospital's intensive care unit on [DATE] at 4:38 P.M. and received 4 units of red blood cells and 1 unit of fresh frozen plasma within the next 12 hours. On [DATE] the resident had an esophagogastroduodenoscopy (EGD) (a test to examine the lining of the esophagus - the tube that connects your throat to your stomach), stomach, and first part of the small intestine. It was done with a small camera (flexible endoscope) that is inserted down the throat) to assess where the resident was bleeding from. The results revealed small bowel arteriovenous malformations as the likely source of the oozing of blood. The resident expired on [DATE] at 7:20 A.M. at the hospital. On [DATE] at 8:05 A.M. licensed nursing staff G revealed that when a resident was on [MEDICATION NAME], the facility would do a PT/INR as ordered by the physician. The nursing staff utilized a flow sheet that included the date, the [MEDICATION NAME] dose, the lab results and the nurse's signature. The nurses should fax the flow sheet plus the laboratory results to the physician. When the physician faxed back an order or called an order then the nurses should fill out another laboratory requisition form for when the next laboratory test was due. The nurse should document a nurse's note in the resident's record. On [DATE] at 11:05 A.M. licensed nursing staff H revealed the evening shift nurses distributed [MEDICATION NAME]. The laboratory staff obtained the blood work as ordered by the doctor. When the facility received the lab results, then the nursing staff should fax the results to the doctor. The doctor would then fax back an order. The licensed nurses would write that order and make out the next laboratory requisition. On [DATE] at 2:30 P.M. administrative licensed nursing staff B revealed that licensed nursing staff J failed to make out the requisition for the laboratory work ordered by the physician. On [DATE] at 2:40 P.M. licensed nursing staff C revealed the physician's office called on [DATE] and ordered staff to hold the [MEDICATION NAME] medication for 2 days and also ordered another blood test PT/INR for Friday [DATE]. Licensed nursing staff C revealed that he/she failed to make out the laboratory requisition form for the blood work as it was supper time and a busy time with passing medications. Licensed nursing staff C revealed he/she wrote the order to hold the [MEDICATION NAME] for 2 days. Licensed nursing staff revealed that he/she held the [MEDICATION NAME] on [DATE] and placed the order in the computer with the date to end on [DATE] The computer only placed the [MEDICATION NAME] on hold for one day. On [DATE] at 4:05 P.M. physician J revealed that it was a "horrible mistake", the facility failed to hold the [MEDICATION NAME] for the 2 days and redraw the labs as he/she ordered. The physician J confirmed the resident had a GI bleed and that his/her INR was greater than 20 when he/she was admitted to the hospital. The resident received 4 units of blood, Vitamin K and 1 unit of platelets at the hospital related to the GI bleed. On [DATE] at 4:20 P.M. administrative licensed nursing staff B stated the nursing staff did not see any symptoms of a GI bleed. The resident was very independent and also very vocal so the resident would have told the nursing staff if he/she was having any problems. The revised ,[DATE] facility policy "physician's orders [REDACTED]. The revised ,[DATE] facility policy "Laboratory Services" documented laboratory services will be done only when ordered by the attending physician. The findings should be promptly reported to the physician and reports will be dated and filed in the resident's medical record. The revised [DATE] facility policy "Anticoagulant Lab/Therapy Record" instructed the nursing staff to document PT/INR results, changes to anticoagulant (e.g. [MEDICATION NAME]) dose and next lab draw on the residents receiving anticoagulant therapy. The facility abated the immediate jeopardy on [DATE] when the facility implemented the following: 1) All licensed nursing staff received education regarding inputting physician orders [REDACTED]. The nursing supervisors were educated on [DATE] at 11:30 am regarding the weekly tracking of residents who receive [MEDICATION NAME] to ensure proper transcription and follow through on the physician orders. All licensed nursing staff will utilize the "Physician order [REDACTED]. That will then be reviewed by nursing supervisor Monday through Friday prior to routing to health information management for auditing purposes. 2) Report was pulled for residents receiving [MEDICATION NAME]. Those residents had their medical records reviewed for recent lab results, orders for next labs to be drawn, and completion of laboratory requisition completion. 3) These reports will be monitored at least weekly after laboratory draws. 4) The quality assurance team, including but not limited to administrator, director of nursing, medical director, health information manager, human resource director, dietary director, maintenance director, infection control nurse, Minimum Data Assessment Set (MDS) nurse and certified nurse aide, will randomly audit ten percent of the medical records of those resident receiving [MEDICATION NAME] weekly for four weeks, monthly for four months, then quarterly thereafter up to one year. The nursing supervisors will review the INR tracking form weekly. The facility failed to follow the physician's orders [REDACTED]. The facility continued to give the medication [MEDICATION NAME] for 15 days after the order to hold had been received from the physician. The resident went to the hospital due to a GI bleed potentially caused by the administration of the medication [MEDICATION NAME] which the physician ordered not given. The resident removed from his/her home and hospitalized , given numerous tests, moved from one unit to another unit and ultimately expired. This deficiency remains at the scope and severity of a G.

The facility identified a census of 137 residents. The sample included 21 residents. Based on observation, interview, and record review the facility failed to provide supplements with meals as ordered to prevent weight loss for resident #133 and failed to adequately monitor resident #71's nutritional status. Findings included: - Resident #133's [DIAGNOSES REDACTED]. The significant change Minimum Data Set 3.0 Assessment (MDS) with the Assessment Reference Date (ARD) of 12-7-11 documented the resident's Brief Interview for Mental Status Score (BIMS) of 7, which indicated the resident had severely impaired decision making, required extensive assistance with eating, and had weight loss. The quarterly MDS with the ARD date of 2-29-12 documented the resident's BIMS of 4 which indicated the resident had severely impaired decision making, required supervision with eating, and had weight loss. The 12-7-11 Cognition Care Area Assessment (CAA) documented the resident had difficulty with recall, had dementia related to his/her [MEDICAL CONDITION], took [MEDICATION NAME] (an antidepressant) for depression, was generally alert and oriented to person and place and had periods of forgetfulness and confusion. The CAA also documented the resident was not able to make his/her needs known at times and had difficulty expressing his/her thoughts. The 12-7-11 activities of daily living (ADL) CAA documented the resident required extensive assistance with ADLs and staff anticipated his/her needs. The ADL CAA documented the resident lost weight. The 12-7-11 nutritional CAA documented the resident with recent significant weight loss with a decline in his/her appetite and with feeding his/herself. Staff moved the resident to the restorative table due to the decline however his/her appetite remained poor. The consultant dietician recommended on 11-23-11 that staff provide the resident with ensure (a high protein, high calorie nutritional supplement) when he/she refused a meal. The resident continued to decline since the recommendation. The CAA also documented the resident with dementia and he/she was not aware of the need to eat, so did not ask for food. On 11-23-11 the registered dietician documented the resident's current weight was 161.4 and was down 6.7% in the past month. The resident was on a regular diet, fed self, refused some meals and had [DIAGNOSES REDACTED]. On 12-14-11 the registered dietician documented the resident's current weight was 152 and was down 6% over the past 30 days. The resident ate at the restorative table one to two times daily for meals, and appeared distracted at meal time. The resident's meal intake varied and staff reported the resident complained of being too tired to eat. The dietician's plan included moving the resident to the assisted dining room for increased feeding support and continue giving the resident ensure with lunch and dinner to increase his/her calorie intake and referred the resident to the nutritional risk committee. Record review of the physician's orders [REDACTED]. The 9-15-11 care plan identified the resident with weight loss and interventions included a regular diet, monitoring the monthly weight, dietician follow the monthly nutritional risk group, document the resident's meal intake, allow the resident to refuse breakfast, staff to offer the resident a drink and/or prepare food when the resident got up, and offer ensure as ordered twice a day. On 3-26-12 the care plan directed staff to give the resident ensure with lunch and dinner, and if the resident missed a meal. The 3-7-12 care plan review documented the resident's appetite had improved on [MEDICATION NAME], lost weight, but had stabilized. Record review of the resident's weights documented the following: 9-15-11 - 166.8 10-5-11 - 173 11-4-11 - 161.4 12-6-11 - 152 1-14-12 - 145.2 2-14-12 - 145.2 3-7-12 - 136.8 During staff interview on 4-17-12 at 12:33 P.M. licensed nursing staff L stated the staff monitored the residents appetite and if he/she had weight loss then staff notified the MDS coordinator, the weight team, and if needed the dietician. Licensed nursing staff L also stated they received copies of the resident's weight and reviewed them and made suggestions also. On 10-20-11 the MDS summary documented the residents weight as stable at 173 pounds. Record review of the resident's labs documented on 3-26-12 the [MEDICATION NAME] level (a test to determine the amount of protein in the blood for evaluation of nutritional status) was 3.1 grams per deciliter (g/dl) with the normal range between 3.2 g/dl to 4.7 g/dl. Observation on 4-16-12 at 11:50 A.M. revealed the resident in the main dining room at the assisted side and staff served the resident meat with gravy, mashed potatoes, zucchini, water, juice, and desert. Staff cut the resident's meat up and the resident ate independently. The tray lacked ensure with the meal as planned. Observation on 4-16-12 at 12:30 P.M. revealed the resident ate 50 percent of the food served and 100 percent of the liquids. Observation on 4-17-12 revealed the resident did not get up for breakfast and remained in bed until 11:23 A.M. when staff entered the resident's room to get him/her up per the resident's request. Staff took the resident to main dining room and served the resident a Philly steak and cheese sandwich, lettuce salad, cottage cheese, potato soup, pudding, juice, and water. The tray lacked ensure with the meal as planned. Further observation of this meal revealed the resident ate 1/4 of the bread from the sandwich, 1/2 of the salad and cottage cheese, and a few spoonfuls of the soup. During staff interview on 4-17-12 at 8:54 A.M. licensed nursing staff J stated the resident's weight was stable now and they were not following him/her on the nutritional risk committee. Licensed staff J continued that the dietician recommended staff give the resident ensure with lunch and supper and the resident did not get up for breakfast. He/she also stated the facility did not weigh residents weekly unless it was based on fluid loss. On 4-17-12 at 1:12 P.M. dietary staff I stated he/she documented the resident ate 26-50% of his/her meal and offered the resident an alternate and he/she refused it. Dietary staff I also stated dietary documented in the computer system how much the resident ate then nursing would be able to see it also. During staff interview on 4-17-12 at 3:44 P.M. administrative nurse B stated the resident received ensure with his/her noon and supper meal and dietary staff recorded it in the computer under fluid intake. He/she also stated the dietary staff gave the ensure with the dietary tray. During staff interview on 4-17-12 at 3:55 P.M. dietary staff J stated dietary personnel knew which residents received a dietary supplement with their meals because it was recorded on their dietary card. Review of the resident's card documented on 10-11-11 to give the resident ensure if the resident refused his/her meal. (Not as documented in the care plan updated on 3-26-12) During staff interview on 4-17-12 at 4:07 P.M. administrative nurse B acknowledged dietary did not give the resident ensure with his/her meals unless he/she refused to eat and stated he/she was just made aware of it and changed it. The facility provided 9/09 Policy and Procedure titled Residents with Impaired Nutrition and Nutritional Risk documented the facility ensured that each resident maintained an acceptable parameter of nutritional status such as body weight, protein levels and hydration status unless the resident's clinical condition demonstrated it was not possible. The facility provided 9/09 Policy and Procedure titled Nutrition Risk Committee documented that dietary staff was responsible for changing diet cards, and the nutrition risk committee members were responsible for communication of pertinent information to coworkers. The facility failed to provide nutritional supplements twice daily for this dependent resident with significant weight loss as planned. - The April 2012 physician's orders [REDACTED]. The admission Minimum Data Set 3.0 (MDS) with an assessment reference date (ARD) of 2/15/12, documented the resident's Brief Interview for Mental Status score of 14, which indicated the resident's cognition and memory were intact, the resident required supervision with transfers and ambulation, set up assistance with meals, weighed 145 pounds, the resident did not have chewing or swallowing problems, and received a therapeutic diet. The nutrition Care Area Assessment (CAA) dated 2/15/12 documented the resident's BMI (Basic Metabolic Index) at 26.5-slightly above normal limits, but the concern was his/her weight related to cardiovascular status. The April 2012 POS documented the resident received the following diet: - No Texture Alteration - No Fluid Alteration - 2 Gram sodium, low fat and low cholesterol. The POS also recorded the resident received the following diuretic medications (medications used to alleviate excess body fluid): [MEDICATION NAME] 20 mg (milligrams) every A.M., [MEDICATION NAME] 80 mg every evening, and [MEDICATION NAME] 50 mg every A.M. Review of the initial dietician's report dated 2/16/12 recorded the resident's weight stable at 148 pounds due to cardiovascular status but listed the resident's ideal body weight of 110 pounds. The revised care plan dated 3/27/12 recorded the resident had a nutritional problem related to [MEDICAL CONDITION], and [MEDICAL CONDITION], and directed staff to: administer medications as ordered, monitor/record intake at each meal/weigh daily and provide a calm, quiet setting and adequate eating time at meals. Review of the clinical record revealed the following weights: 2/15/12=141 lbs. (pounds), 2/27/12=146 lbs., 3/3/12=141 lbs, 3/5/12=134 lbs. The electronic recorded weight of 134 pounds on 3/5/12 represented a 4.96 percent weight loss from 2/15/12 to 3/5/12. The clinical record however, lacked a physician's orders [REDACTED]. Review of the monthly Nutritional Risk meeting notes dated 3/22/12, lacked mention of this resident at risk. Review of laboratory results dated [DATE], indicated the resident's [MEDICATION NAME] level (amount of protein stored in the blood) low at 2.6 milligrams/deciliter (mg/dcl). The reference range 3.2 mg/dcl-4.7 mg/dcl. The resident's clinical record and care plan lacked any additional documentation outlining the resident's weight loss and/or interventions to treat the resident's low protein stores. Continued review of the weight record revealed additional weight loss: 3/7/12=131 lbs., 3/11/12=124 lbs., 3/15/12=131 lbs., 3/21/12=130 lbs., 4/3/12=129 lbs., 4/4/12=111.8 lbs., 4/14/12=111.8 lbs., 4/15/12=111 lbs. From 3/7/12 the resident weighed 131 lbs. and on 4/15/12 the resident weighed 111 lbs which constituted a further weight loss of 15.25 percent which equaled a severe weight loss. Overall, from 2/15/12 to 4/15/12, (2 months) the resident had a 21.27 percent severe weight loss. The nurses progress notes dated 4/10/12 timed 2:53 P.M. recorded: "Weight Warning value 111.8 pounds,- resident has [MEDICAL CONDITION] secondary to [MEDICAL CONDITION] and is taking [MEDICATION NAME] and [MEDICATION NAME], weights are likely to be labile but do need continued monitoring." Review of the daily intake record revealed the resident consumed approximately 70 percent of at least one meal a day usually supper and less than 25 percent of food at breakfast and lunch. Continued review on 4/16/12 at 4:00 P.M. revealed the clinical record lacked physician's progress notes, or dietary notes to identify any interventions to control the resident's weight loss. On 4/12/12 at 2.00 P.M. observation revealed the resident seated in a recliner in his/her room, hair dry, skin dry, alert to verbal, slow to respond, and dentures on the night stand. On 4/16/12 at 8:10 A.M. observation revealed the resident's breakfast room tray on bedside table across the room, observation at that time revealed the resident consumed zero percent of the scrambled eggs, toast and oatmeal served. The resident did consume a cup of coffee. On 4/17/12 at 12:30 P.M. observation revealed the resident remained in his/her recliner in room, ate only a few bites for lunch of the beef served with green beans and potatoes, sips of water and coffee. On 4/17/12 at 11:30 A.M. resident remained in room, in recliner, increased alertness this A.M., sternum/ribs showing, dry hair, and sunken eyes. On 4/17/12 at 5:15 P.M. observation revealed the resident in the main dining room. The staff served the resident skinless chicken breast, sliced carrots, 1 slice bread, butter, ? pint milk, and 1 cup coffee and one slice of pineapple upside down cake. On 4/17/12 at 6:00 P.M. observation revealed the resident's chicken was cut, however the resident did not eat anything. The resident consumed only three bites of cake and cup of coffee. Staff was not observed offering substitutes, cueing or providing encouragement to eat to the resident during meals. During an interview on 4/16/12 at 4:30 P.M. the resident stated, " I just don't have an appetite." The resident stated his/her weight at 110 pounds and stated that he/she weighed 130 pounds most of his/her life and "that's where I feel the best." On 4/17/12 at 11:30 A.M. the resident stated, I was weighed again this morning and I weighed 105 pounds. On 4/16/12 at 2:45 P.M. direct care staff O stated the resident did not eat much for breakfast or lunch this day, only bites, it is not always that way, some days he/she would eat at least half of his/her lunch. On 4/16/12 at 4:10 P.M. direct care staff P stated the resident, sometimes went to the dining room for supper but not all the time. On 4/16/12 at 4:15 P.M. direct care staff Q stated the resident will go down for supper but eats breakfast and lunch in his/her room, if he/she likes it he/she will eat, but otherwise will not. Sometimes he/she will just have a glass of water and a piece of pie. Direct care staff Q added, we offer him/her all types of foods. On 4/16/12 at 11:35 A.M. licensed nursing staff N confirmed the resident's current weigh was 105 pounds and noted that cardiology followed the resident closely. The facility policy titled Nutritional Risk Committee revised September 2009 recorded: The nutrition risk committee will review residents with impaired nutrition or at nutritional risk at least monthly. The facility policy titled Nutrition revised February 2005 recorded: Resident's identified to be at nutritional risk will receive a comprehensive nutritional assessment and monthly follow-up by a dietician or diet technician until no longer determined to be at nutritional risk. The facility policy titled Residents with Impaired Nutrition and Nutritional Risk revised September 2009 recorded: The center would ensure that each resident maintained acceptable parameters of nutritional status such as body weight, protein levels and hydration status unless the residents' clinical condition demonstrated that this was not possible. On 4/16/12 at 400 P.M. Administrative nursing staff B stated the consulting dietician visited the facility every Wednesday but did not know why there were no follow-up notes for this resident. Administrative licensed nursing staff B offered, the dietician's note does indicate the resident's ideal body weight was 110 pounds. Administrative licensed nursing staff B stated, he/she did not know why resident #71 was omitted from the March 2012 Nutritional Risk Meeting notes. The facility failed to provide timely nutritional interventions for this resident that initially lost 4.96 percent, then continued to lose another 15.26 percent of his/her weight without any timely nutritional interventions provided by the facility staff. The clinical record lacked evidence the facility identified, assessed, and provided timely interventions to address the low [MEDICATION NAME] level and weight loss for this resident that was at nutritional risk and overall experienced a 21.27 percent weight loss.