Every finding on record at Heritage Villa Care & Rehab Center

Based on observation, interview, and facility policy review, the facility failed to maintain clean and sanitary food preparation equipment. Specifically, the kitchen ice machine, convection oven, and deep fryer were observed to be dirty. This deficient practice had the potential to affect all residents of the facility who received nutrition from the kitchen.Findings included: A facility policy titled, Sanitation Inspection, revised 08/25/2025, indicated, Policy: Nutritional services employees shall ensure a clean and sanitary work environment; To promote and protect food safety; and, to maintain compliance with Federal, State, and Local regulations governing food sanitation and safety. An observation of the kitchen, on 08/18/2026 at 8:57 AM with the Dietary Manager (DM), revealed the convection oven with burnt food on the bottom shelves of both the upper and the lower levels of the oven. The observation revealed a buildup of a large amount of burnt food on the base of the convection oven and dried seasonings and splattered food on the sides of the convection oven. The observation revealed about 10 potato puffs wedged in the space between the convection oven and the deep fryer. The observation revealed burnt food on the sides of the deep fryer, and food splattered on the bottom and sides of the deep fryer. The observation revealed food drainage along the outside of the deep fryer, from top to bottom, and seasoning and food floating in black oil and piled along the edges of the fryer. An observation of the ice machine at the entrance to the kitchen, on 08/18/2026 at 9:03 AM, revealed a thick, black, moldlike substance in large amounts lining the inside top portion of the machine and tan colored food particles clinging to the inside of the lid. The observation of the thick, black, moldlike substance lining the inside top of the ice machine and the food particles on the ice machine lid was confirmed by the DM. During an interview on 08/18/2026 at 9:10 AM, the DM stated the ice machine in the kitchen should be deep cleaned monthly, and the exterior should be wiped daily by the evening cook who was assigned to the task. The DM stated that she did not have documentation of those tasks being completed. On 08/18/2026 at 9:13 AM the DM stated the inside of the ice machine located by the kitchen door was cleaned weekly by the evening cook. The DM stated that it was the responsibility of the maintenance department to thoroughly clean both ice machines. During a concurrent observation and interviews on 08/19/2026 at 9:41 AM, the DM stated there was burnt food on the bottom of both sections of the convection oven and hardened dried liquid along the entire length of the convection oven. The DM stated the potato puffs remained between the convection oven and deep fryer, the black oil remained and burnt food particles remained in and around the top surface of the deep fryer. The DM stated the food residue and seasonings remained attached to the sides of the deep fryer. The DM stated it was the responsibility of the evening cook to clean the equipment due to the evening tour not being as hectic as the morning tour. The DM stated they were unaware of the date of the last cleaning of either piece of equipment, and there was no signature log of when the equipment was cleaned. [NAME] #2 stated that the kitchen staff usually waited on the maintenance department staff to clean the oven and deep fryer due to the oven and fryer being connected to gas lines. [NAME] #2 stated that she wiped the front of the convection oven but had not cleaned it in a while due to it being used constantly during the morning shift. During an interview on 08/20/2026 at 8:40 AM, [NAME] #1 stated that she was responsible for cleaning some of the equipment in the kitchen such as the convection oven, the deep fryer, and the ice machine. [NAME] #1 stated that she should be cleaning the equipment weekly but sometimes she did not due to being busy. [NAME] #1 stated that the ice machine should be deep cleaned weekly, but some weeks she did not get to clean it. [NAME] #1 stated that the last time it was cleaned was on 08/10/2026. [NAME] #1 stated that she wiped the doors of the convection oven weekly, it was scheduled to be deep cleaned once a month, and the last time that was done was on 08/12/2026. During an interview on 08/20/2026 at 1:28 PM, the Maintenance Supervisor (MS) stated that he did a monthly cleaning of all ice machines when he replaced the filters. The MS stated that there was no way to document when the equipment was cleaned, and he simply wrote the date the filter was installed to remind him when it was due again. The MS stated that he assisted with shutting off gas lines when the dietary staff needed to clean the convection oven and deep fryer, and he had not been asked to do that in at least a month. During an interview on 08/20/2026 at 3:58 PM, the Director of Nursing stated that it was her expectation that cleanliness and infection control were followed as per the facility policy, especially in the kitchen. During an interview on 08/21/2026 at 12:00 PM, the Administrator stated that it was her expectation that the staff were following facility policies and procedures regarding equipment care, sanitation, and maintenance.

Based on interview, record review, and facility document and policy review, the facility failed to ensure that a resident's Power of Attorney (POA) was notified of medication changes for 1 (Resident #2) of 2 residents reviewed for hospice services. Findings included: The facility policy titled, Notification of Change in Condition, revised 01/20/2026, indicated, The Attending Physician/Physician Extender (Nurse Practitioner, Physician Assistant, or Clinical Nurse Specialist) and the Resident Representative will be notified of a Change in a Resident's Condition, according to Standards of Practice and Federal and/or State Regulations. The policy also indicated, PROCEDURE: 1. Guideline for Notification of Physician/Resident Representative (not all inclusive): - Significant Change in Medical or Cognitive baseline- Accident/lncident- Abnormal Laboratory Results in conjunction with a change in condition- Significant weight loss/gain as per RAI [Resident Assessment Instrument] guidelines or provider specific orders- Refusal to take Prescribed Medications- Missing Resident. A facility document titled Nursing Facility Hospice Service Agreement (single patient), dated 06/30/2026, indicated, Any changes in the Plan of Care must be discussed with the Patient or his or her representative and the Facility's representatives and must be approved by the Hospice before being implemented. The agreement also indicated, Hospice acknowledges and agrees that in accordance with the Plan of Care and the Medicare hospice conditions of participation, Hospice assumes responsibility for professional management, including, but not limited to, the planning, coordinating and prescribing, of the hospice services provided to and for determining the appropriate course of hospice care for Patient, including the determination to change the level of services provided. Resident #2's admission Record indicated the facility admitted the resident on 12/24/2025. According to the admission Record, the resident had a medical history that included diagnoses of senile degeneration of the brain (a term used to describe dementia and its accompanying severe mental and physical decline). The admission Record indicated that POA #7 was the resident's Durable Power of Attorney (a trusted individual named by the resident to manage finances, property, medical, or legal matters, if the resident became unable to do so) and Responsible Party. A significant change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/01/2026, revealed Resident #2 had severe impairment in cognitive skills for daily decision-making and had short-term and long-term memory problems per a Staff Assessment of Mental Status (SAMS). The MDS indicated Resident #2 had mild depression. The MDS indicated Resident #2 was taking antidepressant, anticoagulant, opioid, antiplatelet, hypoglycemic, and anticonvulsant medications. The MDS indicated Resident #2 was receiving hospice services. Resident #2's Care Plan Report included a focus area, initiated 06/30/2026, that indicated the resident had a terminal prognosis related to senile degeneration of the brain, not elsewhere classified, and had been admitted to hospice care. Resident #2's Hospice Physician Orders, dated 07/22/2026 at 10:20 AM, indicated the following medications were to be discontinued Per PT [patient] no longer taking: - celecoxib, an NSAID (non-steroidal anti-inflammatory drug) 200 milligrams (mg) for pain/inflammation;- donepezil, a cholinesterase inhibitor, 10 mg for dementia; - duloxetine, a SSNRI (selective serotonin and norepinephrine reuptake inhibitor) antidepressant, 60 mg for neuropathy and depression; - isosorbide mononitrate, an antianginal agent, extended release (ER) 30 mg for angina/heart disease;- levothyroxine, a thyroid drug, 75 micrograms (mcg) for hypothyroidism;- memantine, a central nervous system agent, 10 mg for dementia;- mesalamine, an anti-inflammatory medication, ER 500 mg for ulcerative colitis; and - ranolazine, an antianginal agent, ER 500 mg for chronic angina. Resident #2's Medication Administration Record [MAR], dated 07/2026, revealed the celecoxib, donepezil, duloxetine, isosorbide mononitrate, levothyroxine, memantine, mesalamine, and ranolazine were discontinued from the resident's medication regimen. Resident #2's Order Summary Report contained an order, dated 08/18/2026, for Lorazepam Gel [an antianxiety medication] Apply to Neck/wrists topically every 4 hours as needed for Anxiety/agitation for 14 Days. Resident #2's Client Coordination Note Report dated 08/17/2026, indicated the compounding pharmacy would be able to fill the Lorazepam gel prescription the morning of 08/18/2026. Resident #2's MAR, dated 08/2026, revealed the resident received as needed (PRN) Lorazepam gel on 08/19/2026.Resident #2's Progress Notes revealed no indication that the resident's POA, POA #7, was notified of the medication changes made on 07/22/2026 or about the Lorazepam gel ordered on 08/17/2026. Resident #2's Hospice Notes, dated 06/30/2026 through 08/19/2026, revealed no notes that POA #7 was notified of the medication changes made on 07/22/2026 or about the Lorazepam gel ordered on 08/17/2026. During a telephone interview on 08/20/2026 at 3:45 PM, POA #7 stated no one from the facility or hospice had called them about the medication changes made on 07/22/2026 nor about the Lorazepam gel ordered 08/17/2026. During an interview on 08/20/2026 at 10:10 PM, Licensed Practical Nurse (LPN) #14 stated that medication changes had to be cleared by the resident, their POA or representative, and the physician. LPN #14 stated if the resident were on hospice, any changes would also have to be relayed to the hospice nurse. LPN #14 stated that if hospice made any changes to resident medications, the hospice nurse should contact the resident POAs or representatives and notify them of the changes. LPN #14 reviewed the resident's physician's orders and confirmed that medications, including the resident's antidepressant, had been discontinued on 07/22/2026. During an interview on 08/20/2026 at 11:14 PM, LPN #3 stated that if hospice made changes to resident medications, she would ask if she needed to contact the resident's POA or representative or if the hospice nurse had already informed them of the changes. During an interview on 08/21/2026 at 9:47 AM, the Hospice Registered Nurse (Hospice RN) stated that medications could be discontinued through the hospice physician and the facility nurses, and the resident or their family would be notified of any changes. The Hospice RN stated that if the changes were initiated by hospice, then the hospice nurse should call and notify the family. The Hospice RN stated that if a resident on hospice stopped taking their medications and no adverse reactions were noted from the refusals, the medications would be discontinued. The Hospice RN stated Resident #2 had been refusing medications and there had been no adverse reactions noted, so the medication was discontinued in July 2026. The Hospice RN stated the facility staff had reported increased agitation and further refusals of care from Resident #2, and since the resident was refusing their oral medications, the Lorazepam Gel was ordered to help the resident. The Hospice RN stated that since the changes made on 07/22/2026 as well as the changes made on 08/17/2026 were made by hospice she should have called Resident #2's POA and notified them of the changes in medications. The Hospice RN stated she would usually call the resident's POA before the changes were finalized in the orders. The Hospice RN stated she forgot to call the resident's POA about the changes in medications. The Hospice RN stated she did not recall if she asked the nursing staff to notify the resident's POA of the medication changes or what specifically she shared when the changes were made. During a telephone interview on 08/21/2026 at 12:45 PM, the Hospice Physician stated Resident #2 had been refusing their medication for some time before he wrote the order to discontinue them. The Hospice Physician stated he expected either the hospice or the facility nurse to notify the resident's POA when medication changes were made and was unsure whether that occurred on 07/22/2026 when the medications were discontinued or when the Lorazepam gel was ordered. During an interview on 08/21/2026 at 2:13 PM, the Administrator (ADM) stated that she expected her staff to follow the facility policy and procedure for notifying families of changes. The ADM stated that if the changes to medications were made by hospice, the hospice nurse should notify the POA and the facility. During an interview on 08/21/2026 at 2:42 PM, the Director of Nursing (DON) stated the hospice providers should notify families of any changes they made to resident medications as they called the families after each visit and updated them on the residents' conditions. The DON stated she had been made aware that that did not occur for the medication changes of Resident #2.

Based on interview, record review, and facility document and policy review, the facility failed to ensure an allegation of staff-to-resident abuse was reported immediately to administration and timely to the State Survey Agency (SSA) for 1 (Resident #93) of 2 residents reviewed for abuse.Findings included: A facility policy titled, Abuse Prevention, revised 10/21/2022, revealed, The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff. The section Definitions revealed, Physical abuse: 1. An employee purposefully beating, striking, wounding, or injuring any consumer. The section Prevention revealed, When an incident of resident abuse is suspected or determined, such incident must be reported to facility management regardless of the time lapse since the incident occurred. An admission Record revealed the facility admitted Resident #93 on 08/08/2025. According to the admission Record, the resident had a medical history that included diagnoses of Parkinson's disease with dyskinesia and dementia. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/30/2026, revealed Resident #93 had a Brief Interview Mental Status (BIMS) score of 3, which revealed the resident had severe cognitive impairment. Resident #93's Care Plan Report included a focus area initiated 09/10/2025 that indicated the resident had a history of behaviors, including verbal and physical aggression related to a diagnosis of frontotemporal dementia. Interventions directed staff to intervene as necessary to protect the rights and safety of others, approach/speak in a calm manner, and remove from the situation and take to an alternate location as needed, initiated 09/10/2025. A facility document titled, Incident Report Form: Initial, submitted to the SSA on 06/22/2026 at 12:42 PM, revealed an allegation of Abuse/Mistreatment involving Certified Medication Technician (CMT) #16 and Resident #93. The Incident Report indicated a staff member reported to the Director of Nursing (DON) that they observed CMT #16 strike Resident #93 in the face. A facility document titled, Re [Regarding]: [Resident #93's name], dated 06/26/2026 and signed by the Administrator (ADM) revealed, On 6/22/2026, [CNA #10's name], CNA, reported to DON that they had observed staff member [CMT #16's name] strike resident [Resident #93's name] in the hallway on 6/21/2026. A witness statement regarding the incident, dated 06/25/2026 and signed by Certified Nurse Aide (CNA) #18, revealed at approximately 6:30 PM, CMT #16 told Resident #93 in a loud, firm voice, This is not your room. The statement revealed CNA #18 went out into the hall and saw CMT #16 use CMT #16's left hand to strike the right side of Resident #93's face. The statement revealed CNA #18 went on break from 7:05 PM to 8:54 PM and did not tell anyone of the incident. The statement revealed at 9:30 PM CNA #18 informed RN #12 that CMT #16 hit Resident #93. A witness statement regarding the incident, dated 06/25/2026 and signed by CNA #10, revealed from about 20 feet away CNA #10 witnessed CMT #16 used CMT #16's right hand to hit Resident #93 on the left cheek. The statement revealed CNA #10 did not tell anyone of the incident at the time as they were too stunned to say anything. The statement revealed later CNA #10 informed Registered Nurse (RN) #12 that CMT #16 hit Resident #93. During an interview on 08/20/2026 at 9:29 AM, CNA #10 stated they were working the memory care unit on 06/21/2026 and around 6:30 PM they heard a commotion in the hallway, they looked out into the hallway, and witnessed CMT #16 slap Resident #93. CNA #10 stated they tried to tell RN #12, the charge nurse on duty, but did not get to talk to them until an hour later. CNA #10 stated when nothing happened they called the DON the following morning. CNA #10 stated they tried to tell RN #12, but RN #12 would not listen. During an interview on 08/20/2026 at 12:49 PM, RN #12 stated they were the charge nurse on duty at the time of the incident that happened on 06/21/2026 at 6:38 PM. RN #12 stated they were not aware of the alleged abuse, and no staff told them of any witnessed or alleged abuse. During an interview on 08/20/2026 at 10:44 PM, CMT #16 stated the night of the incident, Resident #93 went into another resident's room, so CMT #16 and CNA #18 went to get Resident #93 out of the other resident's room. CMT #16 stated CNA #18 was attempting to pull Resident #93's wheelchair while CMT #16 was pushing the resident's wheelchair from behind, when Resident #93 went to hit CNA #18 on the head while CNA #18's head was down. CMT #16 stated they saw Resident #93's arm go back to hit, and CMT #16 blocked the resident's hand with their arm. CMT #16 stated the following morning the DON called CMT #16 and informed them that it was reported that CMT #16 hit Resident #93. CMT #16 stated they told the DON they did not hit Resident #93 but blocked the resident from hitting CNA #18. During an interview on 08/21/2026 at 9:42 AM, the DON stated they received a phone call from CNA #10 on the morning of 06/22/2026, and CNA #10 stated something had happened the night before. The DON stated CNA #10 revealed that from across the hall they saw CMT #16 strike Resident #93. The DON stated CNA #10 was assisting a resident in their room when CNA #10 opened the resident's door and witnessed CMT #16 hit Resident #93. The DON stated CNA #10 then closed the door and went back to assisting the other resident. The DON stated CNA #10 and CNA #18 were written up for failing to report the alleged abuse immediately. The DON stated abuse should be reported immediately to administration and within two hours to the SSA. During an interview on 08/21/2026 at 9:40 AM, the Administrator stated the expectation was that staff would report suspected abuse immediately and abuse would be reported to the SSA within two hours of the allegation.

Based on interview, record review, and facility document and policy review, the facility failed to protect a resident from potential abuse when there was an allegation of staff-to-resident abuse and the alleged staff perpetrator was not removed from the resident's care during the incident investigation for 1 (Resident 93) of 2 residents reviewed for abuse.Findings included: A facility policy titled, Abuse Prevention, revised 10/21/2022, revealed, The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff. The section Definitions revealed, Physical abuse: 1. An employee purposefully beating, striking, wounding, or injuring any consumer. The section Investigation revealed, 1. The facility will initiate at the time of any finding of a potential abuse or neglect an investigation to determine cause an effect and provide protection to any alleged victims to prevent harm during the continuance of the investigation. The section Protection revealed, 1. Any allegation of abuses or neglect, misappropriation or exploitation against any employee must result in his/her immediate suspension to protect the resident. An admission Record revealed the facility admitted Resident #93 on 08/08/2025. According to the admission Record, the resident had a medical history that included diagnoses of Parkinson's disease with dyskinesia and dementia. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/30/2026, revealed Resident #93 had a Brief Interview Mental Status (BIMS) score of 3, which revealed the resident had severe cognitive impairment. Resident #93's Care Plan Report included a focus area initiated 09/10/2025 that indicated the resident had a history of behaviors, including verbal and physical aggression related to a diagnosis of frontotemporal dementia. Interventions directed staff to intervene as necessary to protect the rights and safety of others, approach/speak in a calm manner, and remove from the situation and take to an alternate location as needed, initiated 09/10/2025. A facility document titled, Incident Report Form: Initial, submitted to the SSA on 06/22/2026 at 12:42 PM, revealed an allegation of Abuse/Mistreatment involving Certified Medication Technician (CMT) #16 and Resident #93. The Incident Report indicated a staff member reported to the Director of Nursing (DON) that they observed CMT #16 strike Resident #93 in the face. A facility document titled, Re [Regarding]: [Resident #93's name], dated 06/26/2026 and signed by the Administrator (ADM) revealed, On 6/22/2026, [CNA #10's name], CNA, reported to DON that they had observed staff member [CMT #16's name] strike resident [Resident #93's name] in the hallway on 6/21/2026. During an interview on 08/20/2026 at 9:29 AM, Certified Nurse Aide (CNA) #10 stated they were working the memory care unit on 06/21/2026 and around 6:30 PM they heard a commotion in the hallway, they looked out into the hallway, and witnessed CMT #16 slap Resident #93. During an interview on 08/21/2026 at 9:42 AM, the DON stated they received a phone call from CNA #10 the morning of 06/22/2026, and CNA #10 stated something had happened the night before. The DON stated CNA #10 revealed that they saw CMT #16 strike Resident #93. The DON stated CNA #10 was assisting a different resident in their room when the CNA opened the resident's door and witnessed CMT #16 hit Resident #93. The DON stated CNA #10 then closed the door and went back to assisting the other resident. The DON stated CMT #16 was suspended on 06/22/2026 pending the results of the investigation. During an interview on 08/21/2026 at 5:07 PM, the DON stated the expectation was when staff-to-resident abuse was witnessed, the facility would remove the staff from the resident. The DON stated CNA #10 should have told someone of the abuse against Resident #93 so CMT #16 could have been removed from Resident #93's care to protect the resident from further abuse. During an interview on 08/21/2026 at 5:09 PM, the ADM stated the expectation was the facility would remove the alleged abuser from the resident's care to prevent further abuse.

Based on interview, record review, and review of the Long-Term Care Facility Resident Assessment Instrument Version 3.0 Manual, the facility failed to ensure an accurate assessment was completed for 1 (Resident #9) of 2 residents reviewed for nutrition. Specifically, the facility failed to accurately code Resident #9's Minimum Data Set (MDS) assessment related to weight loss.Findings included: A Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.20.1, dated 10/2025, revealed, The RAI process has multiple regulatory requirements. Federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) require that (1) the assessment accurately reflects the resident's status. The manual also indicated, coding instructions for K300: Weight Loss included, Code 1, yes on physician-prescribed weight-loss regimen: if the resident has experienced a weight loss of 5% [percent] or more in the past 30 days or 10% or more in the last 180 days, and the weight loss planned and pursuant to a physician's order. Code 2, yes, not on a physician-prescribed weight-loss regiment: if the resident has experienced a weight loss of 5% or more in the past 30 days or 10% or more in the last 180 days, and the weight loss was not planned and prescribed by a physician. An admission Record revealed the facility admitted Resident #9 on 09/12/2024. According to the admission Record, Resident #9 had a medical history that included end stage renal disease (ESRD), unspecified protein-calorie malnutrition, anemia in chronic kidney disease, and muscle wasting and atrophy. A significant change MDS, with Assessment Reference Date (ARD) of 07/22/2026, revealed the resident had moderate impairment in cognitive skills for daily decision making and had a short-term and long-term memory problem per a Staff Assessment for Mental Status (SAMS). Per the MDS, there was an acute change in mental status from the resident's baseline. The MDS also revealed that the resident weighed 102 pounds. According to the MDS, for question K300 regarding whether the resident had sustained a weight loss of 5% or more in the last month or 10% or more in the last 6 months, the facility coded 1, indicating Yes, the resident was on a physician-prescribed weight-loss regimen. Resident # 9's Care Plan Report included a focus area initiated 11/11/2024. that indicated Resident #9 had a nutritional problem related to unspecified protein calorie malnutrition, anemia, ESRD on dialysis, and history of fluid and electrolyte imbalances. Interventions directed staff to monitor, record, and report signs and symptoms of malnutrition to the Medical Doctor as needed (initiated 11/11/2024). An Order Summary Report, with active orders dated 08/19/2026, revealed an order for house shake three times a day and Nepro (specialized, high-calorie nutritional supplement) three times a day for supplement with meals. The Order Summary Report did not indicate a physician's order for a prescribed weight-loss plan. During an interview on 08/21/2026 at 11:25 AM, the MDS Coordinator confirmed she had completed section K of the MDS for Resident #9. Initially, she stated she believed that a prescribed weight loss program included prescribed supplements to help improve a resident's weight and stated that Resident #9 was on Nepro, and house shakes three times per day. After reviewing the RAI manual section related to a prescribed weight loss regimen, the MDS Coordinator stated that she did not code the MDS section correctly. During an interview on 08/21/2026 at 11:37 AM, the Dietary Manager (DM) stated a prescribed weight loss program would mean the facility projected the weight loss. The DM stated that Resident #9 did not have an order for a weight loss program. During an interview on 08/21/2026 at 12:34 PM, the Director of Nursing (DON) stated that Resident #9 was not on a prescribed weight loss program, and the MDS assessment was coded inaccurately. During an interview on 08/21/2026 at 2:46 PM, the Administrator stated her expectation was that the MDS Coordinator follow the regulations for coding of the MDS.

Based on interview, record review, and facility document and policy review, the facility failed to assess the nutritional status for 1 (Resident #5) of 2 residents reviewed for nutrition. Findings included: A facility policy titled, Weight Variances, revised 08/09/2023, revealed, All residents who experience significant, insidious and/ or unintentional/unplanned weight loss or gains shall be assessed for nutritional status by [the] Registered Dietician [RD]. The policy also indicated, Weights shall be reviewed by Registered Dietitian for review and assessment. The policy revealed, Residents shall be weighed, and weights reported monthly to the Registered Dietitian. If significant, insidious, or unintentional/unplanned weight variances are identified or, if low body weight or malnutrition is identified, the Registered Dietician may be notified by the Dietary Manager or nursing staff. The Registered Dietician shall assess the resident and submit a request for monitoring and/or intervention. The policy indicated, Residents shall be assessed for progress monthly or as needed by the Registered Dietician and adjustment to care made according to resident progress. A facility document titled, Job Description: Registered Dietician, revised 05/2022, revealed, The Registered Dietician's primary responsibility is completing nutrition assessments for all residents. The job description indicated the Registered Dietician (RD) was responsible for the planning, organizing, developing, and directing the nutritional care of residents in accordance with current federal state, and local standards, guidelines, and regulations that govern the center. An admission Record revealed the facility admitted Resident #5 on 06/12/2024. According to the admission Record, Resident #5 had a medical history that included diagnoses of hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting the right dominant side, gastroesophageal reflux disease (GERD), muscle wasting and atrophy, lack of coordination, benign prostatic hypertrophy (BPH), need for assistance with personal care, anemia, colostomy status, hyperlipidemia, depression, dystonia, polyneuropathy, chronic pain, and cervical disc disorder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Data (ARD) of 06/11/2026, revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated Resident #5 needed setup or clean-up assistance with eating (resident completes the activity), weighed 245 pounds, and had not sustained weight loss. The MDS also revealed that the resident had a Stage IV pressure ulcer that was noted upon admission/reentry. Resident #5's Care Plan Report included a focus area initiated 06/26/2024, that indicated the resident had the potential for a nutritional problem related to morbid obesity, anemia, a history of a pressure ulcer, GERD, and gout. Interventions directed staff to report significant weight loss greater than 5 percent (%) in 1 month, greater than 7.5% in 3 months, or greater than 10% in 6 months to the Medical Doctor (MD) and for the RD to evaluate the resident and make diet change recommendations as needed (initiated 06/26/2024). A Weights and Vitals Summary revealed Resident #5's weight on 06/06/2026 was 244.8 pounds. A Weights and Vitals Summary revealed Resident #5's weight on 07/05/2026 was 232.2 pounds, which reflected a 12.6 pounds, or 5.1% weight loss in one month. There was no documented evidence that an RD assessed the resident's nutritional status after weight loss. During a telephone interview on 08/21/2026 at 9:48 AM, the RD revealed she was not notified of Resident #5's weight loss noted on 07/05/2026. The RD stated that she expected the facility to notify her of significant weight loss. The RD also stated that nutritional assessments should be completed quarterly and since Resident #5 had wounds, she should have completed a nutritional assessment for the resident monthly. The RD revealed that she had not completed a nutritional assessment for Resident #5 since 01/15/2026 and it had been seven months since she had reviewed Resident #5's medical record. During a telephone interview on 08/21/2026 at 3:12 PM, the Medical Director (MD) revealed that he was not notified that Resident #5 had weight loss on 07/05/2026. The MD stated his expectation was for the RD to assess a resident who had a wound once a month and at a minimum, quarterly. During an interview on 08/21/2026 at 12:19 PM, the Director of Nursing (DON) revealed that the RD had not conducted a nutritional assessment for Resident #5 since 01/2026. The DON also revealed that Resident #5 had experienced some weight loss since 07/2026. The DON stated that the facility did not have a process for ensuring the RD was notified of weight loss or wounds and had not notified the RD about Resident #5's weight loss or wounds. The DON confirmed the importance of the RD being involved to assist with interventions and supplements to help prevent weight loss and improve wound healing. During an interview on 08/21/2026 at 2:46 PM, the Administrator stated her expectation was for the RD to follow the policy and procedure of the facility for weight loss, which would include completing a nutritional assessment. The Administrator stated she expected the RD to be notified of significant weight loss.

Based on record review and interview, the facility failed to ensure residents and their representatives were provided with a written notice of transfer prior to transferring to an acute care hospital for 3 (#1, 4, and #7) of 3 sampled residents reviewed for discharges.The DON identified 64 residents had been transferred from the facility to a hospital on and between 02/14/25 and 08/14/25.Findings:A facility policy titled Discharge/Transfer-Involuntary, dated 11/01/18, read in part, If transferred to another health care facility upon order of the physician, a transfer form is completed, and a copy is sent with the resident.1.A progress note for Res #1, created date 03/27/25 at 4:39 p.m., written by the administrator, showed they were called to the facility on [DATE] at 10:55 a.m. by the ADON who reported Res #1 was being aggressive. The note showed Res #1 had been transferred to an acute care hospital on [DATE].On 08/13/25 at 9:30 a.m., the DON was asked what information was sent with a resident when they transferred to a hospital. They described the process for transferring and the forms that went with the resident. They did not mention a written letter of transfer. The DON was asked if Res #1 had received a written notice of transfer when they were transferred to a hospital on [DATE]. The DON stated the facility had not given Res #1 or their representative a written notice of transfer for that transfer.2.A progress note for Res #4, dated 07/25/25 at 11:24 a.m., showed Res #4 had been found with decreased blood oxygen saturation and decreased level of consciousness. The note showed the resident was transferred to an acute care hospital.3.A progress note for Res #7, dated 08/05/25 at 6:01 p.m., showed Res #7 had reported unusual physical discomfort and was found to have difficulty standing. The note showed the resident was transferred to an acute care hospital.On 08/13/25 at 9:50 a.m., the DON was asked if Res #4 or their representative had received a written notice of transfer when the resident was sent to an acute care hospital on [DATE], and if Res #7 or their representative had been given a written notice of transfer when the resident was sent to an acute care hospital on [DATE]. The DON stated there were no written notices of transfer given to any of those individuals.On 08/14/25 at 12:44 a.m. the DON was asked to explain when the facility would give a written notice of transfer to a resident. They explained they had been unaware they were required to give a written notice of transfer to residents or their representatives prior to being transferred to a hospital. They stated they had not been giving those statements at the facility.

Based on record review and interview, the facility failed to ensure a resident received a head-to-toe physical assessment after being found to have an injury of unknown origin for 1 (#3) of 3 sampled residents reviewed for injuries of unknown origin.The administrator identified one resident who was found to have an injury of unknown origin from 03/01/25 through 08/13/25.Findings:An addendum to a final incident report written by the facility administrator, dated 05/15/25, showed the administrator had become aware of Res #3's bruised forehead on 04/12/25, after a family member of the resident showed the bruise to them.On 08/14/25 at 10:35 a.m., the DON was asked for the progress notes related to the bruise found on Res #3's forehead on 04/12/25. They stated they did not know why, but there were no progress notes regarding the resident's bruise. They stated there were no skin assessments for that day in Res #3's medical record. The were asked who the nurse on duty was that day. The DON stated LPN #1 was on duty that day.On 08/14/25 at 10:40 a.m., LPN # 1 was asked if they had been on duty when the bruise on Res #3's head was found. They stated they were on duty on the day the bruise to Res #3's forehead was found. They were asked to describe what they saw and did when the bruise was discovered. They stated they did not recall exactly, but it was one of the resident's family members who pointed out the bruise. LPN #1 was asked if they could describe the bruise. They stated it was about nickel size and looked several days old. They were asked if they had found any other injuries that day. LPN #1 stated they had not assessed the rest of Res #3's body that day. They stated that at that time they were not aware they should have assessed the rest of the body when they discovered a new injury. They were asked where the documentation of the resident's forehead assessment. They stated at that time they had been unaware that they should have documented their assessment so, they had not documented their observations of Res #3 on that day. On 08/14/25 at 12:46 p.m., the DON stated LPN #1 had not followed their training and should have assessed Res #3 to ensure there were no other injuries.

Based on record review and interview, the facility failed to ensure staff announced their presence in a resident's room while the resident was using the bathroom for 1 (#2) of 3 sampled residents reviewed for dignity.The DON reported 77 residents resided at the facility.Findings:An undated facility policy titled Resident Rights, read in part, Prior to entering a resident room, always knock and identify yourself. CNA #1's signature was written on the bottom of the policy document under a statement of acknowledgment and agreement to comply with the policy. CNA #1's signature was dated 10/06/23.An undated facility training document titled Course Results Report showed CNA #1 had completed and passed a training course on resident rights on 02/25/25.A progress note for Res #2, dated 02/25/25 at 6:28 p.m., showed the resident had been angry about something that occurred in their bathroom and the resident threatened to contact the state about whatever had occurred. The note showed the resident repeatedly told staff members to leave them alone before they did so.On 08/14/25 at 7:27 a.m., CNA #1 was asked if they were aware of an incident regarding Res #2 and privacy issues. CNA #1 stated on 02/25/25 there had been an incident where they and two nurse aide students had entered the resident's room without alerting them the students were there. CNA #1 stated they had knocked on the resident's door and entered the room with the students. They stated they had said Hey to the resident and the resident replied back in the same manner. They stated the resident's bathroom door was open, and they went to the door. CNA #1 stated the resident was on the toilet and when they looked up the resident saw all of them and became angry. They stated the resident said they did not want them (the students) to watch them and that they did not want an audience. CNA #1 stated they repeatedly apologized to the resident and sent the students from the room. They stated the resident remained upset and angry about the incident the rest of the day. CNA #1 was asked their thought on how the resident would have felt about the incident. CNA #1 stated if they were in a nursing home they would be ok with the students being there. They stated at the time they thought they had provided the resident with privacy and treated them with dignity, but afterward they rethought about what had occurred. They stated they now know they did not provide the resident with privacy and had not treated the resident in a dignified manner.On 08/14/25 at 8:42 a.m., the DON was asked to describe the incident that had occurred regarding Res #2 and CNA #1 on 02/25/25. The DON stated CNA #1 had entered the resident's room without informing the resident who was coming into the room. They stated the resident was on the toilet at the time and was upset the CNA and students had seen them on the toilet. They then stated the nurse aides had been trained upon hire and during the year about resident rights. They had been instructed to knock on a resident's door and announce themselves before entering. The DON stated they had been told by CNA #1 they had entered Res #2's room without telling them the students were coming into the room. They stated CNA #1 and the students should have informed the resident they were all entering the room.

Based on record review and interview, the facility failed to ensure a thorough investigation was completed following the discovery of an injury of unknown origin for 1 (#3) of 3 sampled residents reviewed for injuries of unknown origin.The administrator identified one resident with an injury of unknown in the past six months.Findings:Res #3's progress notes were reviewed for the period 04/01/25 through 04/31/25. The review showed no documentation of a bruise having been found on Res #3.A skin assessment for Res #3, dated 04/11/25, conducted by LPN #2, showed the resident did not have a bruise on their forehead at that time.An undated incident report showed Res #3 had been found to have a bruise on their forehead and the injury was of an unknown origin. A time stamp on the incident report showed the Oklahoma State Department of Health had received the incident report on 04/12/25.A facility policy titled Abuse, Neglect, and Exploitation, dated 04/29/25, read in part, The facility will initiate an investigation at the time of any finding of potential abuse or neglect to determine cause and effect and protection to any alleged victims to prevent harm during the continuance of the investigation.On 08/13/25 at 1:38 p.m., the administrator was asked about their investigation of Res #3's bruised forehead discovered on 04/12/25. They stated they could not interview residents in the case of Res #3 as they lived in a memory care unit. They stated they did interview staff, and they had written statements from two hospice employees that had worked with Res #3 and the facility nurse (LPN#1) who was on duty when the bruise was found. They were asked if they had spoken with any other facility staff who worked with the resident. They stated they had talked to some staff members, but had not documented any of those interviews. They stated they should have documented their investigation. They were asked if they had discovered when or how the resident's forehead was bruised. They stated they had not discovered what had occurred or when.On 08/14/25 at 11:24 a.m., LPN #2 was asked if they had worked with Res #3 around the time the resident had been found to have a bruised forehead. They stated they had, and they had performed a head-to-toe skin assessment of Res #3 on 04/11/25. They stated they did not observe any injury to the resident's forehead on that date. LPN #2 was asked if they had been interviewed about Res #3's bruised forehead. They stated no one had spoken to them about it. They were asked if the administrator or DON had talked to them about the injury after it was found. They stated they had not talked to them about it.On 08/14/25 at 12:41 a.m., the DON was asked if the facility had discovered what had happened to Res #3 that caused the bruise. They stated they had not. The DON stated they had not conducted a thorough investigation and should have interviewed and documented more interviews with the facility staff.

Based on record review and interview, the facility failed to ensure a resident received medications as prescribed by a nurse practitioner for 1 (#1) of 3 sampled residents reviewed for unnecessary medications.The DON identified 77 residents were prescribed and administered medications in the facility.Findings:A facility policy titled Physician Orders, dated 09/28/22, read in part, To provide guidance and ensure Physician Orders are transcribed and implemented in accordance with Professional Standards, State and Federal Guideline, .Physician orders shall be provided by Licensed Practitioners (Physicians, Nurse Practitioners, and Physician's Assistants) authorized to prescribe Orders.A medication order written by NP#1, dated 03/20/25, showed Res #1's Seroquel (an antipsychotic medication) order was to be decreased to 25mg at bedtime and Trazadone (an antidepressant medication) 50mg at bedtime was to be started as a new medicine for the resident.A March 2025 MAR for Res #1 showed on 03/20/25, 03/21/25, and 03/22/25 the resident had been administered Seroquel 50mg once daily at bedtime although the medication was ordered to be reduced to 25mg at bedtime on 03/20/25 by NP #1. The MAR also did not have the medication Trazadone 50mg added to it although the medication had been ordered by NP #1 on 03/20/25. This resulted in Res #1 not receiving doses of the Trazadone on 03/20/25, 03/21/25, and 03/22/25.On 08/13/25 at 11:23 a.m., the DON was asked about Res #1's order for Seroquel that was prescribed for dementia. The DON stated they had an order to decrease the medication from 50mg to 25mg from a nurse practitioner, dated 03/20/25. They stated the resident arrived with that order and they intended to wean them off the medication. They stated they were off when the order came in, but the ADON was on duty.On 08/13/25 at 11:33 a.m., the DON was asked why Res #1's current MAR showed the resident had continued to receive Seroquel 50mg at bedtime when NP #1 had ordered it to be reduced to 25mg at bedtime. The DON stated that prior to taking some time off they had instructed the ADON to hold off implementing any psychotropic medications (medications use to treat various mental health disorders) while they were gone. They were asked why Trazadone 50mg at bedtime was not added to the resident's medication regimen when it had been ordered by NP#1. They stated they told the ADON they would take care of those orders when they returned. They stated by the time they had returned from their time off, Res #1 had been discharged from the facility.On 08/13/25 at 11:41 a.m., the ADON was asked why they had not implemented the medication orders from NP #1 for Res #1 on 03/20/35. The ADON stated they were told by the DON not to implement psychotropic medications while they were off work. They stated they put those in a folder for the DON to take care of when they returned. On 08/14/25 at 12:37 p.m., the DON stated they felt it was probably not in the best interest of the resident to hold those orders until they had returned from their time off.

Based on record review and interview, the facility failed to ensure a certified nurse aide did not attempt to transfer a resident from a bed to a wheelchair by themselves for a resident that required a two person lift for one (#16) of three sampled residents reviewed for falls. The DON stated there were 19 residents at the facility that required two staff members for transfers. Findings: A facility policy titled Fall Management, read in part, To provide an environment that remains as free of accident hazards as possible. The Facility will complete a Morse Fall Scale Evaluation on Residents to determine who are at risk for falling and to develop appropriate interventions to provide supervision and assistive devices to prevent to minimize further Falls and/or reduce injuries. Resident #16 had diagnoses which included hemiplegia and hemiparesis. A care plan intervention, dated 08/05/24, documented the resident required the assistance of two staff members when transferred. A quarterly MDS assessment, dated 10/11/24, documented the resident was dependent on staff for tranfers between their bed and a chair. A care plan intervention, dated 10/21/24, documented the resident required a mechanical lift for all transfers. An incident note, dated 12/16/24 at 7:30 p.m., documented CNA #1 had assisted the resident to transfer from a bed to a wheelchair and the resident's legs gave out and they had to be lowered to the floor. A nurses note, dated 12/18/24 at 10:45 a.m., documented Resident #16 had been seen by a physician and complained of left ankle pain and the ankle was swollen. The note further documented an order for an x-ray of the ankle. A nurses note, dated 12/20/24 at 1:04 p.m., documented the results of Resident #16's ankle x-ray was sent to the physician. A risk note, dated 12/23/24 at 3:46 p.m., documented interdisciplinary team met to discuss Resident #16's recent fall that had resulted in an ankle fracture. On 01/14/25 at 11:22 a.m., RN #1 was interviewed via telephone. They stated when Resident #16 fell on [DATE], CNA #1 attempted to transfer the resident from their bed to a wheelchair without assistance of other staff. RN #1 stated the resident required a two person assist with tranfers. On 01/14/25 at 11:27 a.m., the DON stated Resident #16 was not suppose to be transferred by one person. They stated CNA #1 needed to be educated on how to find the information on how to transfer particular residents. They stated the CNA had not followed facility policy on transferring residents.

Based on record review and interview, the facility failed to ensure a discharge MDS assessment was transmitted in the required time frame for one (#76) of 27 sampled residents reviewed for MDS assessments. The administrator stated 82 residents resided at the facility at the time of entry. Findings: A facility policy titled MDS 3.0, dated 04/25/19, read in part, The Minimum Data Set (MDS) is a standardized comprehensive assessment of all residents in Medicare or Medicaid certified facilities mandated by federal law (P.L.100-203) to be completed and electronically transmitted to CMS in compliance with the guidelines provided in the MDS 3.0 RAI User's Manual. An admission record found in the electronic health record of Resident #76 documented the resident was admitted to the facility on [DATE]. A minimum data set discharge reporting form, dated 09/20/24, documented Resident #76 discharged from the facility on 09/20/24 and was not anticipated to return. A review of Resident #76's electronic health record revealed a discharge MDS was not transmitted in the required time frame. On 01/13/25 at 3:41 p.m., MDS coordinator #1 stated the discharge MDS for Resident #76 was transmitted late. They stated it had been transmitted on 01/11/25. They stated they believed they made an incorrect selection on the electronic form that gave the choice to sent or not send the document to CMS. They stated they discovered the error when they received a report from a regional employee and it documented the discharge record had not been submitted. They stated they also ran that particular report monthly and did so in December 2024, but did not see the error on that or previous reports.

Based on record review and interview, the facility failed to ensure involuntary movement assessments were completed for a resident receiving an antipsychotic medication for one (#31) of five sampled residents reviewed for unnecessary medications. The DON reported eight residents received antipsychotic medications. Findings: Resident #31 had diagnoses which included major depressive disorder and repeated falls. A care plan intervention, initiated 04/27/23, read in part, EPS: Assess for EPS, TD, psuedoparkinsonism. A quarterly assessment, dated 10/31/24, documented Resident #31 routinely received an antipsychotic medication. A physician order, dated 12/12/24, documented the resident was to receive aripiprazole (an antipsychotic medication) 2.5 mg by mouth every day. On 01/13/25 at 11:48 a.m., the DON stated they did not complete involuntary movement assessments for residents receiving antipsychotic medications.

Based on observation, record review, and interview, the facility failed to ensure a resident was provided education on the use of bed rails and given the option to consent or decline the use of bed rails prior to their attachment to the bed for one (#72) four sampled residents reviewed for accident hazards. The DON identified 16 residents had bed rails attached to their assigned beds. Findings: Resident #72 had diagnoses which included muscle wasting and atrophy. A care plan focus for ADL self-care deficit, dated 06/07/24, documented an intervention on 09/15/24 was bilateral U rails were to be used to assist the resident with positioning. A Safety Device Evaluation Tool, dated 10/11/24, documented Resident #72 had an assist bar attached to their bed. A MDS five day assessment, dated 11/28/24, documented the resident was cognitively intact. On 01/12/25 at 10:03 a.m., Resident #72 was observed in bed. The bed was observed to have grab bar type rails (referred to as U rails) attached to each side of their bed about shoulder level. The resident stated they did not recall anyone discussing the pros or cons of using the rails and did not recall giving consent to use them. On 01/13/25 at 12:57 p.m., the DON stated they did not have documentation the resident had been educated on the dangers associated with the use of bed rails and did not have documentation the resident had given consent for the use of bed rails. They stated they would need to do better in this area and would go over it with the QAPI team. On 01/13/25 at 1:56 p.m., the regional nurse stated they did not have a facility policy regarding the use of bed rails, but they used the posted CMS guidelines for the use of assistive devices.

Based on observation, record review, and interview, the facility failed to ensure physician orders were followed for insulin administration for one (#31) of one sampled resident reviewed for insulin administration. The DON reported 19 residents received insulin. Findings: Resident #31 had diagnoses which included diabetes mellitus and major depressive disorder. A physician order, dated 04/10/23, documented Resident #31 was to receive insulin aspart per a sliding scale. For a blood sugar between 150 and 175 the resident was to receive one unit of insulin. For a blood sugar between 176 and 200 the resident was to receive two units of insulin. For a blood sugar of 201 to 225 they were to receive three units of insulin. On 01/13/25 at 11:07 a.m., LPN #1 was observed performing a finger stick blood sugar on Resident #31. The residents blood sugar was 213 milligrams per deciliter. LPN # was then observed to inject two units of insulin subcutaneously into Resident #31's abdomen. On 01/13/25 at 11:20 a.m., LPN #1 stated according to the sliding scale order, the resident should have received three units of insulin, but they had only administered two units of insulin. On 01/13/25 at 11:40 a.m., the DON stated physician orders should be followed.

Based on record review and interview, the facility failed to: a. ensure a physician provided a reason for disagreeing with a pharmacy GDR for one (#28); b. ensure a resident who received psychotropic medications received a gradual dose reduction in a timely manner for one (#15); and c. a prn psychotropic medication was limited to 14 days and had an end date for one (#3) of five sampled residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents report, dated 09/18/23, documented 51 residents received psychoactive medications. Findings: The Psychotropic Management Guidelines policy, dated 07/26/23, read in part, .Residents who use Psychotropic Drugs receive a Gradual Dose Reduction (GDR) and Behavioral Interventions, unless clinically contraindicated, to discontinue these Drugs .PRN Orders Psychotropic Drugs are limited to 14 days and should not be renewed unless the Attending Physician/Prescriber evaluated the Resident for appropriateness of that Medication .Prescribers should document their rationale in the Resident's Medical Record and indicate the duration of the PRN Order .Facility should have the Physician's documentation justification in the Medical Record for dosages that exceed the recommended ranges for Psychotropic Drugs or when the Physician deems a GDR with rationale would be inappropriate . 1. Resident #28 had diagnoses which included depressive disorder, recurrent, severe with psychotic symptoms and mood disorder. A Physician Order, dated 06/24/21, documented Resident #28 was to receive Seroquel 300mg tablet one by mouth at bedtime for depression. A Physician Order, dated 10/31/22, documented Resident #28 was to receive Seroquel 50 mg tablet one by mouth in the morning related to major depressive disorder, recurrent, severe with psychotic symptoms and unspecified mood disorder. A Physician Order dated 06/15/23, documented behavior monitoring related to antidepressant, antipsychotic and antianxiety medication every shift. It documented the targeted behavior was agitated. A Pharmacy Note to Attending Physician/Prescriber, dated 07/14/23, documented Resident #28 was currently receiving Seroquel 50 mg in the morning and 300mg at bedtime for depression. It documented please reduce Seroquel to 50mg in the morning and 200mg at bedtime for depression. The note was signed by the Pharmacist. The note documented Physician #1 gave a response of disagreewith no clinical rationale given on 07/18/23. The August 2023 TAR documented Resident #28 did not experience the targeted behavior of agitated for the entire month. The September 2023 TAR documented Resident #28 experienced the targeted behavior of agitated one time for the month. On 09/21/23 at 9:45 a.m., LPN #3 was asked the policy for residents receiving antipsychotic medications. They stated, I don't know. On 09/21/23 at 9:46 a.m., LPN #3 was asked to identify any antipsychotic medication Resident #28 was receiving. They stated, Seroquel. On 09/21/23 at 9:47 a.m., LPN #3 was asked what behaviors, if any, the resident experienced. They stated the resident was often withdrawn and got in moods. They stated the resident wouldn't want to get up or leave the room. On 09/21/23 at 9:48 a.m., LPN #3 was asked when the last time the resident experienced these behaviors. They stated approximately two months ago when they were discussing hospice services. They stated since then, the resident had done well and had not had any negative behaviors. On 09/21/23 at 10:00 a.m., the DON was asked the policy for residents receiving antipsychotic medications, They stated the resident had to have a qualifying diagnoses. They stated a mental health provider would also see the resident. On 09/21/23 at 10:02 a.m., the DON was asked to identify any antipsychotic medication Resident #28 was receiving. They stated, Seroquel. On 09/21/23 at 10:04 a.m., the DON was asked what behaviors, if any, did the resident experience. They stated, Agitation. They were asked how many times the resident experienced the behavior in September 2023. They stated, One. On 09/21/23 at 10:06 a.m., they were asked how many times the resident experienced the behavior in August 2023. They stated, Zero. On 09/21/23 at 10:08 a.m., the DON was asked who was responsible for following up when the pharmacist requested a GDR. They stated, Myself. On 09/21/23 at 10:09 a.m., the DON was asked to explain the process. They stated the facility had two providers which they would discuss current behaviors with if they were exhibiting any. They stated GDRs would be requested to evaluate residents for possible reductions. On 09/21/23 at 10:10 a.m., the DON was asked to review Resident #28's GDR for Seroquel on 07/14/23 and identify the physician's response. They stated, Disagree, no rationale given. They were asked to identify what physician signed it. They stated Physician #1. 48344 2. Resident #3 had diagnoses which included anxiety disorder, restlessness, and agitation. A Physician's order, dated 06/21/23, documented lorazepam oral concentrate 2 mg/ml, give 0.25 ml by mouth every 6 hours as needed for anxiety/agitation. Resident #3's quarterly resident assessment, dated 08/09/23, documented the Resident was cognitively impaired and received psychotropic medication during the review period. A pharmacist MRR, dated 08/09/23, read in part, Please note CMS guidelines implemented in November 2017 advise against the use of an as needed or PRN psychotropic agents (i.e. anti-psychotics, anxiolytics .) for longer than 14 consecutive days without physician evaluation and justification for continued use .Our patient has the following such order: Give 0.25 ml by mouth every 6 hours as needed for anxiety/agitation .please consider and check one of the following . A physician's response, dated 08/15/23, documented disagree and read in part, .Resident is receiving hospice services and is terminal. Hospice team reviews every 14 to 15 days or more for appropriateness. Physician will review as appropriate and therapy should continue as ordered and renewed every 30 days .CMS does not provide an exception for hospice . On 09/21/23 at 7:47 a.m., the DON was asked the policy for residents who received prn psychotropics. They stated prn psychotropics should be prescribed for 14 days. On 09/21/23 at 7:49 a.m., the DON was asked if the lorazepam oral Concentrate 2 mg/ml, give 0.25 ml by mouth every 6 hours as needed for anxiety/agitation had an end date. The DON stated the ordered did not have an end date. On 09/21/23 at 7:50 a.m., the DON was asked how many times Resident #3 received the prn dose of lorazepam 0.25 ml in July. They stated the Resident received it twice. On 09/21/23 at 7:52 a.m., the DON was asked how many times Resident #3 received the prn dose of lorazepam 0.25 ml in August. They stated the Resident received it two times on the same day. On 09/21/23 at 7:53 a.m., the DON was asked how many times Resident #3 received the prn dose of lorazepam 0.25 ml in September. The DON and the Administrator stated, None. 3. Resident #15 had diagnoses which included generalized anxiety, hallucinations, and depression. A Physician Order, dated 03/04/19, documented buspirone hcl tablet 5 mg give 1 tablet by mouth two times a day for anxiety related to generalized anxiety disorder. Resident #15's annual resident assessment, dated 08/16/23, documented the Resident was cognitively impaired and received psychotropic medication during the review period. There was no documentation that a gradual dose reduction had been attempted for the buspirone hcl tablet 5 mg give 1 tablet by mouth two times a day in the past 12 months. On 09/21/23 at 12:41 p.m., the Administrator stated they were unable to locate a gradual dose reduction for Resident #15's buspirone hcl tablet 5 mg.

Based on observation, record review, and interview, the facility failed to ensure an accurate account of controlled medications was maintained for three (#62, 175, and #176) of three sampled residents reviewed for medication storage. The Resident Census and Conditions of Residents report, dated 09/18/23, documented 73 residents resided in the facility. Findings: A Controlled Substance Disposal policy, dated 04/18, read in parts, Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal and record keeping in the facility in accordance with federal, state and other applicable laws and regulations . On 09/20/23 at 10:04 a.m., CMA #2 was asked what the process was for removing a discontinued controlled medication from circulation. They stated they would pull the narcotic card and the narcotic sheet, take them to the DON, and log them into the double lock narcotic book. The CMA stated together they would drop it in the drop slot so there was always two people with it in the medication room. The discontinued controlled medications were observed to be located under a double locked cabinet that had a slot to drop things into. On 09/20/23 at 10: 35 a.m., the DON was asked what the process was for removing discontinued controlled medications from circulation. They stated, The staff will bring them to me, log it out, put it in the double lock box to be destroyed by myself and the pharmacist. The DON was asked if there were any signatures on the forms when they were put into the lock box. They stated, Yes, the staff who brings it in and myself sign to the correct count and that it was locked up in the box. The DON was asked what the process was to ensure an accurate disposition of controlled medications. They stated the pharmacist came in for their audit once a month. They stated they would sit together and use the count sheet and the medications to make sure the correct amount was there and destroyed. On 09/20/23 at 10:39 a.m., an observation was made with the DON present, of the discontinued controlled medications located under double lock in the medication room. The following medications were observed with no narcotic count sheet present: a. Resident #175's morphine 10 mg/25 ml RX# 224760, count of 18. The DON verified no count sheet present; b. Resident #176's Hydromorphone 4 mg/ml RX#2256415, count of 30. The DON verified no count sheet was present. Hydromorphone 1 mg/ml RX# 2257849, count of 13. The DON verified no count sheet was present. Lorazepam 2 mg/ml RX# 4298269, count of 11. The DON verified no count sheet was present; and c. Resident #62's Hydrocodone 7.5/325 RX#215070, count of 50 tabs. The DON verified no count sheet was present. On 09/20/23 at 10:50 a.m., the DON stated they did not know the named medications were in there. They stated the medications were placed there before they were hired. They stated the facility received pill punch cards now, not bottles. They stated they did not know how the medications go there. They stated they were the only person with access to both keys.

Based on record review and interview, the facility failed to: a. monitor the amount of meals a resident who experienced weight loss consumed for one (#43); and b. provide a physician ordered health shake with breakfast for one (#43) of one sampled resident reviewed for nutrition. The Resident Census and Conditions of Residents report, dated 09/18/23, documented 73 residents resided in the facility. Findings: Resident #43 had diagnoses which included dementia. A Physician Order, dated 10/03/21, documented regular diet, mechanical soft texture, regular consistency with thin liquids. A Significant Change Resident Assessment, dated 07/31/23, documented the resident had severe cognitive impairment, and required supervision, setup help only for the task of eating. The July 2023 Amount of Meal Eaten record documented: a. blanks 48 out of 93 opportunities and b. na 18 out of 93 opportunities. A Nutrition/Dietary Note, dated 08/18/23, documented Resident #43 had experienced a significant weight loss of 11 percent over three months and 16 percent weight loss in six months. It documented a current weight of 151 pounds and the resident was on hospice. It documented the recommendation of health shakes four times a day with meals and at hour of sleep. The August 2023 Amount of Meal Eaten record documented: a. blanks 25 out of 93 opportunities and b. na 22 out of 93 opportunities. The September 2023 Amount of Meal Eaten record documented: a. 10 blanks out of 57 opportunities and b. na 17 out of 57 opportunities. Resident #43's weight summary documented: a. on 07/05/23 152.2 pounds; b. on 07/31/23 152.2 pounds; c. on 08/07/23 151 pounds; and d. on 09/08/23 140.2 pounds. On 09/18/23 at 3:11 p.m., Family Member #1 was asked what type of assistance Resident #43 required from staff. They stated for eating one person. They stated staff did not feed the resident, but did try to encourage the resident to eat. They stated staff did not encourage the resident enough. They stated they had been at the facility during meal service and no one came by and encouraged the resident to eat. They stated it seemed the resident had experienced weight loss but were unsure of how much. On 09/19/23 at 8:24 a.m., CNA #3 delivered a meal tray to Resident #43. They stated the resident's name several times, stated they had breakfast for them, placed the meal tray on the bedside table, turned on the light, and opened the tray. The only liquid observed on the tray was a brown liquid in a tall cup. There was no health shake observed on the tray. On 09/19/23 at 10:24 a.m., after the entire breakfast meal of Resident #43 was observed, CNA #3 was asked if the resident received a health shake with their breakfast. They stated, No. On 09/20/23 at 1:24 p.m., CNA #2 was asked the policy for monitoring residents for weight loss. They stated residents were weighed weekly, or everyday depending on how rapid they were losing weight. On 09/20/23 at 1:25 a.m., CNA #2 was asked if Resident #43 had experienced weight loss. They stated they had. They stated it was hard to get the resident to eat because they really enjoyed snacking. On 09/20/23 at 1:26 p.m. CNA #2 was asked what interventions were in place to prevent weight loss. They stated they were trying to ensure the resident was up for meals and awake. They stated if the resident did not go to the dining room, staff would be present in the room to ensure they ate. They stated the resident rarely refused to go to the dining room. On 09/20/23 at 1:27 p.m., CNA #2 was asked how staff monitored how much of a meal the resident consumed. They stated the aides in the dining room watched residents during the meal. They stated one aide from each hall would chart how much was eaten. On 09/20/23 at 1:28 p.m., CNA #2 was asked where the information was documented. They stated they would document it in the resident's clinical record. On 09/20/23 at 1:40 p.m., LPN #3 was asked if Resident #43 had experienced weight loss. They stated, Yes. They were asked what the resident's risk factors for weight loss were. They stated the resident had a poor appetite and only wanted to eat junk food. They stated another risk factor was the resident stayed in bed. On 09/20/23 at 1:41 p.m., LPN #3 was asked what interventions were in place to prevent weight loss. They stated the resident had an order for health shakes. On 09/20/23 at 1:51 p.m. LPN #3 was asked how staff monitored how much a resident consumed. They stated staff would put the amount in as a task. On 09/20/23 at 1:53 p.m., LPN #3 was asked to review Resident #43's July, August, and September 2023 amount eaten records and identify what the na and the blanks meant. They stated the facility had a high turn over for the Thursday, Friday, Saturday, and Sunday shift and they would not be the best person to ask that question to. They did not know the answer for the blanks and na documented on the Mondays, Tuesdays, and Wednesdays. On 09/20/23 at 2:14 p.m., the DON and Administrator were asked how staff knew how much of a meal a resident consumed. The DON stated staff would document the amount in the electronic record. They stated the CNA or whoever fed them was responsible for documenting it. On 09/20/23 at 2:14 p.m., the DON and Administrator were asked what it meant if the meal intake was blank or had an na. The DON stated either it hadn't been documented for the shift or not applicable if they didn't eat. The DON stated there was a zero option so they did not know what the na was. The Administrator stated it could be if family took the resident out. On 09/20/23 at 2:16 p.m., the DON was asked to review Resident #43's July, August, and September 2023 meal consumption record and was asked how staff would know how much the resident consumed when there were blanks and na documented. They stated, I don't think they would know if nothing is documented. On 09/20/23 at 2:19 p.m., the DON was asked if the resident had experienced weight loss. They stated, Yes. They were asked what risk factors the resident had for weight loss. The DON stated the resident was on hospice and had been sick. The DON stated the resident ate a lot of junk food that the family brought in. The Administrator stated the resident had also had Covid recently and had dementia.

Based on observation, record review, and interview, the facility failed to maintain comfortable air temperatures in resident rooms for two (#3 and #8) of 24 sampled residents reviewed for air temperatures. The Resident Census and Conditions of Residents report, dated 09/18/23, documented 73 residents resided in the facility. Findings: A Homelike Environment policy, dated 02/01/16, read in part, .The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include .Comfortable temperatures . 1. Resident #3 had diagnoses which included paraplegia, depression, and anxiety. A Quarterly Resident Assessment, dated 08/09/23, documented severe cognitive impairment. On 09/18/23 at 3:29 p.m., Resident #3 stated the room was too cold. They stated they hoped the room would be warm enough soon. The resident was observed with a sheet and three blankets on in bed. On 09/19/23 at 8:54 a.m., Resident #3's room temperature was observed to be 66 degrees Fahrenheit. The resident stated it was cold. There were no blankets observed on the resident. On 09/19/23 at 8:56 a.m., staff were observed covering the resident up with two blankets. On 09/18/23 at 4:25 p.m., Resident #3's room temperature was observed to be 70.4 degrees Fahrenheit. 2. Resident #8 had diagnoses which included anxiety disorder. An Admission Resident Assessment, dated 08/11/23, documented Resident #8's cognition was intact. On 09/19/23 at 8:59 a.m., Resident #8 stated they wanted the room to be warmer. The ambient air temperature was observed to be 63.6 degrees Fahrenheit. They stated they had been at the facility a month and it had been cold. They stated they wore a sweater and used three blankets, but it wasn't enough. On 09/19/23 at 9:10 a.m., the Maintenance Supervisor was asked who was responsible for maintaining the temperatures in the building. They stated, I guess me. On 09/19/23 at 9:11 a.m., the Maintenance Supervisor was asked what was an acceptable temperature range. They stated they tried to stay around 72 degrees when it was hot. The stated the unit was set at 74 because the evenings were cooler now. They stated there was a control for each side of the hall. On 09/19/23 at 9:12 a.m., the Maintenance Supervisor was asked how they ensured the temperature was at an acceptable range in the facility. They stated it was hit and miss. They stated at the end of the hall, it could be an eight to ten degree difference than the beginning of the hall. They stated it was usually warmer at the end of the hall.

On 02/04/19 an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to identify ongoing severe weight loss; notify the Registered Dietician and physician of severe weight loss; and to identify and implement interventions to prevent further severe weight loss. Resident #79 had weight loss every month from (MONTH) through January. The resident had a three month severe weight loss of 8.7% in (MONTH) (YEAR); a three month severe weight loss of 7.9% in (MONTH) (YEAR); and a one month severe weight loss of 6.3%, three month severe weight loss of 11.9%, and a six month severe weight loss of 19.66% in (MONTH) 2019. At 1:10 p.m., the Oklahoma State Department of Health verified the existence of an IJ situation. At 1:12 p.m., the administrator was notified of an IJ situation related to the facilities failure to intervene when a resident experienced severe weight loss. At 3:52 p.m., an acceptable plan of removal was provided. The plan of removal documented: EDUCATION: Provide nursing and dietary staff an inservice (via phone or in person) on ensuring the residents receive their supplements. A 'supplement log' will be made for the staff to document supplement percentages with each meal. The supplements include fortified shakes, mighty shakes, fortified foods, and super cereal. A 'protein powder log' will be made for the dietary staff to document when using protein powder with a resident meal. To be completed by the DON and/or MDS coordinator, RN on 2/4/19 at 10 PM. Provide nursing and dietary staff education (via phone or in person) on the definition of significant weight loss. The MDS triggers at 5%. The facility will intervene at 3%. To be completed by MDS Coordinator, RN on 2/4/19 by 10 PM. An inservice (via phone or in person) will be completed with the nurses on notifying the physician of any significant weight loss after each weekly weight meeting. To be completed by MDS Coordinator, RN and/ or DON on 2/4/19 by 10 PM. The CDM will be inserviced by the MDS coordinator/RN on section K of the MDS per RAI manual. The CDM will be inserviced on section K of the care plan. To be completed by the MDS Coordinator, RN on 2/4/19 by 10PM. The nurses will be inserviced by the MDS coordinator, RN on identifying residents with loss of appetite and change of ADL's. To be completed on 2/4/19 by 10PM. The restorative aide (RA) will be inserviced by the MDS Coordinator, RN of weighing residents accurately. To be completed on 2/4/19 by 10PM. The nursing and dietary staff will be provided an inservice (via phone or in person) on notifying the charge nurse and CDM of any resident with a loss of appetite. To be completed on 2/4/19 by 10PM. IDENTIFY WHO IS AT RISK TODAY FOR WEIGHT LOSS: The facility weighed each resident today by 330 PM. After the weights have been obtained, the MDS Coordinator/RN and /or DON will review each weight. If the weight signifies a weight loss, the family and physician will be contacted. The RN will contact the RD and further interventions will be put into place (supplements, fortified foods/shakes etc). by 10PM INTERVENTIONS FOR RESIDENT, (#79): The RD will be contacted 2/4/19 by the CDM. An RD will be visiting the facility this afternoon to assess the resident. The physician will be notified effective 2/4/19, by 5PM The care plan will be reviewed and revised effective 2/4/19. The immediate jeopardy was removed on 02/04/19 at 10:00 p.m., when all components of the plan of removal were carried out. The deficient practice remained at a pattern of actual harm. Based on observation, interview, and record review, it was determined the facility failed to: ~ monitor resident weights to identify severe weight loss; ~ notify the registered dietitian of a resident's severe weight loss; ~ notify the resident's physician of a resident's severe weight loss; ~ identify and put interventions in place to prevent further weight loss; ~ consistently provide adequate assistance with meals; and ~ consistently provide alternate meals and/or supplements for one (#79) of five sampled residents reviewed for weight loss. Resident #79 had weight loss every month from (MONTH) through January. The resident had a three month severe loss of 8.7% in (MONTH) (YEAR); a three month severe weight loss of 7.9% in (MONTH) (YEAR); and a one month severe weight loss of 6.3%, three month severe weight loss of 11.9%, and a six month severe weight loss of 19.66% in (MONTH) 2019. The administrator identified eleven residents with significant weight loss. Findings: An undated policy on significant weight loss documented: In the event that a resident demonstrates significant weight loss as identified on the Weight Variance Report, the following procedure is followed: 1. Resident is re-weighed under the supervision of a licensed nurse; 2. If re-weight still shows a significant loss, Nursing notifies the Dietary Services Manager or dietitian of weight loss in writing using Condition Change form, Notification of Nutritional Changes form, or Dietary Memo; 3. If the weight loss can be attributed to an identifiable factor, such as initial administration of a diuretic, this is not considered a significant change of status and re-assessment is not necessary. However, the identified cause of weight loss must be documented in both the nursing and dietary progress notes. 4. Onset of significant unplanned weight loss is considered a significant change in status. Therefore, a full assessment, including Comprehensive Resident Assessment, MDS, and RAP's are completed by all disciplines. The plan of care is updated to include the status change; 5. Nursing notifies the physician and family of weight loss and for involvement in the plan of care; 6. Resident is weighed weekly for four weeks. At the end of each week, the resident's plan of care is reviewed and updated as necessary . An undated policy, titled IDENTIFICATION, TREATMENT AND MONITORING OF RESIDENTS AT NUTRITIONAL RISK, documented: Both the Nursing and Dietary departments have specific responsibilities in the identification, treatment and monitoring of residents at nutritional risk. In no other instance is the interdisciplinary approach so vital in providing appropriate care. Risk factors are characteristics that are associated with an increased likelihood of poor nutritional status. They include the presence of various acute or chronic disease [DIAGNOSES REDACTED]. The following are specific indicators of nutritional risk that should be identified and assessed by the health care team: 1. Resident consistently refuses to eat all or the majority of foods from a major food group . 2. Resident routinely refuses to eat 50% or more of two meals and/or supplements per day. 3. Resident experiences a significant unplanned weight gain or loss, greater than or equal to the following: 1 month 5% gain or loss 3 months 7% gain or loss 6 months 10% gain or loss 4. Resident is 10% or more over or under desirable weight . Resident #79 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A care plan, dated 03/12/18, documented, I am at risk for altered nutrition due to not having much of and (sic) appetite at this time .My goal is to try to find foods that I like on the menu, thru my next review date. No interventions were identified for 03/12/18. Updates to the care plan for altered nutrition, dated 04/18/18, included: I don't want cheese on my sandwiches or burgers. I like having a variety of foods to choose from. I like most foods. If I eat less than 50% of my meals, offer me an alternative or a fortified shake. Refer me to the RD upon admit, annually and as needed. Sometimes I want to come out to the dining room and visit during meals, other times I wish to eat in my room. Weigh me per the facility policy. An update to the care plan for altered nutrition, dated 05/10/18, documented, I am on a regular diet. A monthly weight report, dated July, (YEAR), documented the resident weighed 153.6 pounds. A monthly weight report, dated August, (YEAR), documented the resident weighed 147.2 pounds. A nurse's note, dated 8/15/18 at 11:41 a.m., documented the resident's daughter visited the resident daily and had concerns that her mother did not seem to be eating much. A day planner for resident nutrition care and dietary consult report, dated 08/16/18, documented the resident's name was not on the report. This report was used to indicate who needed to be assessed by the Registered Dietician. A dietary progress note, dated 08/20/18 at 10:24 a.m., documented, (Resident's) weight 147#. On a regular diet. Feeds self in the dining room. PO fair to good. Alternate or fortified shake offered if eats less than 50% of meals. No wounds or [MEDICAL CONDITION] .Will refer to RD as needed. The note was signed by the dietary manager. A monthly weight report, dated September, (YEAR), documented the resident weighed 143.2 pounds. A day planner for resident nutrition care and dietary consult report, dated 09/11/18, documented the resident's name was not on the report. A quarterly assessment, dated 09/12/18, documented the resident was moderately impaired cognitively, required extensive assistance with bed mobility, transfer, dressing, toileting, hygiene, and bathing, and required supervision only with eating. The assessment documented the resident weighed 143 pounds and had experienced no weight loss. A dietary progress note, dated 09/12/18 at 6:25 a.m., documented, .Weight 143#. On a regular diet. Feeds self in the dining room. PO fair to good. Alternate or fortified shake offered if eats less that 50% of meals. No wounds or [MEDICAL CONDITION] .Will refer to RD as needed. The note was signed by the dietary manager. A monthly weight report, dated October, (YEAR), documented the resident weighed 140.2 pounds. This represented a three month severe weight loss of 13.4 pounds or 8.7% A significant change assessment, dated 10/02/18, documented the resident was moderately impaired cognitively; required extensive assistance with bed mobility, transfer, dressing, toileting and hygiene; required total assistance with bathing; and required supervision only with eating. The assessment documented the resident weighed 140 pounds and had experienced no weight loss. The resident had a decline in bathing ability. A physician's progress note, dated 10/10/18, documented the resident had weight loss. There were no new interventions documented. A day planner for resident nutrition care and dietary consult report, dated 10/12/18, documented the resident's name was not on the report. A monthly weight report, dated November, (YEAR), documented the resident weighed 137.4 pounds. A physician's progress note, dated 11/07/18, documented the resident had weight loss. There were no new interventions documented. A nurse's note, dated 11/08/18, documented the nurse called the family to let them know the resident had a change in condition and was being moved to the assisted dining table where staff would assist the resident to eat. A day planner for resident nutrition care and dietary consult report, dated 11/09/18, documented the resident's name was not on the report. An update to the care plan for altered nutrition, dated 11/20/18, documented, Crush my medications as needed. A dietary progress note, dated 11/29/18 at 9:52 a.m., documented, weight 137#. On a regular diet. Assisted by staff in the restorative dining area. PO poor to fair. Alternate or fortified shake offered if eats less than 50% of meals. No wounds or [MEDICAL CONDITION] .Will refer to RD as needed. This note was signed by the dietary manager. The (MONTH) (YEAR) Follow Up Question Report which answered the question, What percentage of the meal was eaten?, recorded 80 of 90 opportunities for meal observations. The report documented the resident had refused one meal, was not available for one meal, consumed 0-25% 11 times, consumed 26-50% 29 times, consumed 51-75% 22 times, and consumed 76-100% 16 times. A monthly weight report, dated December, (YEAR), documented the resident weighed 131.8 pounds. This represented a three month severe weight loss of 11.4 pounds or 7.9%. A physician's progress note, dated 12/05/18, documented the resident had weight loss. A nurse's note, dated 12/05/18 at 5:07 p.m., documented the resident was seen by the physician and a new order for a complete blood count, a chem eight, a [MEDICAL CONDITION] stimulating hormone level, and a vitamin B12 level was received. A day planner for resident nutrition care and dietary consult report, dated 12/10/18, documented the resident's name was not on the report. A dietary progress note, dated 12/28/18 at 2:24 p.m., documented, .weight 132# down 5#. On a regular diet. Assisted by staff in the restorative dining area. PO poor to fair. Alternate or fortified shake offered if eats less than 50% of meals. No wounds or [MEDICAL CONDITION] .Will refer to RD as needed. This note was signed by the dietary manager. A lab report, dated 12/30/18, documented the resident had a protein level of 6.0 grams per deciliter which was below normal levels. The reference range for protein levels are 6.4 - 8.9 grams per deciliter. The resident's [MEDICATION NAME] level was 3.6 with a reference range of 3.5 - 5.7. The (MONTH) (YEAR) Follow Up Question Report which answered the question, What percentage of the meal was eaten?, recorded 89 of 93 opportunities for meal observations. The report documented the resident had refused two meals, was NA for two meals, consumed 0-25% 15 times, consumed 26-50% 42 times, consumed 51-75% eight times, and consumed 76-100% 20 times. A monthly weight report, dated January, (YEAR), documented the resident weighed 123.4 pounds. This represented a severe weight loss in one month of 8.4 pounds or 6.3%; a severe weight loss in three months of 16.8 pounds or 11.9%; and a severe weight loss in six months of 30.2 pounds or 19.66%. A quarterly assessment, dated 01/02/19, documented the resident was severely impaired cognitively, required extensive assistance with bed mobility, dressing, eating, hygiene, and bathing. The assessment documented the resident weighed 123 pounds and had experienced no weight loss. The assessment indicated the resident had experienced a decline in her cognition and in her ability to feed herself. A dietary progress note, dated 01/02/19 at 1:30 p.m., documented, .Weight 123# down 7#. On a regular diet. Assisted by staff in the restorative dining area. PO poor to fair. Alternate or fortified shake offered if eats less than 50% of meals. No wounds or [MEDICAL CONDITION] .Will refer to RD as needed. This note was signed by the dietary manager. A physician's progress note, dated 01/09/19, documented the resident had weight loss. There were no new interventions documented. A Diet Type Report, dated 01/27/19, provided by the facility documented the resident was on a regular diet with thin fluid consistency. The areas for Diet Supplement and Additional Directions were blank. The end of the report listed residents who received dietary supplements. The resident was not on the list. A Drink List provided by the facility on 01/27/19 identified 16 residents who were to receive a milk shake with all meals. Resident #79 was not on the list. A dietary progress note, dated 01/28/19 at 4:08 p.m., documented, Had a meeting with (resident's) family and discussed the possibility of a feeding tube on 01/15/2019. They said they didn't want one, because she had signed a advanced directive and did not want a feeding tube. This note was signed by the dietary manager. No documentation of fortified shakes being provided was found for the resident throughout her stay. On 01/28/19 at 4:10 p.m., the dietary manager was asked to review the day planner for resident nutrition care to see if the resident had been referred to the dietitian since she had experienced weight loss. She stated the resident had not been referred to the dietitian. The dietary manager was asked whose responsibility it was to notify the dietitian if a resident had experienced weight loss. She stated it was her responsibility to notify the dietitian and she had not done it. She stated the dietitian was provided a list of resident weights but she did not think she looked at the list. On 01/29/19 at 12:05 p.m., the resident was observed at the assisted dining table with her food in front of her. The resident's head was down, her eyes were closed, and she made no attempt to feed herself. There was not a staff member available to assist the resident to eat. A fortified shake was not present. At 12:22 p.m., a staff member came to assist the resident to eat. The staff member gave the resident one bite and began talking to other residents seated at the table. The staff member offered the resident a small glass of juice which she drank. At 12:29 p.m., a staff member was observed feeding the resident. Then the staff member went to another resident at the table and began to feed her. The resident put her head down and closed her eyes. A few minutes later another staff member kneeled down to talk to the resident and then removed the resident from the table and took her to her room. The resident had been observed to consume approximately three bites of food and one small glass of juice. The resident was not provided with an alternate meal or a fortified shake. The Follow Up Question Report which answered the question, What percentage of the meal was eaten? dated 01/29/19 at 1:48 p.m., documented the resident had eaten 26-50% of her meal. On 01/29/19 at 3:17 p.m., CNA #3 was asked if the resident was offered a snack in the evening. She stated the resident's daughter usually came and fed the resident in the evening. She stated the resident usually had a cookie for her snack. The CNA was asked if the resident was offered a supplement at snack time. She stated no the resident was only given supplements at meal time. On 01/29/19 at 4:14 p.m., the dietary manager was asked who was notified of the residents' weights. She stated up to two weeks ago she was totally responsible for monitoring the residents' weights. She stated as of two weeks ago they had weekly weight meetings with the director of nursing, the assistant director of nursing, the MDS coordinator and herself. She stated as of two weeks ago the nursing staff also received a copy of the resident's weights. An update to the altered nutrition care plan, dated 01/29/19, documented, Discussed with family about feeding tube due to decreased intakes, and weight loss. They do not want at this time. On 01/30/19 at 1:32 p.m., the dietary manager was asked how supplements were documented when a resident consumed one. She stated there was no documentation if a resident consumed a health shake or how much they consumed. On 01/30/19, a recommendation from the Registered Dietician documented, wt loss: - 8.4 lbs, - 6.4% x 1 mo - add 1 serving of multimix protein powder to health shakes TID to promote wt maintenance and increase daily protein/calorie intake. The (MONTH) 2019 Follow Up Question Report which answered the question, What percentage of the meal was eaten?, recorded 89 of 93 opportunities for meal observations. The report documented the resident had refused one meal, consumed 0-25% 10 times, consumed 26-50% 30 times, consumed 51-75% 26 times, and consumed 76-100% 22 times. On 02/02/19 at 9:15 a.m., the MDS RN was asked how she was notified if a resident had weight loss. She stated they had a stand up meeting every morning Monday through Friday. She was asked who was responsible for notifying staff of a resident's weight loss. She stated the dietary manager was responsible for letting them know if a resident had weight loss. On 02/04/19, the resident weighed 122.6 pounds. On 02/04/19 at 9:28 a.m., the dietary manager was asked why they started the weekly weight meetings. She stated so they could get interventions done quicker. She was asked what part she has in the meetings. She stated she discusses who has weight loss or gain. She was asked what she does with the weight sheets and who received a copy of them. She stated the DON, the restorative aide, the MDS nurse, the ADON and the administrator get a copy weekly. She was asked if they were aware of the resident's weight loss. She stated the resident's daughter knew of her weight loss. She was asked what interventions the resident received. She stated, I asked her daughter about a feeding tube, and health shakes if she doesn't eat. She was asked how the percentages of food eaten were recorded. She stated if the resident drinks the supplement, it counts as 25% of food eaten and recorded as such. She was asked why hadn't any interventions been put into place before this past week for weight loss. She did not answer. On 02/04/19 at 9:40 a.m., the DON was asked how she was notified if a resident had weight loss. She stated she received a copy of the resident's weights in her box every week. She stated they also had weekly weight meetings. She stated the dietary manager let them know which residents had weight loss. She stated she did not see how the weights were calculated. She stated before two weeks ago no one but the dietary manager was aware if a resident had weight loss. She stated until two weeks ago the dietary manager was responsible for notifying the registered dietitian of a resident's weight loss. She stated the restorative aide weighs each resident, and the dietary manager records the weights and gives it to her. She keeps the weights in a binder so they can compare them. She stated they are having weekly weight meetings since two weeks ago, to review the weights. She stated if weight is lost, they reweigh the resident, talk to the resident, look at their intake, talk about supplements, and look at the orders. She stated before two weeks ago, they were recording weights, but no one was monitoring weights. She was asked what they had done for the resident. She stated since two weeks ago, they had started fortified shakes, talked to Hospice about a referral, talked to the family and tried to make sure the resident received her shake. She was asked how they confirm the resident gets or drinks the supplement. She said she hadn't thought of that. On 02/04/19 at 11:25 a.m., the resident was taken to the dining room and was positioned at an assisted dining table. Activities assistant #1 asked the resident if she would like a hot hamburger with french fries and the resident responded yes. The resident was given hot chocolate, two glasses of milk, and a health shake. The resident was observed to drink approximately one quarter of her glass of milk. She sipped on her hot chocolate. Staff assisted the resident to drink her health shake. The resident was observed to drink one half of the health shake. At 12:00 p.m., the resident had not received her food and she put her head down and closed her eyes. At 12:03 p.m., activity assistant #2 was observed to assist the resident to drink three fourths of a glass of milk. The resident was alert and looking around. At 12:16 p.m., the resident received her meal. The meal included an open faced hamburger and potatoes with gravy over the hamburger and potatoes. The resident was assisted to drink a few more sips of her health shake. The resident lowered her head and closed her eyes. At 12:20 p.m., the resident picked up her fork with her right hand and then dropped her fork with her attempt to feed herself. Activity assistant #2 cut up the resident's food into smaller pieces and the resident fed herself a few bites. At 12:30 p.m., the resident was given her medication. The resident fed herself a few more bites, wiped her mouth and dropped her head. The resident finished the health shake. The resident was observed to eat approximately 25% of the food on her plate. After observing the noon meal, the dietary manager was asked about the shakes. She stated the shakes are prepared the night bfore. She was asked how the protein powder was given today. She stated it was in the resident's gravy. The dietary manager was asked if the protein powder was ever put in the shake. She stated she hadn't thought of that, but she would now.

Based on observation, interview, and record review, it was determined the facility failed to ensure a resident did not receive an unnecessary medication for 4 (#5, #7, #8, and #10) of 5 sampled residents who were receiving an antipsychotic medication. The facility failed to: a) Ensure a resident who was receiving an antipsychotic medication had a supporting [DIAGNOSES REDACTED].#7, #8, and #10. b) Ensure appropriate target behaviors were documented to support the use of an antipsychotic medication for resident #5, #7, #8, and #10. Resident #5 experienced declines in the areas of activity of daily living performance and incontinence status, and developed a pressure ulcer after the initiation of an anti-psychotic medication. The facility census and condition identified 12 residents resided in the facility who were receiving an antipsychotic medication. Findings: An undated facility monitoring of antipsychotic policy documented, "...The continued need for and the effectiveness of the antipsychotic medication is reassessed monthly by the responsible physician. If continuation of the medication is deemed necessary, the physician indicates this in the resident's medical record..." A facility Antipsychotic Medication Use policy, revised April 2007, documented, "...1. Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective...2. The Attending Physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, symptoms, and risks...4. Nursing staff will document in detail an individual's target symptom(s)..." The policy documented, "Antipsychotic medications will not be used if the only symptoms are one or more of the following...Wandering...Poor self care... Restlessness...Impaired memory...Mild [MEDICAL CONDITION] expressions or behaviors that are not due to conditions listed above...and do not represent a danger to the resident or others..." A facility Monitoring of Antipsychotics policy, undated, documented, "...Residents receive antipsychotic medications only when medically necessary. Every effort is made to ensure that residents who use antipsychotics receive the intended benefit of the medications and to minimize the unwanted effects of the antipsychotic medications...Upon initiation of antipsychotic medication therapy (or upon admission for new residents receiving antipsychotics) and quarterly thereafter, the Abnormal Involuntary Movement Scale (AIMS) or similar test is administered to the resident...Monitoring of adverse consequences shall also be done each shift and recorded..." A facility Dementia - Clinical Protocol policy, revised October 2010, documented, "...The physician will order appropriate medications and other interventions to manage behavioral and psychiatric symptoms related to dementia based on pertinent clinical guidelines and regulatory expectations...Medications should be targeted to specific symptoms and should be used in the lowest possible doses for the shortest possible time, unless clinical rationale for higher doses or longer-term use is documented...The physician and staff will review the effectiveness and complications of the long term use of medications used to enhance cognition and of psychoactive medications used to manage behavioral and psychiatric symptoms related to dementia and will adjust, stop, or change such medications appropriately..." 1. Resident #5 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A Norton Scale for Predicting Risk of Pressure Ulcer, dated 01-29-15, documented the resident had a score of 8 and was a high risk for developing a pressure ulcer. A facility skin assessment, dated 02-02-15, documented the resident's skin was warm and dry. The assessment documented her heels and buttocks were intact. An admission assessment, dated 02-05-15, documented the resident was severely impaired cognitively, had no behaviors, required limited assistance with ambulation, transfers and toileting, required extensive assistance with bathing and dressing, was occasionally incontinent of urine, was continent of bowel, was at risk for skin breakdown, had no skin problems, used a pressure reducing device for her bed, and had not received any antipsychotic medication during the seven day look back period. A speech therapy discharge summary, dated 02-13-15, documented, "...Pt (patient) tolerating reg (regular) diet textures well at recently monitored meals..." A nurse's note, dated 03-05-15, documented resident #5 had not been feeling well that morning. The note documented the resident had increased confusion for the last couple of days and had complained of full urination with burning. The note documented the physician had been notified by fax of the resident's complaints and a request to obtain urine for a urinary analysis (UA). A nurse's note, dated 03-08-15, documented resident #5 had stood up from her wheelchair at the nursing station and was very unsteady on her feet. The note documented the resident had been hollering out and had become very agitated and combative with staff. The note documented the physician had been notified and an order had been received to administer [MEDICATION NAME] 0.5 milligrams (mg) one tablet by mouth daily at bedtime. A physician's telephone order, dated 03-08-15, documented an order for [REDACTED]. A urinalysis laboratory result, dated 03-10-15, documented the urinalysis final report was no growth. The laboratory result documented the physician had not ordered any treatment. A significant change assessment, dated 03-28-15, documented the resident was severely impaired cognitively, rejected care, was physically and verbally abusive with staff, required extensive assistance with transfers, did not ambulate, required extensive assistance with bathing, dressing, and toileting, was occasionally incontinent of both bowel and bladder, was at risk for skin breakdown, had no skin problems, no skin treatments, and had received and antipsychotic medication seven days of the seven day look back period. The significant change assessment completed fifty-one days after admission, documented a decline in Resident #5's ability to transfer, ambulate, eat, perform personal hygiene, bowel and bladder function, and toilet use. A care plan, updated on 03-29-15, documented, "...I am at risk for adverse side-effects because of the medication I take...I take [MEDICATION NAME] at HS (bedtime)..." A pharmacy drug regimen review consultation report, dated 03-30-15, documented [MEDICATION NAME] was not indicated for the treatment of [REDACTED]. The report requested the physician add a supporting [DIAGNOSES REDACTED]. The report documented the physician's response was to add a [DIAGNOSES REDACTED]. The report had been noted by facility staff on 05-03-15 at 10:45 p.m. A care plan, updated on 03-31-15, documented, "...Encourage me to drink plenty of water with meals and in between...Take to the assisted dining area and assist me with all meals..." A facility behavior monthly flow sheet, dated March 2015, did not contain documentation for the use of [MEDICATION NAME]. The flow sheet only documented the use of an antidepressant with a targeted behavior of being depressed and withdrawn. A review of resident #5's clinical record for the month of March 2015 did not contain any documentation the resident had experienced delusions or that an AIMs assessment had been completed for the initiation of an antipsychotic medication as per the facility's policy. A care plan, updated on 04-03-15, documented, "...Behavioral disturbance related to occasional wandering, frequent [MEDICATION NAME] in the hall, rejecting care and attempting to hit staff..." A facility skin assessment, dated 04-13-15, documented the resident had shingles on her left inter buttocks. The assessment documented the physician had been notified. A physician's progress note, dated 04-23-15, documented under the psych area, "confused." A nurse's note, dated 04-23-15 at 7:07 p.m., documented resident #5 was transferred to the hospital to evaluate for increased [MEDICAL CONDITION]. A nurse's note, dated 04-23-15 at 10:15 p.m., documented resident #5 returned to the facility from the hospital. A hospital discharge note, dated 04-23-15, documented resident #5 had skin breakdown on her sacrum and [MEDICATION NAME] had been applied. A hospital physician discharge order, dated 04-23-15, documented, "...Sacrel (sic) [MEDICATION NAME] to Sacrum BID (twice a day)..." A facility skin assessment, dated 04-24-15, documented the resident had shingles on her left buttocks and sacral area for the past two weeks. The assessment documented the sacral area had one open area and the physician from the emergency room had diagnosed the area as a sacral decubitus. The assessment did not document any measurements, color, odor or drainage of the wound. A medication administration note (MAR), dated 04-22-15, documented, "...un-able to swallow..." A care plan, updated on 04-24-15, documented, "...I have a stage I to my coccyx..." A MAR indicated [REDACTED] A Norton Scale for Predicting Risk of Pressure Ulcer, dated 04-25-15, documented the resident had a score of 10 and was a high risk for developing a pressure ulcer. A quarterly assessment, dated 04-27-15, documented the resident was severely impaired cognitively, had physical behaviors toward staff, wandered, required extensive assistance with transfers, bathing, dressing and toileting, did not ambulate, was occasionally incontinent of bowel, and frequently incontinent of bladder, was high risk for skin breakdown, had an open lesion, used a pressure reducing device for bed, was receiving a medication treatment, and had received an antipsychotic medication five days of the seven day look back period. The quarterly assessment completed thirty days after the significant change assessment, documented resident #5 had further declined from being occasionally incontinent of urine to frequently incontinent of urine, had an open lesion, and had frequent pain. A Medication Administration Record [REDACTED]. A facility behavior monthly flow sheet, dated April 2015, documented [MEDICATION NAME] 0.5 mg for [MEDICAL CONDITION]. The flow sheet documented the target behavior was striking out, hitting, and agitation. A review of resident #5's clinical record for the month of April 2015 did not contain any documentation the resident had experienced delusions or that an AIMs assessment had been completed since starting an antipsychotic as per the facility's policy. A facility pressure ulcer report, dated 04-28-15, documented resident #5 had a stage II sacral wound that had been acquired inside the facility. The report documented the wound was 0.5 centimeters (cm) and did not have any drainage or odor. The report documented the treatment was [MEDICATION NAME]. The assessment did not document the color, odor or drainage of the wound. A care plan, updated on 04-28-15, documented to apply [MEDICATION NAME] twice daily to shingles area on the resident's left buttock and to use a wedge pillow while in bed at times. A nurse's note, dated 04-30-15, documented, "...(resident name deleted) has lost 10.2 pounds over the past week. Sending weights to primary care physician (physician name deleted) to notify and see if he desires any changes to her medication regimen..." A facility skin assessment, dated 05-02-15, documented resident #5 continued to have a sacral decubitus and treatment continues. The assessment did not document any measurements, color, odor or drainage of the wound. A facility pressure ulcer report, dated 05-04-15, documented resident #5 had a stage II wound on her coccyx. The report documented there was no drainage or order. The report documented the wound was 3.5 cm long, 0.5 cm wide and 0.1 cm deep. The report documented the treatment was [MEDICATION NAME]. A facility skin assessment, dated 05-07-15, documented resident #5 had a stage II pressure ulcer on her sacrum. The assessement documented the ulcer was 3.5 cm long, 0.5 cm wide, and 0.1 cm deep. The report documented a 4 inch cushion had been placed in the resident's wheelchair to help relieve pressure from the sacral area and the primary care physician had been updated. The assessment did not document the color, odor or drainage of the wound. A MAR, dated May 2015, documented [MEDICATION NAME] 0.5 mg had been administered daily at bedtime for [MEDICAL CONDITION] until 05-03-15 when the [DIAGNOSES REDACTED]. The MAR indicated [REDACTED]. A facility Weekly Wound Rounds document, dated 05-12-15, documented resident #5 had a 3.0 cm long by 1.6 cm wide by 0.5 cm deep stage II pressure ulcer on her sacral area. The assessment did not document the color, odor or drainage of the wound. A nurse's note, dated 05-12-15, documented resident #5's daughter had been called and informed the resident's wound was not improving with the current treatment. The note documented the daughter was asked for permission to contact the wound physician for an evaluation. The note documented the daughter said ok and the primary care physician would be notified to obtain an order. A facility weekly skin assessment, dated 05-12-15, documented an alternating air mattress had been put on resident #5's bed. A wound physician progress notes [REDACTED]. is caused by pressure..." The note documented to cleanse the wound with normal saline, apply Santyl to the wound and cover with a border gauze daily. A physician's telephone order, dated 05-14-15, documented to give Bactrim DS one by mouth twice daily for 5 days. A nurse's note, dated 05-14-15, documented, "...nurse assisted resident with eating lunch tried puree food and did eat and tolerated well may we change diet texture to puree... A care plan, updated on 05-15-15, documented, "...Cleanse wound to my coccyx with normal sline (sic), apply santyl, cover with dry dressing daily until healed...I am on a repositioning program. 1. Resident is to be laid down in bed after each meal. 2. When in bed turn from side to side every 2 Hours and when requested by resident. 3. Encourage resident to not lie on back except for meal times.4. Encourage resident to limit time up in wheelchair...I take zinc, vitamin c, [MEDICATION NAME] and a multivitamin daily..." On 05-18-15 at 11:50 a.m., resident #5 was observed sitting in a wheelchair at the dining room table. No behaviors were observed. On 05-19-15 at 8:05 a.m., resident #5 was observed sitting in a wheelchair at the dining room table. No behaviors were observed. On 05-19-15 at 10:14 a.m., wound care for resident #5 was observed being done by registered nurse (RN) #1. The wound was observed on the resident's inner right sacral area. The wound contained yellow slough with an area of black eschar. The peri wound skin was inflamed and red. There was no odor or drainage noted. RN #1 stated the resident was on an antibiotic for the wound infection. RN #1 was asked about resident #5's wound. She stated the resident had shingles on her buttocks in that area and one of the blisters had broken and the area became a wound. RN #1 was asked what measures were put in place to promote healing. She stated the resident had an air mattress on her bed, a cushion in her chair, and she was repositioned when in bed. RN #1 stated they encouraged the resident to lay down between meals. On 05-19-15 at 1:05 p.m., certified nurse's aide (CNA) #1 was asked if resident #5 ever exhibited any behaviors. She stated the resident would resist going to bed sometimes just because she did not like to go to bed. CNA #1 stated she would assist the resident to change into her pajamas and toilet her and let her stay up like she wanted. CNA #1 stated occasionally resident #5 would be hateful but she had never witnessed the resident cursing or hitting staff. On 05-19-15 at 2:00 p.m., resident #5 was observed lying on her right side in bed. An air mattress was observed on the resident's bed. The wheelchair was observed to have a seat cushion. On 05-20-15 at 8:40 a.m., resident #5 was observed sitting in her wheelchair in the dining room feeding herself breakfast. No behaviors were observed. On 05-20-15 at 11:00 a.m., CNA #7 was asked if resident #5 had declined in her ability to perform her ADLs. She stated the resident had started to decline about two months ago. She stated the resident used to be more active and now the resident would fall asleep sitting in her chair. CNA #7 stated the resident was now a two staff person assist for toileting and transferring. She stated the resident used to be continent and would tell them when she needed to go to the bathroom, but now she was more incontinent. CNA #7 was asked if resident #5 exhibited any behaviors. She stated the resident used to stay calm in one place and now the resident was constantly in motion. On 05-20-15 at 11:37 a.m., LPN #1 was asked if resident #5 exhibited behaviors. She stated not lately. She stated at one time the resident had been hitting and kicking staff and was hard to reason with. LPN #1 was asked if resident #5 had ever had delusions. She stated not that she knew of. On 05-20-15 at 2:00 p.m., resident #5 was observed resting in bed with her eyes closed. A antibiotic note, dated 05-20-15, documented, "...Wound on sacrum, edges [DIAGNOSES REDACTED]tous, slough present. Length- 4.2 cm Width- 2.0 cm Depth- Unable to determine...Continue Bactrim DS as ordered..." A review of resident #5's clinical record for the month of May 2015 did not contain any documentation the resident had experienced delusions or that an AIMs assessment had been completed since starting an antipsychotic as per the facility's policy. On 05-21-15 at 10:00 a.m., resident #5 was observed lying in bed on her right side. A monthly physician's orders [REDACTED]. A facility behavior monthly flow sheet, dated May 2015, documented [MEDICATION NAME] 0.5 mg for [MEDICAL CONDITION]. The flow sheet documented the target behavior was striking out, hitting, and agitation. On 05-21-15 at 11:15 a.m., CNA #2 was asked if resident #5 had declined in her ability to perform her ADLs. She stated the resident used to be more alert and talk to staff. She stated the resident started to change about a month ago. CNA #2 stated the resident used to help with transfers but now she required total assistance by staff for transfers. On 05-21-15 at 11:30 a.m., licensed practical nurse (LPN) #7 was asked if resident #5 had declined in her ability to perform her ADLs. She stated the resident used to propel herself up and down the halls [MEDICATION NAME], now she is not as mobile, she does not smile and looks depressed. LPN #7 stated the resident was not eating as well and was requiring more staff assistance at meals. LPN #7 was asked if the resident had exhibited any behaviors. She stated the resident would hit the walls with her wheelchair. She stated she was not aware of the resident hitting or biting staff. On 05-21-15 at 12:50 p.m., the director of nursing (DON) was asked what measures were put in place to promote wound healing for resident #5. She stated the resident had an overlay mattress on her bed, a cushion in her chair, and was turned every two hours. The DON was asked if the measures put in place were timely since the chair cushion was not put in place until 05-07-15, vitamins and supplements were not started until 05-09-15, and the air mattress was put in place on 05-12-15. She stated no. On 05-21-15 at 1:20 p.m., the director of nursing (DON) was asked if resident #5 had declined in her ability to perform her ADLs. She stated when the resident was first admitted she ambulated using a rolling walker and now she was in a wheelchair. The DON stated the resident had required limited assistance with ADLs and now required extensive assistance. The DON was asked what had caused resident #5's decline in ADLs. She stated she did not know. She further stated the staff had discussed the resident's decline in the morning staff meetings. The DON was asked if resident #5's decline could be a result of the use of an antipsychotic medication. She stated it could be, but it could also be a result of her disease process. The DON was asked if the resident's decline in ADLs, weight loss, falls, difficulty swallowing, and a pressure ulcer were possible side effects of the use of an antipsychotic. She stated yes. On 05-21-15 at 1:30 p.m., resident #5's primary care physician (PCP) was asked about the [DIAGNOSES REDACTED].#5. The PCP was informed there was no documentation in the resident's clinical record related to her having delusions. He stated he had based his [DIAGNOSES REDACTED]. He stated he would have to look at the resident's records more closely. The physician was asked if the resident's decline in ADLs, weight loss, falls, difficulty swallowing, and a pressure ulcer were possible side effects of the use of an antipsychotic. He stated it was always a potential, but could also be her disease process. 2. Resident #7 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A facility admission order, dated 02-03-14, documented, "[MEDICATION NAME] ([MEDICATION NAME]) 0.5 MG Tablet Oral (By mouth) - twice daily Everyday: one tab (tablet) po (by mouth) bid (twice a day)...Anxiety; Agitation...." A drug regimen review consultation report, dated 02-25-14, documented [MEDICATION NAME] was not indicated for the treatment of [REDACTED]. The response by the physician was dated 03-07-14 and documented, "...I decline the recommendations(s)...because a GDR is CLINICALLY CONTRAINDICATED for this individual...Dx (diagnosis) Dementia with behavior disturbance...sometimes violent...This will not change...." A behavior charting report, dated 05-17-14, documented, "...Resident continues use of [MEDICATION NAME] change in behavior...." A significant change in condition assessment, dated 05-18-14, documented resident #7 was severely impaired cognitively, had a mood severity score of 2 out of a total of 27, had physical and verbal behaviors directed toward others one to three days of the seven day look back period, had a psychiatric/mood disorder [DIAGNOSES REDACTED]. A behavior charting report, dated 06-17-14, documented, "...Resident continues use of [MEDICATION NAME] previous behaviors and also has difficulty following safety instructions...." A significant change in condition assessment, dated 07-08-14, documented resident #7 was severely impaired cognitively, had a mood severity score of 4 out of a total of 27, had verbal behaviors toward others one to three days of the seven day look back period, had a psychiatric/mood disorder [DIAGNOSES REDACTED]. A care plan, revised on 07-10-14, documented "...I have anxiety...Interventions/Tasks...I take [MEDICATION NAME] twice daily...." A care plan, revised 07-10-14, documented "...I have cognitive loss due to dementia...Interventions/Tasks...I take [MEDICATION NAME] twice daily...." A behavior charting report, dated 07-17-14, documented, "...Resident continues use of [MEDICATION NAME]. (continues) to curse and hollar (sic) out at peers but this behavior has decreased...." A behavior charting report, dated 08-16-14, documented, "...Patient continues on current meds (medications)...no Beh (behaviors) noted." A behavior charting report, dated 09-10-14, documented, "...Patient continues on current meds...No Beh noted...." A physician's orders [REDACTED]." A behavior charting report, dated 10-10-14, documented, "...Patient continues on current meds...No Beh noted...." A behavior charting report, dated 11-08-14, documented, "...Patient continues on meds...No beh noted...." A behavior charting report, dated 12-06-14, documented, "...Pt cont on current meds...No Beh...." A behavior charting report, dated 01-03-15, documented, "...Patient continues on current medications...No Change in behaviors noted...." A social service monthly note, dated 01-28-15, documented, "...(resident name deleted) is out of room daily to meals she interacts with her tablemates. Her mood state is pleasant at this time...." A behavior charting report, dated 02-08-15, documented, "[MEDICATION NAME] routine for Dementia with behavioral disturbances...No behaviors noted..." A behavior monthly flow sheet, dated February 2015, documented, "[MEDICATION NAME] Tablet 0.25 MG...DEMENTIA CCE W/BEHAVIORAL DISTURBANCES...BEHAVIOR...Anxiety...." The behavior flow sheet documented no exhibited behaviors. A social service monthly note, dated 02-26-15, documented, "...attends meals in the dining room does converse some with tablemates...Her mood state good at this time...." A behavior charting report, dated 03-11-15, documented, "[MEDICATION NAME] routine for dementia with behavioral disturbances...No behaviors noted...." A behavior monthly flow sheet, March 2015, documented, "[MEDICATION NAME] Tablet 0.25 MG...DEMENTIA CCE W/BEHAVIORAL DISTURBANCES...BEHAVIOR...Anxiety...." The flow sheet documented the resident had two episodes of anxiety during the month. A quarterly assessment, dated 04-10-15, documented resident #7 was severely impaired cognitively, had a mood severity score of 3 out of a total of 27, exhibited no behaviors, had a psychiatric/mood disorder [DIAGNOSES REDACTED]. A behavior monthly flow sheet, dated April 2015, documented, "[MEDICATION NAME] Tablet 0.25 MG...DEMENTIA CCE W/BEHAVIORAL DISTURBANCES...BEHAVIOR...Anxiety...." The flow sheet documented the resident had one episode of anxiety during the month. A social service monthly note, dated 04-10-15, documented, "...mood state good at this time. She participated in interview...enjoys her meals in the dining room does converse with tablemates...." A medication review report, dated May 2015, documented, "[MEDICATION NAME] Tablet 0.25 MG ([MEDICATION NAME])...Give 1 tablet by mouth two times a day for dementia with behavioral disturbances related to DEMENTIA CCE W/BEHAVIORAL DISTURBANCES...." A behavior progress note, dated 05-05-15, documented, "[MEDICATION NAME] twice a day for dementia with behavioral disturbances. No behaviors noted...No interventions needed...." On 05-18-15 at 10:10 a.m., resident #7 was observed in the television area, sitting in her wheelchair with her eyes closed. The resident responded to verbal stimuli. No behaviors were noted. On 05-18-15 at 11:58 a.m., resident #7 was observed in the dining room, sitting in her wheelchair. No behaviors were noted. On 05-19-15 at 8:05 a.m., resident #7 was observed in the dining room, sitting in her wheelchair. No behaviors were noted. On 05-19-15 at 1:00 p.m., resident #7's May 2015 behavior monthly flow sheet was reviewed. The flow sheet documented, "[MEDICATION NAME] Tablet 0.25 MG...DEMENTIA CCE W/BEHAVIORAL DISTURBANCES...BEHAVIOR...Anxiety...." The flow sheet showed no documentation of behaviors. On 05-19-15 at 1:10 p.m., CNA #1 was asked what type of behaviors resident #7 exhibited. She stated the resident would cuss, but not necessarily at the staff. CNA #1 was asked if she had ever seen the resident hit another resident or staff member. She stated not that she was aware of. On 05-19-15 at 1:40 p.m., CNA #3 was asked what type of behaviors resident #7 exhibited. She stated she had not seen any behaviors in quite awhile. CNA #3 stated there had been one time in the past the resident had rejected care during a shower, but that was the only time she could remember. CNA #3 stated the resident at times would cuss a lot and say some sexually inappropriate things. She stated she had not seen those behaviors in awhile On 05-19-15 at 3:10 p.m., the DON was shown resident #7's behavior monthly flow sheets. The DON was asked if anxiety was the only target behavior being monitored for the [MEDICATION NAME]. She stated yes. On 05-20-15 at 9:55 a.m., resident #7 was observed in the main lobby area, located by the nurses' station, sitting in a wheelchair with 5 other residents present beside her. The resident was quiet and had her hands folded in her lap. No behaviors were observed. On 05-20-15 at 10:05 a.m., LPN #2 was asked what type of behaviors did resident #7 exhibit. She stated at times the resident would curse, was confused and disoriented, was incontinent, and had been combative to staff. LPN #2 was asked when would the resident become combative. The LPN stated the resident at times would become combative with showering, changing clothes, or even helping her out of her bed. LPN #2 stated the CNAs would usually step back, letting the resident calm down. She stated once the resident calmed down she was okay. LPN #2 was asked what behaviors were being monitored for the use of [MEDICATION NAME]. She stated she did not know and would have to ask the CMA. On 05-19-15 at 10:10 a.m., LPN #2 returned to this surveyor and reported the target behavior being monitored for the use of [MEDICATION NAME] was anxiety. On 05-20-15 at 10:50 a.m., resident #7 was observed in the main lobby across from the nurses station, sitting in her wheelchair. No behaviors were noted. On 05-20-15 at 11:45 a.m., minimum data set coordinator/licensed practical nurse (MDSC/LPN) #1 was asked what type of behaviors resident #7 exhibited. She stated the resident had what some people would consider a "potty mouth." She stated she had heard from other staff members the resident would spit out her medications. The MDSC/LPN #1 stated she had not seen any behaviors. The MDSC/LPN was asked if she knew why resident #7 was still receiving the [MEDICATION NAME] if she was not having behaviors. She stated the resident's physician was reluctant to discontinue the medication, stating the resident was having recurrent behaviors. The MDSC/LPN #1 was asked if dementia with behavioral disturbances was an appropriate [DIAGNOSES REDACTED]. She stated she did not thi

Based on observation, interview, and record review, it was determined the facility failed to ensure a resident who had a pressure sore received the necessary services to promote healing by notifying the physician of wound changes for 2 (#4 and #10) of 4 sampled residents who were observed for pressure sores. The facility failed to: a. notify the physician of wound changes. b. update the care plan with wound changes, wound treatment, and new wound development. Resident #4's and resident #10's pressure sores worsened. Resident #10 developed new pressure sores. The facility resident census and condition identified 7 residents who resided in the facility and had pressure sores. Findings: A facility policy, titled "Pressure Ulcers/Skin Breakdown - Clinical Protocol," documented, "...During resident visits, the physician will evaluate and document the progress of wound healing-especially for those with complicated, extensive, or non-healing wounds...The physician will help the staff review and modify the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions..." A facility policy, titled "...Change in a Resident's Condition or Status..." documented, "...Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status...The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been...A significant change in the resident's physical/emotional/mental condition...A need to alter the resident's medical treatment significantly..." 1. Resident #4 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. An admission evaluation and interim care plan, dated 04-24-13, did not document any redness or breakdown in the peri area. A nurse's note, dated 04-24-13, documented, "...Break down scrotum and Lower groin Bilateral..." A temporary care plan, dated 04-24-13, documented the resident was at risk for skin break down. The interventions documented were to encourage fluids and use pillows for positioning. A facility document, dated 04-24-13 and titled "Norton Plus Pressure Ulcer Scale," documented the resident was at high risk for pressure ulcer development. A nurse's note, dated 04-28-13, documented, "...CNA's (certified nurse aide) report breakdown to coccyx, upon assessment observed approx (approximately) 1cm (centimeter) x 5cm x (less than) .25cm unstageable ulcer to coccyx. Tissue moist et (and) 100% pale yellow slough periwound dark red et angry. 0 (no) drainage 0 odor noted, cleansed c NS et drsg applied per nursing judgement, new orders rec'd (received) to tx (treat) per facility policy. see T.O. (telephone order)..." A physician's telephone order, dated 04-28-13, documented "...Cleanse coccyx c (with) NS (normal saline), pat dry, apply Santyl ointment to wound bed, barrier cream to wound edges, cover c bordered gauze drsg (dressing) & (and) (change) QD (every day) & PRN (as needed) until resolved..." A facility document, titled "Pressure Ulcer Narrative Notes," documented, "...4/30/13 coccyx/L (left) Buttock new area 1.3 cm x (by) 0.4 cm...unstageable. 80% slough 20% pink granulation noted periwound area soft c stage II in close proximation to wound area. New order to tx c Santyl and cover c bordered drsg approp. (appropriate) for drainage control...4/30/13 coccyx 0.1 stage II 100% pink granulation noted periwound soft boggy to touch. 0 (no) drainage noted. New order tx c [MEDICATION NAME] cream daily et PRN..." A hospice physician's order, dated 04-30-13, documented, "Cleanse coccyx c (with) NS (normal saline) Pat dry. Apply debridmax ointment to wound bed and barrier cream to wound edges, cover c bordered gauze daily & (and) PRN (as needed)..." An initial assessment, dated 05-01-13, documented the resident was severely impaired cognitively, required extensive to total assistance with most activities of daily living, had an indwelling urinary catheter, and had one stage II pressure sore. A care plan, dated 05-01-13, documented, "I have altered skin integrity related to impaired mobility, incontinence, poor oral intake, and present skin breakdown...I will be free from further skin breakdown or red areas for the next 90 days...*Apply barrier cream to my skin as needed...*Cleanse me well with each incontinent episode...*Examine my skin during personal care and report any new red or open areas...*Help me turn and reposition frequently...*I have a poor appetite and sometimes refuse meals...*I have a pressure reduction mattress...*Treatment nurse monitors my current wounds daily and does a skin assessment on me every two weeks..." A facility document, titled "Pressure Ulcer Narrative Notes," documented, "...5/14/13 coccyx above areas combined 4.2 x 2.0...100% slough, yellow in color. Mod (moderate) of drainage c 0 odor noted. periwound pink soft cont c previous tx of Santyl and cover c bordered drsg..." A facility document, titled "Pressure Ulcer Narrative Notes," documented, "...5/21/14 coccyx 4.5 x 2.3...100% slough yellow/white in color. Moderate drainage noted. periwound WNL (within normal limits). Cont. (continue) c previous wound orders..." A facility document, titled "Pressure Ulcer Narrative Notes," documented, "...5/28/13 coccyx 4.7 x 2.6...100% yellow white slough. Periwound pink soft moderate drainage noted c 0 odor. Periwound area WNL cont c prev tx orders..." No documentation was found in the resident's clinical record documenting the physician had been notified of the resident's wound changes. A physicians' telephone order, dated 06-03-13, documented, "Cleanse wound on posterior R (right) ankle c NS, apply Santyl to wound bed, cover c drsg. approp for drainage control. Change daily & PRN..." A facility document, titled "Pressure Ulcer Narrative Notes," documented, "...6/4/13 coccyx 4.5 x 2.4...unstageable 100% yellow slough, moderate drainage c 0 odor noted. Periwound pink, moist cont c prev tx orders..." A facility document, titled "Pressure Ulcer Narrative Notes," documented, "...6/4/13 R heel new area 2.8 cm x 1.9 cm ...100% yellow slough stage III, minimal drainage noted 0 odor area rubs on heel of shoe. New order to Tx c Santyl and cover c bordered drsg. approp for drainage control..." A nurses' note, dated 06-06-13, documented, "...Dr (physician name deleted) in house to see resident. 0 new orders..." On 06-10-13 at 2:42 p.m., LPN (licensed practical nurse) #1 was observed as she provided wound care to resident #4. LPN #1 washed her hands and applied gloves. Wound care was observed to be provided per physician's orders. LPN #1 was asked to describe the wound on the resident's coccyx. She stated the wound was a stage 3 with 90% slough and some pink granulation tissue. LPN #1 was asked to describe the resident's posterior heel wound. She stated the wound was a stage 3 with 80% slough and some pink granulation tissue. The wound was observed to be free of odor. On 06-11-13 at 2:50 p.m., LPN #7 was asked about resident #4's temporary care plan upon admission. LPN #7 stated the resident's peri area was red. She stated she should have documented the resident should be turned every two hours. LPN #7 stated the resident's initial admit nursing assessment should have documented the resident's peri area redness. On 06-11-13 at 3:20 p.m., MDS (minimum data set coordinator) #1 was asked how wound changes were updated on the resident's care plan. She stated, "I get weekly wound reports to make care plan updates. I try to update weekly but it doesn't always happen." MDS coordinator #1 was asked if resident #4's care plan had been updated. She stated no it had not been updated. 2. Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Norton Plus Pressure Ulcer Scale, dated 04-11-13 and updated on 05-03-13, documented the resident was at high risk for skin breakdown. A facility document, titled "Pressure Ulcer Narrative Notes" and dated 04-12-13, documented, "... R.(right) Buttock medial gluteal cleft...admitted c (with) area stage III 0.7cm (centimeters) x 0.9cm x 0.1cm. 10% slough, 90% pink granulation. Minimal amount of Serous, Exudate noted. New order to tx (treat) c Santyl, Cover c Bordered drsg (dressing) Change qd (every day) et (and) PRN (as needed)..." The 04-12-13 Pressure Ulcer Narrative Notes documented, "...R. Buttock...admitted c area Stage II 0.3cm x 1.5cm x 0.1cm. 80% slough, 20% pink granulation noted. Minimal Serous Exudate noted no odor, Periwound WNL (within normal limits) New order. Cleanse c NS (normal saline) apply Santyl, cover c bordered drsg change qd et PRN..." The 04-12-13 Pressure Ulcer Narrative Notes documented, "...L. (left) buttock...admitted with area Stage II 0.9 x 1.1x <0.1. 90% pink granulation 10% slough. Minimal amount of drainage noted. New order cleanse c NS, apply Santyl, cover c bordered gauze. Change qd et PRN..." The 04-12-13 Pressure Ulcer Narrative Notes documented, "...L. buttock medial gluteal cleft...admitted c area Stage II. 1.5cm x 1.5cm x 0.1cm. 80% pink granulation, 20% slough. Minimal amount of drainage noted. no odor. Periwound WNL. New order. Cleanse c NS, apply Santyl cover c Bordered gauze. Change daily et PRN..." A physician's monthly order sheet, dated June 2013, documented an original order, dated 04-11-13 and discontinued on 04-17-13 for "[MEDICATION NAME], Zinc Oxide and [MEDICATION NAME] mix to open areas to coccyx and buttocks every day and prn with incontinence episodes- once daily Everyday and PRN..." An admission assessment, dated 04-18-13, documented the resident was moderately impaired cognitively, required total assistance with activities of daily living, was incontinent of bowel and bladder, and had three stage 2 pressure ulcers and one stage 3 pressure ulcer. A physician's telephone order, dated 04-18-13, documented, "...Cleanse wounds on R. et L. Buttocks c NS, apply Santyl to wound beds, skin prep to periwound area, cover c bordered dressings proper for drainage control. Change daily et PRN..." A review of the clinical record indicated the facility physician was not updated regarding the wounds or treatments. A Doctor's Orders and Progress Notes, dated 05-21-13 and signed by the facility physician did not address the resident's wounds or current treatment. A facility document, titled "Pressure Ulcer Narrative Notes and dated 06-04-13, documented, "...L. Buttock gluteal cleft...3.8cm x 1.8cm x <0.1 cm Stage III. 100% slough c moderate purulent drainage noted. Foul odor periwound soft, boggy. Notified physician (name deleted)..." The 06-04-13 Pressure Ulcer Narrative Notes documented, "...L. Buttock #2...1.5cm x 0.9cm x 0.1cm Stage III. 100% yellow slough c dark grey center. Moderate drainage noted c no odor periwound soft, boggy dark in color. Cont. (continue) c previous tx orders..." The 06-04-13 Pressure Ulcer Narrative Notes documented, "...L. Buttock #3...1.3cm x 1.5cm x 0.2cm Stage III 100% yellow slough area moderate drainage noted c no odor. Periwound soft c dark color Cont c previous tx orders..." The 06-04-13 Pressure Ulcer Narrative Notes documented, "...R. buttock *new area...1.0cm x 0.9cm x <0.1. Stage II. 100% pink granulation noted periwound within normal limits. No odor, no drainage noted. New order tx with [MEDICATION NAME] cream..." A review of the clinical record showed no documentation the physician had been updated regarding the worsening wounds and no physician order was found for the [MEDICATION NAME] cream treatment. A Hospice Physician's Order form, dated 06-06-13, documented, "...OBTAIN WOUND CULTURE, SEND TO LAB (name deleted) FOR IDENTIFICATION AND SENSITIVITY. FAX RESULTS TO (NAME DELETED) HOSPICE AND PHYSICIAN (NAME DELETED)..." An abscess final culture report, dated 06-09-13, documented, "...small amount of mixed bacterial flora with many staphylococcus aureaus ([MEDICAL CONDITION] sensitive) and few proteus mirabilis and few escherichia coli..." A hospice fax sheet, dated 06-10-13, documented the hospice physician ordered, "Bactrim DS 1 PO BID (twice daily) x 10 days..." On 06-11-13, resident #10 was observed lying in bed on right side. She was alert and oriented and able to communicate clearly. She stated she had just returned from a physician's appointment for her fractured arm and was very tired. She was clean, well groomed, and wearing a hospital gown. On 06-11-13 at 1:40 p.m., LPN #1 was asked if the physician had been notified regarding resident #4's and resident #10's wound changes. LPN #1 stated she had not notified the physician regarding the resident's wound changes. She stated she had talked to the hospice nurse about the resident's wounds. On 06-11-13 at 3:40 p.m., the director of nursing (DON) was asked about resident #4's and resident #10's wound changes and physician notification. The DON stated, "The physician should be notified of new wounds or wound changes."