Every finding on record at Jacob Healthcare Center

Based on interview, and record review, the facility failed to verify the correct placement of Resident 1's gastrostomy tube (G-tube-a flexible tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications). The nursing staff failed to verify Resident 1's G-tube had not migrated further into or out of the stomach, by not observing through assessment a printed number or measurable level on the tubing that exited Resident 1's abdomen (G-tube length). The nursing staff also failed to follow the facility's policy to use a pH strip (used to measures acidic content of the stomach) to verify the placement of Resident 1's G-tube prior to the administration of medications and enteral feeding (tube feeding, the delivery of nutrients via a feeding tube). These failures were identified for one of three sampled residents reviewed for gastrostomy tubes. As a result, Resident 1 experienced emergency surgery and hospitalization on 7/6/26 when Resident 1's G-tube position shifted to outside of the stomach and approximately one liter of liquid feeding was removed from Resident 1's intraperitoneal cavity (a space inside the abdomen). Resident 1 also developed abdominal sepsis (a serious, life-threatening infection).Findings:A record review of Resident 1's undated admission Record indicated Resident 1 was admitted on [DATE] with diagnoses to include Amyotrophic Lateral Sclerosis (ALS- a nervous system disease that affects muscles needed to move, speak, eat and breathe).A record review of Resident 1's Minimum Data Set (MDS- an assessment tool that captures information about a resident's physical, mental and social status) dated 7/26/2026, indicated Resident 1 had moderately impaired decision-making skills. The MDS further indicated Resident 1 was completely dependent [required total assistance from staff] for mobility and for all Activities of Daily Living (ADLs- eating, toileting, bathing, dressing). Per the MDS, Resident 1 required a feeding tube (or a gastrostomy tube-G-tube).A record review of Resident 1's Order Summary dated 4/12/2026 indicated, Enteral Feed Order every shift ENTERAL: Check feeding tube placement QS [every shift] before feeding, flushing [pushing water through a tube to prevent it from becoming clogged] and medication administration. The Order Summary did not indicate how to check for G-tube placement and did not indicate an external catheter length (the measurement of the G-tube outside the body).During a record review of Resident 1's document titled SBAR [a communication method used in nursing to communicate important information clearly] & INITIAL COC (Change of Condition)/ALERT CHARTING & SKILLED DOCUMENTATION dated 7/6/2026 at 8:25 A.M., the document indicated, [Resident 1] was noted with low temp [temperature] of 94.3, pulse was fluctuating at 90-120 [heart beats per minute, normally ranging from approximately 60 to 100 beats per minute], diaphoretic [heavily sweating], BS [blood sugar] check and was 164 [normally ranges from 60 to 100], double blankets was placed but hypothermia [an abnormally low body temperature] was unresolved at 95.9 [a normal body temperature is around 98.6 degrees Farenheit- a unit of measurement]. Resident looks pale than usual [sic].Reported to [Nurse Practitioner] with order to send to ER [Emergency Room].During a record review of Resident 1's hospital document titled Operative Note, dated 7/6/2026, authored by the Emergency General Surgery Attending Physician, the note indicated, Date of Surgery: 07/06/26.Preoperative [before surgery] Diagnosis: Displaced G-tube.Procedures: Emergent exploratory laparotomy [an emergency surgical operation in which an incision is made in the abdomen to try to identify or treat a problem], Gastrostomy feeding tube placement.Indicated: This is a [AGE] year old male with end-stage [the final or most advanced stage of a disease or medical condition] ALS trach [tracheostomy- a surgically created opening in the front of the neck into the windpipe to help a person breathe] and G-tube dependent who presented from his SNF [Skilled Nursing Facility] with abdominal sepsis found to have extra gastric [related to the stomach] gastrostomy tube on CT [a test that uses x-rays to take pictures of the inside of the body] scan with significant free fluid [fluid that is present inside a body cavity but is not contained inside an organ].Findings: 1 L [Liter- a unit of measurement for liquids] of tube feeds intraperitoneal. G-tube adhered to stomach wall with balloon inflated outside of the stomach.During a record review of Resident 1's Progress Note dated 5/18/2026, authored by the Wound Nurse Practitioner indicated, Referral was received from [Facility Name] asking [Wound Care Company Name] to consult patient [sic] for urgent feeding tube replacement. Pt [Patient] is a [Resident's Age] yo [year old] male with dysphagia [difficulty swallowing] requiring tube feedings. [Patient] currently with 16 fr [French- a unit of measurement] g-tube [gastrostomy tube] that required urgent replacement due to dislodgement today. G-tube Replacement with G-tube with KUB [an x-ray of the kidney, ureter, bladder]: . In the event of accidental dislodgement, Patient's nurse was educated on the importance of gently reinserting the G-tube back through the stoma [a surgically created opening on the body] to maintain patency [the state of being open, clear, and free from obstruction], as well as to NOT use it for administration of medicine or feeding and then notify Wound Docs for replacement. The progress note did not indicate that the gastrostomy tube was marked with a line to indicate the insertion site. In addition, the Wound Nurse Practitioner did not document the length of the newly inserted external catheter.During an interview with Licensed Nurse (LN) 1 on 7/22/2026 at 9:34 A.M., LN 1 stated to verify gastrostomy tube placement, I put 30 cc's [cubic centimeters- a unit of measurement] of air [into the G-tube] and listen for the bowel sounds with my stethoscope. If I hear air that means the tube is in the stomach. LN 1 stated the facility's policy to check for G-tube placement was to remove gastric content using a syringe, and to test the gastric content using a pH strip (a strip used to verify the placement of a gastrostomy tube by testing gastric content) but the pH strips were not available at the facility. LN 1 stated she had never seen or used the pH strips at the facility.During an interview with LN 2 on 7/22/2026 at 10 A.M., LN 2 stated the facility had a new policy to use pH strips to verify gastrostomy tube placement. LN 2 stated, We don't have the strips yet. LN 2 stated she verified gastrostomy tube placement by pushing air into the G-tube and auscultating (listening) for a gurgling sound with a stethoscope. LN 2 stated if there was a gurgling sound, that meant the gastrostomy tube was inside the stomach.During a concurrent interview and review of Resident 1's record with the Director of Nursing (DON) on 7/22/2026 at 10:20 A.M., the DON stated on 7/21/2026 she conducted an in-service for licensed nurses to review the policy and procedure for gastrostomy tube placement verification. The Inservice Sign-In sheet dated 7/21/2026 indicated, Content Summary: Staff reminded of policy and procedure for Gtube dislodgement and placement verification- x-ray/KUB. The DON stated the facility had not been following their policy, which included utilizing pH strips. The DON stated because the facility did not have any pH strips available at the facility the nurses could not verify G-tube placement per the facility policy.During a follow up interview with the Director of Nursing (DON) on 8/14/2026 at 10:44 AM, the DON stated on 7/6/2026, licensed nurses were not able to see a line on gastrostomy tubes because it was faded. The DON further stated, It wouldn't be safe to assume [the gastrostomy tube] is in its place because you see a line. The DON further stated it was not the facility's practice to document the external catheter length for residents with gastrostomy tubes. The DON stated the most reliable way to confirm a gastrostomy tube was placed in the stomach correctly was to use a pH strip to test gastric contents. The DON verified the facility never used pH strips to verify gastrostomy tube placement for any residents prior to 7/22/2026.During a review of the policy titled Confirming Placement of Feeding tubes, revised September 2018, the policy indicated, The purpose of this procedure is to ensure proper placement of an existing feeding tube prior to administering enteral feedings or medication.Verify that placement of the feeding was confirmed by X-ray upon initial insertion and that the tube has been marked or the tube length has been documented.To Confirm Placement of an Existing Tube at the Bedside.The exit site of the feeding tube should be marked (by incremental marking on the tube or by documented tube length) at the time of initial placement.If a change in the incremental markings or tube length is observed, use additional method(s) to test whether the tube is properly positioned: a. Observe for symptoms of elevated gastric residual volume [an increase in the contents of the stomach] (GRV): (1) A sharp increase in residual volume may indicate that a small bowel tube has moved into the stomach; (2) Little to no residual volume may suggest that the tube has migrated from the stomach to the esophagus. B. Observe and check the pH of aspirate.If the above suggests improper tube positioning, do not administer feeding or medication. Notify the Charge Nurse of Physician.

Based on observation, interview, and record review, the facility failed to ensure dignity and respect were maintained for six of six residents (1, 2, 3, 4, 5, 6) while providing care when:1. Certified Nursing Assistant (CNA) 1 was rude and used a vulgar ( F) word when Resident 1 asked for assistance and threw soiled towels and linens after care leaving stains on the wall.2. Resident 2 verbalized CNA 1 was rude and had an attitude when CNA 1 entered the room and stated, What do you want?3. Resident 3 verbalized CNA 1 would leave him wet all night and was rude and rough while changing him. 4. Resident 4 verbalized he preferred not to ask CNA 1 for help because CNA 1 was rude and rough in her patient care and would say, What the 'F.ck' do you want?5. Resident 5 verbalized she felt scared to death and was observed crying, also stating that CNA 1 would glare at her when she asked for anything. 6. Resident 7 verbalized CNA 1 would start care without explaining what was going to be done and was rough when turning her, and treated her like an animal. As a result, this failure caused the residents to feel that their needs were not met and felt disrespected and to cry because of the fear of CNA 1, and to refuse care by CNA 1.Findings:1. A review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE] with hemiplegia and hemiparesis (conditions resulting from central nervous system damage that cause weakness or paralysis on one side of the body) affecting left side of her body.A review of Resident 1's Minimum Data Set Assessment (MDS, a comprehensive assessment tool) dated 12/1/25, indicated the resident's BIMS (Brief Interview for Mental Status) was 15 out of 15, indicating the resident was cognitively intact (no memory, focus, or judgment issues). 2. A review of Resident 2's admission Record indicated the resident was admitted to the facility on [DATE] with hemiplegia and hemiparesis affecting her right side of the body and moderate dementia.A review of Resident 2's Minimum Data Set assessment dated [DATE], indicated the resident's BIMS was 3 out of 15, indicating the resident's cognition was severely impaired.3. A review of Resident 3's admission Record indicated, the resident was admitted to the facility on [DATE] with congestive heart failure (a chronic condition where the heart muscle is too weak or stiff to pump blood efficiently) and muscle weakness.A review of Resident 3's Minimum Data Set assessment dated [DATE], indicated the resident's BIMS was 12 out of 15, indicating the resident's cognition was moderately impaired. 4. A review of Resident 4's admission Record indicated the resident was admitted to the facility on [DATE] with quadriplegia (a form of paralysis that causes the loss of movement and feeling in all four limbs and the torso) and pressure ulcers (an area of damaged skin and tissue caused by prolonged pressure, friction, or shear, usually over bony areas like the heels, hips, or tailbone).A review of Resident 4's Minimum Data Set assessment dated [DATE], indicated the resident's BIMS was 10 out of 15, indicating the resident's cognition was moderately impaired. 5. A review of Resident 5's admission Record indicated the resident was admitted to the facility on [DATE] with hemiplegia and hemiparesis affecting left side of her body.A review of Resident 5's Minimum Data Set assessment dated [DATE], indicated the resident's BIMS was 13 out of 15, indicating the resident was cognitively intact. 6. A review of Resident 7's admission Record indicated the resident was admitted to the facility on [DATE] with pressure ulcers and fracture of fifth cervical vertebra (one of the seven bony segments in the neck).A review of Resident 7's Minimum Data Set assessment dated [DATE], indicated the resident's BIMS was 15 out of 15, indicating the resident was cognitively intact. On 2/18/26 at 2:34 P.M., an interview with Resident 1 was conducted. Resident 1 stated when CNA 1 comes into the room she would say What do you want? your light is on. Resident 1 stated when she called for a brief change, CNA 1 checked the brief and told her Don't fucking call if you're not wet when CNA 1 felt that Resident 1 was not wet enough to be changed. Resident 1 stated that CNA 1 would throw soiled linens and towels on the floor, which left stains on the wall. Resident 1 further stated that CNA 1 did not greet her or explain procedures before starting. On 2/18/26 at 2:50 P.M., an interview was conducted with Resident 2. Resident 2 stated she felt CNA 1 was rude, uncaring, and had an attitude. Resident 1 stated CNA 1 would treat her as if passing you up as nothing. Resident 2 stated CNA 1 would say What do you want? upon entering her room which made her feel disrespected. Furthermore, Resident 2 stated CNA 1 did not help assist her with turning the TV and told her to Just turn it a little bit and walked out of the room. Resident 2 stated she felt she could not reach CNA 1 when she needed help. On 2/18/26 at 4:10 P.M., a follow-up interview was conducted with Resident 1 and her daughter. Resident 1 stated CNA 1 was always rude, and her actions made Resident 1 feel she was not heard and disrespected. Resident 1's daughter stated she was worried that someone like CNA 1 was assigned to her mother and stated that she was worried for the other residents who were more vulnerable. On 2/19/26 at 7:08 A.M., a phone interview was conducted with CNA 1. CNA 1 denied the allegations. On 2/19/26 at 7:54 A.M., an interview with Licensed Nurse (LN) 1 was conducted. LN 1 stated Resident 1 was quiet and sweet, only calling for brief changes and pain meds at night, with very minimal calls for assistance. LN 1 stated Resident 1 was alert and that she has never heard Resident 1 making false accusations regarding staff. LN 1 stated she did not want to work with CNA 1 because CNA 1's work performance was not consistent and the way she spoke made staff feel uncomfortable. LN 1 stated staff should not use profanity or act rudely toward residents. On 2/19/26 at 8:20 A.M., a phone interview was conducted with CNA 2. CNA 2 stated CNA 1 was careless in performing resident care. On 2/19/26 at 11:55 A.M., a follow-up phone interview with LN 1 was conducted. LN 1 stated Resident 1's experience should not have occurred. LN 1 stated Resident 3 refused to have CNA 1 assigned but did not explain why. On 3/24/26 at 10:38 A.M, a phone interview with Charge Nurse (CN) was conducted. CN stated she heard CNA 1 say what do you want while rounding. CN stated she observed CNA 1 demonstrated no compassion or empathy toward the residents. CN stated CNA 1 became very defensive when given feedback about her patient care. CN stated CNA 1 wore a hoodie on her head, and this scared Resident 2. CN stated it was important for the leadership to address CNA 1's behavioral concerns to create a safe space for residents, as they should not feel fearful or disrespected by staff. CN stated CNA 1 should never have been verbally abrasive or rough during care. CN stated it was disheartening to hear her residents' experiences with CNA 1.A review of text message conversations initiated by CN to notify the Director of Nursing (DON) and Director of Staff Development (DSD) regarding CNA 1's behavioral concerns dated 1/5/26, 1/23/26, and 1/30/26, indicated:On 1/5/26 at 11:12 A.M., CN reported, Big concern related to [CNA1], new NOC shift CNA. [Resident 4], [Resident 5] Fears her, [Resident 7], [Resident 3], [Resident 1] say she is really rude, she is rough when changing, tells them [Residents 1, 2, and 3] not to turn on [Call] light if she has changed them once during shift. [Resident 7] is alert and ambulatory was told by her he can do [what he asked her to do] for himself why is he calling, [resident 3] says she rude and rough doesn't come for. [Resident 1] says she is rude and used a dirty washcloth after being changed to clean her face or says she saw her use the dirty one. All these patients state they do NOT want her to provide care at all. Please find a new home section for her. So, I can reassure my patients she will not be back.DON response: This is not good. This is not the first time I had ask [sic] her and (name of staff) one Sunday coz the pts were not changes [sic].CN : She [CNA 1] doesn't seem to care. I told her this morning to remove the hood of sweater when providing care. [Resident 5] is terrified of her crying saying she's scared of her and she looks at her so mean when she asks for anything.DSD: Oh no, not good at all.CN : Please do not assign her to (name of a unit) moving forward hall [sic] of her section doesn't want her. The res are not able to say on their part but I can only imagine.On 1/23/26 at 10:25 A.M., CN reported, [Resident 2] stated that the Cna on doc [NOC] last night the black girl was really rude to her. [Resident 2]'s words are she was a bitch. The sign in [folder with assignments for the shift at the station] isn't there so I can say who it was. [Resident 2] is super forgetful so for her to retain this morning and tell me says a lot.DSD: They're both black women last night.CN : She's [Resident 2] in room [ROOM NUMBER].DSD: OK I'll follow up with the assignment.On 1/30/26 7:48 A.M., the text message indicated, The NOC SHIFT didn't get [Resident 6] up AGAIN [ Residents on get up list are written on the board in the station and on the assignment sheet. He was the only get up res in the morning for this section]. They already know that he is a daily and haven't been doing it. This is becoming redundant with the Nov [NOC] shift staff. Is anything even being addressed. Feels like it's a waste of time bringing issues up because nothing changes. He didn't get up yesterday d/t WHEELCHAIR being washed otherwise he should be up. It's like we have to babysit adults. [CNA 1] was assigned to that side. On 3/26/26 at 12:33 P.M., a follow up interview was conducted with CN to clarify the contents of the texts.For the text sent on DON and DSD on 1/5/26:Resident 4 reported to CN that CNA 1 was rude and rough, he preferred not to ask CNA 1 for help and would rather wait for the morning shift to come to help him.Resident 5 was upset and crying and reported to CN that she was scared to death, and that CNA 1 was assigned to her again and would glare at her.Resident 7 reported to CN that CNA 1 was really rough when turning her and would push her over side-to-side in hurry and treated her like an animal. CNA 1 would not tell her the process of care.Resident 3 reported to CN that CNA 1 would leave him in wet brief all night, he could not get CNA 1 change him.Resident 1 reported to the CN that CNA 1 wiped her face with a washcloth that had previously been used to clean the resident's bottom. The resident expressed that she was appalled by this action. Furthermore, Resident 1 reported experiencing rough care during turns by CNA 1. CN stated she heard CNA 1 say what do you want to Resident 1 while making rounds. Resident 1 told CNA 1 to get out of her room as soon as Resident 1 saw CNA 1. CNA 1 said she had already changed resident and turned off the call light in the room and walked out. CN stayed behind with Resident 1 and heard what happened with the washcloth. CN reported this to the DSD. CN stated the facility's protocol was to change their residents' soiled brief as many times as they needed.CN stated she heard CNA 1 telling a resident, Don't turn on the call light if you can do it yourself. CN stated she corrected CNA 1 on the spot but could not recall CNA 1's response. The incident was reported to leadership. CN further noted that during the following shift, CNA 1 was again wearing a hood on her head.CN stated her residents should not have experienced any of what they reported to her and it was not a safe environment for them. CN stated this was violation of the residents' dignity. CN stated CNA 1 was removed from her unit after the incident on 1/30/26.CN stated she became upset when she saw CNA 1 working in another unit. CN expressed concern that the facility continued to subject other residents to CNA 1, and she feared for those who could not verbalize their concerns. On 4/1/26 at 11:48 A.M., a phone interview was attempted with the DSD. The DON stated that the DSD left the facility a few weeks ago and the DON is currently covering the position. On 4/1/26 at 2:25 P.M., an interview was conducted with Resident 4, who stated that CNA 1 would say, What the fuck do you want? when called for help. The resident stated that CNA 1 became upset when asked to bring items, making it difficult to receive assistance. Furthermore, Resident 4 stated he had difficulty getting help with turning every two hours, adding that CNA 1 did not seem to care about patient care and never returned to assist him. Finally, the resident stated he had previously complained to the facility regarding CNA 1. On 4/1/26 at 3:05 P.M., an interview was conducted with LN 2. LN 2 stated staff must always introduce themselves, ask what the resident's needs are, and explain the procedure before starting, even if the residents were in vegetative condition. LN 2 stated CNA 1 should never have used profanity or tone of aggression toward residents. On 4/3/26 at 11:50 A.M., an interview was conducted with the DON. The DON stated the residents have the right to exercise their rights as residents of the facility. After hearing what some of the residents experienced with CNA 1, the DON acknowledged resident rights were not protected when CNA 1 was not treating the residents with respect and dignity. The DON stated CNA 1 should have treated the residents with not only respect and dignity but also should have treated them as her own family.A review of facility policy titled Resident Rights, dated December 2016, indicated, .Employees shall treat all residents with kindness, respect, and dignity.1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignifies existence, b. be treated with respect, kindness, and dignity, c. be free from abuse, neglect, misappropriation of property, and exploitation.g. exercise his or her rights as a resident of the facility and as a resident.

Based on observation, interview and record review, the facility failed to provide a written notice of bed hold rights for one of two residents (Resident 26) reviewed for hospitalization. This failure had the potential for the resident and/or the resident's representative not to have information regarding bed hold rights.Findings: Resident 26 was re-admitted to the facility on [DATE] with diagnoses including chronic respiratory failure with hypoxia (a condition where the lungs fail to adequately exchange oxygen, leading to low oxygen in the blood) according to the facility's admission Record. During an observation on 1/12/26 at 8:34 A.M., Resident 26 was in bed with his eyes closed. Resident 26 was observed with a tracheostomy (an opening on the neck with a tube to help with breathing) and a feeding tube (tube placed in the stomach). During a review of Resident 26's Minimum Data Set (MDS-a clinical assessment tool) dated 11/18/25, the MDS section C1000 indicated Resident 26's cognitive skills for daily decision making was severely impaired. A review of Resident 26's electronic medical record was conducted. A document titled, SBAR (is a structured, four-step communication tool - Situation, Background, Assessment, Recommendation, used by staff to efficiently report changes in a resident's condition to physicians or nurses) & INITIAL COC [change of condition]/ALERT CHARTING & SKILLED DOCUMENTATION indicated, Resident 26 had fever and abnormal vital signs on 11/18/25. The document further indicated Resident 26's physician ordered to transfer Resident 26 to the emergency room. The document did not indicate if Resident 26's responsible party was provided with a written notice of bed hold rights. An interview on 1/14/26 at 9:43 A.M. was conducted with Licensed Nurse (LN) 2. LN 2 stated Resident 26 was transferred to the hospital on [DATE] for a change in condition. LN 2 stated the notice of transfer and discharge was sent to the family by social services. LN 2 stated she was unsure if bed hold was sent to the family. An interview on 1/14/26 at 10:52 A.M. was conducted with the social service assistant (SSA). The SSA stated the nursing staff notified responsible parties regarding bed hold, but did not know who sent the form to them. A follow up interview on 1/14/26 at 11:17 A.M. with the SSA was conducted. The SSA stated a written notice of bed hold was not mailed or sent to residents' responsible parties. An interview was conducted on 1/15/26 at 1:10 P.M., with the Director of Nursing (DON). The DON stated if a resident was transferred to the hospital, a bed hold must be offered, and a written copy should be provided to confirm notification of bed hold rights. A review of the facility's policy and procedure (P&P) titled, Bed-Holds and Returns, dated March 2017 was conducted. The P&P indicated, Prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy. The P&P did not provide guidance regarding who was responsible for sending a written bed hold rights to the resident or responsible party when a resident was transferred to the hospital.

Based on observation, interview, and record review, the facility failed to complete a significant change Minimum Data Set (MDS- clinical assessment tool) assessment for one of 24 sampled residents (Resident 115).This failure had the potential to cause the resident to not receive appropriate care.Findings: Per the facility's admission record, Resident 115 was admitted on [DATE] with a diagnosis of other encephalopathy (a brain disease that can cause confusion, memory loss, and coma [a prolonged state of deep unconsciousness]).During a record review of Resident 115's electronic medical record (EMR), the record indicated Resident 115 was admitted to hospice (is specialized, comfort-focused care for residents with a terminal illness (typically six months or less to live) who reside in a nursing home) with a diagnosis of late effect of Cerebral Vascular Accident (CVA-stroke, loss of blood flow to a part of the brain) on 5/20/25. During a record review of Resident 115's paper medical record, the record indicated Resident 115 was discharged from hospice on 11/2/25 for extended prognosis.During a review of Resident 115's MDS assessment dated [DATE], Section O, Special treatment, Procedures, and Programs, the assessment indicated that Resident 115 was receiving hospice services while a resident resided at the facility. During an interview on 1/14/25 at 9:25 A.M. with the MDS nurse (MDSN), the MDSN stated the MDS assessment was used to establish care plans and reimbursement rates. The MDSN further stated that an MDS assessment should have been completed when Resident 115 was discharged from hospice services. The MDSN further stated there should have been a change in condition assessment, the resident could miss care because we thought hospice was coming.During an interview on 1/14/25 at 9:45 A.M. with the Director of Nursing (DON), the DON stated the MDS was the picture of the resident, and that it impacts payment and the resident's plan of care. The DON stated CMS and insurance would think he was still on hospice; the MDSN should have checked No.During a review of Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.20.1 dated October 2025 indicated, The SCSA [Significant Change in Status Assessment] is a comprehensive assessment .for either a major improvement or decline . The document further indicates .The nursing home is required to complete an SCSA when the resident comes off the hospice benefit .

Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS- a standard assessment to facilitate residents' care) related to hospice (medical care for residents expected to live six months or less) services were coded accurately for one of 24 sampled residents (Resident 9). This failure could affect the residents' plan of care.Findings: Resident 9 was admitted to the facility on [DATE] with diagnoses that included dysphagia (difficulty swallowing) and hemiplegia (paralysis affecting one side of the body) per the admission Record. A review of Resident 9's clinical record was conducted on 1/12/26. Per the MDS assessment, dated 11/23/25, Section O: Special Treatments, Procedure, and Programs, indicated Resident 9 was under hospice care and services. Per the Physician's Order dated 6/25/25, Resident 9 was under hospice care and services. A further review of Resident 9's clinical record revealed no documented evidence in the Interdisciplinary Team (IDT- a group of healthcare professionals working together to create a person-centered care plan) notes or progress notes indicating that Resident 9 revoked hospice care and services. On 1/13/26 at 4:00 P.M., a joint interview and record review was conducted with Licensed Nurse (LN) 6. LN 6 stated Resident 9 was discharged from hospice two months prior because the resident requested more aggressive treatment. On 1/13/26 at 4:25 P.M., the Director of Nursing (DON) stated that Resident 9 revoked hospice on 11/13/25. The DON further stated there was no physician order documenting the physician's awareness of the revocation. On 1/14/26 at 3:15 P.M., an interview was conducted with the Minimum Data Set Nurse (MDSN). The MDSN acknowledged she was aware that Resident 9 revoked hospice care and services on 11/13/25 but made a coding error. The MDSN stated she completed the MDS assessment on 11/23/25 and incorrectly coded Resident 9 as under hospice care and services. The MDSN acknowledged that accurate MDS coding was essential to reflect the resident's current health status and ensure an appropriate plan of care. On 1/16/26 at 1:33 P.M., the DON stated the MDS should have been coded accurately. Per the Resident Assessment Instrument (RAI- instructions for MDS completion), dated 10/1/25, indicated .nursing homes are responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate assessment.

Based on interview and record review, the facility failed to follow level 2 (evaluation and determination) screening process of the PASARR (Pre-admission Screening and Resident Review, a federally required document to ensure residents are appropriately placed and/or for services) for two of two residents (Resident 5 and 114) reviewed for PASARR. This failure had the potential for Residents 5 and 114, not to receive the care and necessary services in the most appropriate setting. Findings: 1. A review of the clinical record for Resident 5 was conducted. The admission record indicated Resident 5 was admitted to the facility on [DATE] with diagnoses which included paranoid schizophrenia (severe mental health disorder involving distrust and suspicion of other people), and depression. A review of Resident 5's PASARR 1 dated 12/18/25 was conducted. PASARR 1 indicated Resident 5 was positive with Level 1 indicating Level 2 should have been submitted for evaluation and proper placement of Resident 5. An interview with the Minimum Data Set Nurse (MDSN, nurse responsible for conducting an assessment tool) was conducted on 1/13/26 at 3:12 P.M. The MDSN stated she did not see PASARR Level 2 being conducted for Resident 5. The MDSN stated she did not know what happened and that she should have followed up to make sure Resident 5 was getting the right services at the facility. An interview with the Director of Nursing (DON) was conducted on 1/15/26 at 2:03 P.M. The DON stated Resident 5's PASARR Level 2 should have been followed up to ensure proper placement of Resident 5 to meet her care needs. A review of the facility's policy titled admission Criteria, revised 3/2019, indicated, Our facility admits only residents whose medical and nursing care needs can be met .9. All new admission and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process.b. If the level 1 screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASARR representative for the Level 2 (evaluation and determination) screening process. 2. A review of Resident 114's clinical record was conducted. The admission record indicated that Resident 114 was re-admitted to the facility on [DATE] with diagnoses which included schizophrenia (a mental illness that is characterized by disturbances in thought), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). A review of Resident 114's PASARR 1 dated 5/21/24 was conducted. PASARR 1 indicated Resident 114 was positive with Level 1 indicating Level 2 should have been submitted for evaluation and proper placement of Resident 114. An interview with the MDSN was conducted on 1/13/26 at 3:12 P.M. The MDSN stated she did not see PASARR Level 2 being conducted for Resident 114. The MDSN stated Resident 114's PASARR level 1 indicated a level 2 was required for Resident 114. The MDSN stated she should have followed up to make sure Resident 114 was getting the right services at the facility. An interview with the Director of Nursing (DON) was conducted on 1/15/26 at 2:03 P.M. The DON stated Resident 114's PASARR Level 2 should have been followed up to ensure proper placement of Resident 114 to meet her care needs. A review of the facility's policy titled admission Criteria, revised 3/2019, indicated, Our facility admits only residents whose medical and nursing care needs can be met .9. All new admission and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process.b. If the level 1 screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASARR representative for the Level 2 (evaluation and determination) screening process.

Based on observation, interview, and record review, the facility did not develop patient centered care plans for two of six residents (Resident 1 and 6) reviewed for care plans. 1. Resident 1 had no teeth. 2. Resident 6 had a GT (GT-a tube inserted into the stomach for nutrition) dressing with discharge. These failures had the potential to negatively affect the residents' (1, 6) needs, affecting their dignity, comfort, safety, and well-being. Findings: 1. Resident 1 was admitted to the facility on [DATE] with diagnoses including respiratory failure with hypoxia (a condition where the lungs fail to adequately exchange oxygen, leading to low oxygen in the blood) according to the facility's admission Record. The admission Record also indicated Resident 1's daughter was the responsible party (RP). An observation of Resident 1 was conducted on 1/12/26 at 9:06 A.M. Resident 1 was in bed with a tracheostomy (an opening on the neck with a tube to help with breathing) and feeding tube (tube in the stomach). Resident 1 had a beard and long moustache which covered half of Resident 1's mouth. Resident 1 attempted to speak but had no voice. A phone interview on 1/13/26 at 9:49 A.M. was conducted with Resident 1's daughter/RP. The RP stated she notified facility staff during care conference that Resident 1 needed dentures but had not heard back from the facility. The RP stated Resident 1 wavered on trimming moustache and shaving because it covered Resident 1's mouth. During a follow up observation and interview on 1/14/26 at 9:39 A.M. with Resident 1, Resident 1 whispered he would like to keep his moustache. Resident 1 further whispered he had no teeth and would like dentures. A review of Resident 1's care plans was conducted. Care plans for Resident 1 did not indicate Resident 1's oral status. During an interview on 1/15/26 at 7:55 A.M. with the Minimum Data Set Nurse (MDSN- a nurse who assessed and evaluated the quality of care being given to residents), the MDSN stated care plans should address residents' oral status because they affect the overall plan of care for residents. An interview and concurrent record review on 1/15/26 at 8:12 A.M. was conducted with the Social Service Director (SSD). The SSD reviewed the social service assessments for Resident 1. The SSD stated the social service assessments dated 7/24/25 and 10/23/25 indicated, Resident 1 has own teeth. The SSD stated if a resident had no teeth, she would refer to the dentist if the resident or responsible party requested dentures. The SSD further stated residents with tube feeding should also have dentures if requested, for their self-esteem. During an interview on 1/15/26 at 8:22 A.M. with Licensed Nurse (LN) 3, LN 3 stated she checked Resident 1's mouth and confirmed Resident 1 did not have teeth. An interview and concurrent record review on 1/15/26 at 8:26 A.M. with LN 4 was conducted. LN 4 stated there was no care plan for Resident 1 to address Resident 1 not having teeth. LN 4 stated it was important to care plan for resident's risk for infection and low intake due to not having teeth. During an interview on 1/15/26 at 1:10 P.M. with the Director of Nursing (DON), the DON stated having dentures were part of resident's body image which allowed the resident to eat and chew, and prevent weight loss. The DON stated it was important to have a care plan because it was the resident's plan of care. 2. Resident 6 was admitted to the facility on [DATE] with diagnoses including other specified muscular dystrophies (MD- a genetic disease-causing progressive muscle weakness and loss) and presence of gastrostomy (GT-a tube inserted into the stomach for nutrition) according to the facility's admission Record. An interview and concurrent observation of Resident 6 was conducted on 1/13/26 at 3:28 P.M. with Licensed Nurse (LN) 1. Resident 6 was in bed with tube feeding infusing. LN 1 removed Resident 6's dressing from the GT site. The dressing had a small amount of grayish/tan discharge. The GT site's surrounding was pink in color. LN 1 stated the discharge could be pus. A follow up interview and concurrent observation of Resident 6 was conducted on 1/14/26 at 3:33 P.M. with Treatment Nurse (TN) 1. TN 1 removed the dressing from Resident 6's GT site. The dressing had grayish/green discharge and a small amount of blood on the opening of the split of the dressing. The GT site was observed with reddened surroundings. An interview and joint record review was conducted on 1/15/26 at 8:32 A.M. with LN 4. LN 4 reviewed the care plans for Resident 6. LN 4 stated there was no care plan to address the GT discharge. LN 4 stated the care plan was only developed yesterday, 1/14/26. LN 4 stated there should have been a care plan prior to 1/14/26 because it was a change in condition and the GT site required monitoring for signs of infection. During an interview on 1/15/26 at 1:10 P.M. with the Director of Nursing (DON), the DON stated it was important to have a care plan because it was the resident's plan of care. A review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated December 2016 was conducted. The P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.The care planning process will.Facilitate resident and/or representative involvement.

Based on the interview and record review, the facility failed to ensure the Interdisciplinary Team (IDT- a group of healthcare professionals working together to create a person-centered care plan) meeting was documented for one of 24 sampled residents (Resident 9), when Resident 9 decided to revoke hospice service (medical care for residents expected to live six months or less). This failure had the potential to affect the revision of the care plan to reflect Resident 9's goals and preferences.Findings: Resident 9 was admitted to the facility on [DATE] with diagnoses that included dysphagia (difficulty swallowing) and hemiplegia (paralysis affecting one side of the body) per the admission Record. On 1/12/26 at 9:10 A.M., Resident 9 was observed in bed with eyes closed and wearing a hospital gown. A review of Resident 9's clinical record was conducted on 1/12/26. Per the MDS assessment dated [DATE], Section O: Special Treatments, Procedures, and Programs indicated Resident 9 was under hospice care and services. Per the Physician's Order dated 6/25/25, Resident 9 was under hospice (a specialized, interdisciplinary care model for individuals with terminal illnesses (typically with life expectancy of six months or less) care and services. Further review of Resident 9's clinical record revealed no documented evidence in the Interdisciplinary Team meeting notes or progress notes to indicate Resident 9 revoked hospice care and services. In addition, there was no physician order to indicate hospice services were discontinued. On 1/13/26 at 4:00 P.M., a joint interview and record review was conducted with Licensed Nurse (LN) 6. LN 6 stated Resident 9 was discharged from hospice care two months prior because the resident requested more aggressive treatment. On 1/13/26 at 4:25 P.M., the Director of Nursing (DON) stated Resident 9 revoked hospice on 11/13/25. The DON further stated that there was no physician order documenting the physician's awareness of the revocation, and there should have been. On 1/14/26 at 10:00 A.M., an interview was conducted with LN 6. LN 6 stated she recalled there was an IDT meeting about Resident 9 no longer receiving hospice, but she could not explain why it was not documented. LN 6 stated that social services was responsible for documenting the meeting. On 1/14/26 at 4:15 P.M., a joint interview and record review was conducted with the Social Service Director (SSD). The SSD stated there was no formal IDT meeting when Resident 9 revoked hospice care and services. The SSD further stated there should have been documented evidence of the IDT meeting to assess and update the care plan and to ensure that the care was aligned with Resident 9's wishes. On 1/15/26 at 1:33 P.M., the DON stated she received a call from family members and explained the hospice revocation process. The DON stated on 11/6/25, there was an IDT (is a collaborative group of healthcare professionals, staff, and family members responsible for developing and implementing a comprehensive, person-centered care plan for residents) meeting that she facilitated about hospice revocation, and on 11/13/25, Resident 9 revoked hospice care and services. The DON further stated the IDT meeting should have been documented in Resident 9's clinical record to show collaboration amongst the IDT. Per the facility's policy and procedure dated 3/2022, titled Care Planning - Interdisciplinary Team, The interdisciplinary team is responsible for the development of resident care plans. Per the facility's policy and procedure dated 12/2022, titled Care Plans, Comprehensive Person-Centered, .8. The Comprehensive, person-centered care plan will: Reflect the resident's expressed wishes regarding care and treatment goals

Based on observation, interview, and record review, the facility failed to ensure one of six residents (128), who was unable to carry out activities of daily living (ADLs - self- care activities such as grooming, bathing, and toileting), received assistance with nail care [cleaning, trimming and/or filing of nails]) and shaving. As a result of this deficient practice, Resident 128 was unshaven with debris under Resident 128's fingernails which had the potential to affect Resident 128's comfort and wellbeing.Findings: Resident 128 was admitted to the facility on [DATE] with diagnoses including respiratory failure (a condition when lungs cannot get enough oxygen in the blood) and need for assistance with personal care according to the facility's admission Record. During an observation and interview of Resident 128 was conducted on 1/12/26 at 8:49 A.M. Resident 128 was eating breakfast with black debris under fingernails and unshaven. Resident 128 had a tracheostomy (an opening on the neck with a tube to help with breathing) and nodded, indicating he wanted to be shaved. During a follow-up observation on 1/13/26 at 3:22 P.M. Resident 128 was sitting up in bed, shaved with a moustache. Resident 128 smiled and touched his head and face. Resident 128's fingernails were short but had black debris underneath. A review of Resident 128's electronic medical record (EMR) was conducted. The Minimum Data Set (MDS-a clinical assessment tool) dated 1/13/26, section C0500 indicated, Resident 128's Brief Interview for Mental Status (BIMS- evaluates cognition, the ability to remember and think clearly) score was 15, which indicated intact cognition. Section GG0130I indicated Resident 128 required substantial/maximal assistance with personal hygiene. During an interview on 1/14/26 at 10:14 A.M. with Licensed Nurse (LN) 2, LN 2 stated nail care was provided by the assigned CNA (certified nursing assistant) on Saturdays. LN 2 stated the treatment nurse was responsible for checking. LN 2 stated shaving of residents were provided during showers. An interview and joint observation was conducted on 1/15/26 at 8:57 A.M. with Treatment Nurse (TN) 2. TN 2 stated nail care was provided on Tuesdays and Thursdays, and as needed. TN 2 stated shaving of residents was provided as needed. Resident 128 was in bed and showed his fingernails to TN 2. TN 2 stated Resident 128's fingernails were dirty and should be cleaned. An interview with the Director of Nursing (DON) was conducted on 1/15/26 at 1:10 P.M. The DON stated shaving and nail care were part of personal care and skin care. The DON stated personal care was important for the resident's body image, dignity, and comfort. The DON further stated shaving should be done daily if needed. A review of the facility's policy and procedure (P&P) titled, Activities of Daily Living [ADL], Supporting, dated March 2023 was reviewed. The P&P indicated, Resident will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living [ADLs]. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.

Based on observation, interview, and record review, the facility failed to provide social service assistance for one of six residents (Resident 1) reviewed for medically-related social services when:1. A dental referral was not provided, 2. A hearing consultation was missed, 3. The social services assessments were inaccurate. These failures had the potential to delay care and services for the resident which could affect the resident's health and wellbeing, and quality of life. Findings: 1.Resident 1 was admitted to the facility on [DATE] with diagnoses including respiratory failure with hypoxia (a condition where the lungs fail to adequately exchange oxygen, leading to low oxygen in the blood) according to the facility's admission Record. The admission Record also indicated Resident 1's daughter was the responsible party. An observation of Resident 1 was conducted on 1/12/26 at 9:06 A.M. Resident 1 was in bed with a tracheostomy (an opening on the neck with a tube to help with breathing) and feeding tube (tube in the stomach). Resident 1 was observed with a beard and long moustache which covered half of Resident 1's mouth. Resident 1 attempted to speak but had no voice. A phone interview on 1/13/26 at 9:49 A.M. was conducted with Resident 1's daughter. Resident 1's daughter stated she notified facility staff during care conference that Resident 1 needed dentures but had not heard back from the facility. Resident 1's daughter stated Resident 1 wavered on trimming and shaving the moustache because it covered Resident 1's mouth. An interview on 1/14/26 at 9:08 A.M. was conducted with the Social Service Director (SSD) and Social Service Assistant (SSA). The SSD stated dental visits were on an as-needed basis. The SSD stated Resident 1 was not in the log for dental referral. During a follow up observation and interview on 1/14/26 at 9:39 A.M. with Resident 1. Resident 1 had no teeth, whispered that he would like to keep his moustache and would like dentures. 2. During an interview on 1/14/26 at 9:08 A.M. with the SSD and the SSA, the SSA stated Resident 1's last care conference was held in October 2025. The SSA stated Resident 1's daughter had requested an eye, nose and throat (ENT) consultation due to Resident 1's difficulty with hearing. The SSA reviewed the referral log. Resident 1's name was not on the list for ENT. The SSA stated she missed checking the log to ensure that Resident 1 was added. The SSD stated it was important for residents to be seen by ancillary services (additional services from providers outside the facility) to have normality and assist the residents' quality of life. 3. An interview and concurrent record review was conducted with the Social Service Director (SSD) on 1/15/26 at 8:12 A.M. The SSD stated residents' oral status was checked upon admission and quarterly and there was a standing physician's order for dental and hearing consultations upon admission to the facility. The SSD reviewed the social service assessments for Resident 1. The SSD stated the social service assessments dated 7/24/25 and 10/23/25 indicated Resident 1 has own teeth. The SSD stated if a resident had no teeth, she would refer to the dentist, provided the resident or responsible party requested dentures. The SSD further stated residents with tube feeding should also have dentures if requested for their self-esteem. During an interview on 1/15/26 at 8:22 A.M. with Licensed Nurse (LN) 3, LN 3 stated she checked Resident 1's mouth and confirmed Resident 1 did not have teeth. An interview on 1/15/26 at 1:10 P.M. was conducted with the Director of Nursing (DON). The DON stated she confirmed that Resident 1 did not have teeth and the social services assessments were inaccurate. The DON stated resident referrals should be followed because it was part of the facility's services provided to the residents. The DON stated it was important to provide a homelike environment such as having consultations from outside services. The DON further stated dental assessments should be accurate to ensure a dental referral would be made if needed. During a review of the facility's policy and procedure (P&P) titled, Dental Services, dated December 2016, the P&P indicated, Social services representative will assist residents with appointments, transportation arrangements, and reimbursement for dental services under the state plan, if eligible. A review of the facility's P&P titled, Referral, Social Services, dated December 2008 was conducted. The P&P indicated, Social services personnel shall coordinate most resident referrals with outside agencies.Social services will coordinate with nursing staff or other pertinent disciplines to arrange for services that had been ordered by the physician.Social services will document the referral in the resident's medical record. During a review of the facility' P&P titled, Dental Examination/Assessment, dated December 2013, the P&P indicated, Each resident shall undergo a dental assessment prior to or within ninety (90) days of admission. Resident shall be offered dental services as needed.Dental examinations will be made by the resident's personal dentist or by the facility's Consultant Dentist. The policy did not provide guidance on how facility staff should conduct a dental assessment to determine the need for a referral.

Based on observation, interview, and record review, the facility failed to ensure an open food item was labeled with an open date and stored properly in the reach-in refrigerator in the kitchen. This failure had the potential to cause food borne illness.Findings: On 1/12/26 at 7:49 A.M., a joint observation of the kitchen area was conducted with the Dietary Manager (DM). Inside the reach-in refrigerator was a torn-opened, used, unsealed crumpled plastic wrapper containing butter. The DM disposed of the butter and stated the butter should have been labeled, dated, and stored properly for the safety of the residents. Per the facility's policy and procedure, dated 2023, titled Labeling and Dating of Foods, indicated .Newly opened food items will be closed and labeled with an open date and used by the date that follows the various storage guidelines .

Based on observations, interview, and record review the facility failed to ensure infection control procedures were followed when: 1. Licensed Nurse (LN) 11 did not wear a gown consistently while providing care to Resident 86 who was on enhanced barrier precautions (EBP - involves gown and glove use during high-contact resident care activities for residents [example: residents with medical devices]), during medication (med) pass. 2. A certified nursing assistant (CNA) failed to properly use personal protective equipment (PPE - equipment such as gown and gloves used to protect staff and residents from potentially infectious diseases) while providing care for one of 24 sampled residents (Resident 94). These failures had the potential for cross contamination and spread of infection. Findings: 1. A review of Resident 86's admission Record indicated Resident 86 was admitted to the facility on [DATE], with diagnoses which included End Stage Renal Disease (ESRD-irreversible kidney failure). On 1/15/26 at 7:50 A.M., an observation and interview were conducted with Licensed Nurse (LN) 11. LN 11 prepared the medications for Resident 86. There was an EBP sign attached to Resident 86's door. LN 11 stated she will check Resident 86's vital signs. LN 11 checked Resident 86's vital signs without donning a gown. LN 11 went back to the medication cart, looked at the EBP sign at Resident 86's door, and stated, I should have worn PPE. I was in close contact with the resident because she was on EBP. On 1/15/25 at 8:32 A.M., another observation and interview of LN 11 was conducted. LN 11 went back to Resident 86's room and listened to Resident 86's lung sounds without putting on a gown. LN 11 spent 14 minutes with Resident 86 while conducting and assisting Resident 86 on an incentive spirometer (a way to do breathing exercises). LN 11's clothing was in close contact with Resident 86's clothes. LN 11 stated, I should have worn a gown, and I forgot again when I assessed her. On 1/15/26 at 2:02 P.M., an interview with the Director of Nursing (DON) was conducted. The DON stated the expectation was for the staff to follow the procedures on EBP consistently to prevent spread of infection especially if in close contact with the resident. A review of the facility's policy titled, Enhanced Barrier Precautions revised August 2022, indicated, .1. Enhanced barrier precautions (EBP) are used as an infection prevention and control interventions to reduce the spread of multi-drug resistant organisms (MDRO- bacteria resistant to multiple medications) to residents.6. EBPs remain in place for the duration of the resident's stay or.discontinuing of the indwelling medical device that places them at increased risk. 2. Resident 94 was admitted to the facility on [DATE] with diagnoses that included neuromuscular dysfunction of the bladder (a condition that causes loss of control, holding, or releasing urine) per the facility's admission Record. On 1/12/26 at 8:30 A.M., Resident 94 had EBP(enhanced barrier precautions [EBP] - involves gown and glove use during high-contact resident care activities for residents [example: residents with medical devices) signage posted on the door. Resident 94 was in bed and noted an indwelling catheter (a flexible tube that drains urine) attached to the catheter bag that was hanging on the side of the bed. On 1/12/26 at 9:22 A.M., an interview was conducted with Resident 94. Resident 94 stated he had a suprapubic catheter (urine tube inserted in the stomach) and was on EBP because of an infection he had in the past. On 1/14/26 at 8:47 A.M., Resident 94's door was observed fully opened, and the privacy curtain was drawn up to the edge of the bed. The staff was wearing gloves without a gown while assisting Resident 94 to dress, reposition, and move the indwelling catheter to the side of the bed. On 1/14/26 at 9 A.M., an interview was conducted with the staff after providing care to Resident 94 who introduced as certified nursing assistant (CNA 2). CNA 2 stated she emptied the indwelling catheter and provided a bed bath to Resident 94 without proper PPE (equipment such as gown and gloves used to protect staff and residents from potentially infectious diseases). CNA 2 stated she did not wear the PPE because Resident 94 was in a hurry to get up. CNA 2 stated she should have used the PPE to prevent the spread of infection. On 1/15/26 at 8:30 A.M., an interview was conducted with the Infection Preventionist Nurse (IPN). The IPN stated the staff should wear the PPE (gown and gloves) during high-contact resident care because the PPE served as a barrier to protect themselves and others, and avoid the spread of germs. On 1/15/26 at 8:35 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated that staff should follow the EBP protocol to prevent the spread of infection. Per the facility's policy and procedure, dated 8/2022, titled Enhanced Barrier Precaution, Enhanced barrier precaution (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDRO- bacteria resistant to multiple medications) to residents.

Based on interview and record review, the facility failed to follow their policy regarding receipt and storage of controlled medications (drugs regulated by the government for its use, possession, and manufacture). This failure resulted in a medication card containing 60 tablets of Morphine (a controlled medication used for pain) to be missing and unaccounted for. Findings: On 11/1/24, the facility reported to the Department On 10/30/24, Staff reported to the DON that a medication Morphine Sulfate 15 milligrams 60 tablet card was nowhere to be found . On 11/13/24 at 8:45 AM, the Assistant Director of Nursing (ADON) was interviewed. The ADON stated the missing medication was for Resident 1. The ADON stated the medication was noted to be missing on 10/30/24 when the facility attempted to reorder it. The ADON stated the pharmacy informed them it was already delivered on 10/20/24. The ADON stated the Facility Delivery Log was retrieved which indicated the medication was delivered on 10/20/24, and was signed in by a Licensed Nurse (LN 1). The ADON stated upon receipt of controlled medications, the licensed nurse was supposed to sign the delivery record and put the medication card and accompanying count sheet in the locked controlled medication drawer. The controlled medications were then supposed to be counted and reconciled at each shift change. The ADON stated controlled medications and associated count sheets were reconciled every shift, but since there was no sheet for the missing Morphine, reconcilation can not be verified. On 11/13/24 at 9:35 A.M., a concurrent review of the Facility Delivery Log was conducted with LN 1. LN 1 stated Resident 1 ' s Morphine was running low and he had messaged pharmacy to refill the order. LN 1 stated it was later determined it was already delivered on 10/20/24. LN 1 stated when medications were delivered, he was supposed to verify delivered medications against the list and sign the delivery sheet. LN 1 stated if controlled medications were delivered, he was supposed to put them in the locked controlled medication box with the controlled sheet that came with it. LN 1 acknowledged his signature on the Facility Delivery Log dated 10/20/24. The first line of the Log indicated, 10/20/24 .Morphine Sulf ER 15 milligram Tablet .Quantity 60 .LN 1 stated he did not remember any details about the delivery. LN 1 stated he did not know why it was missing and did not remember checking that medication in. On 11/13/24 License Nurse 2 (LN 2) was interviewed. LN 2 stated Resident 1 ' s Morphine was running low and the facility was attempting to re order it. LN 2 stated pharmacy indicated it was delivered on 10/20/24 but LN 2 stated she never saw a new medication card or sheet for Resident 1. LN 2 stated when accepting a medication delivery, the licensed nurse was supposed to sign and verifiy each medication on the list. LN 2 stated if there was a discrepancy they were supposed to document on the sheet and notify the Director of Nursing (DON) and pharmacy. LN 2 stated that on occasion the drug shipment sheet did not match what was delivered. LN 2 stated controlled medications and associated count sheets were reconciled every shift. LN 2 stated since there was no count sheet for Resident 1 ' s missing Morphine, it was not noted to be missing. On 11/14/24 at 9 A.M., the Director of nursing (DON) was interviewed. The DON stated she was notified on 10/30/24 that a Morphine 60 tablet card supposedly delivered on 10/20/24 for Resident 1 could not be located. The DON stated Resident 1 still had Morphine in stock so it was not noted the new medication card was missing until 10/30/24 when staff attempted to re order it. The DON stated the facility was searched and the mediation was not found. The DON stated this was reported to pharmacy and law enforcement. Per facility policy, Controlled Substances, dated April 2019, .Controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift .Policies and procedures for monitoring controlled medications to prevent loss, diversion or accidental exposure are periodically reviewed and updated . Per facility policy, Accepting Delivery of Medications, dated February 2021, .Before signing to accept the delivery, the nurse must reconcile the medications in the package with the delivery ticket/order receipt. If an error is identified when receiving medication from the pharmacy, the nurse verifying the order shall inform the delivery agent of any discrepancies and note them on the delivery ticket . The dispensing pharmacy, consultant, pharmacist, and director of nursing services should be notified of medication order errors .

Based on observation, interview, and record review, the facility failed to ensure assistance with activities of daily living (ADL - basic and everyday skills that are essential to living independently) were provided to two of three residents (Resident 28 and Resident 30) reviewed for ADL care when: 1. Resident 28 were not provided with incontinence (loss of bladder and/or bowel control) care in a timely manner and, 2. Resident 30 was not provided with nail care. This deficient practice placed Resident 28 and Resident 30 at risk for skin breakdown and decreased quality of life. Findings: 1. According to the Admission Record, Resident 28 was admitted on [DATE] with diagnoses which included quadriplegia (inability to use both arms and legs), need for assistance with personal care, and personal history of urinary tract infections. A review of Resident 28's Minimum Data Set (MDS, an assessment tool), dated 10/1/23 indicated, a BIMS (Brief Interview of Mental Status - a tool to assess cognition) score of 3. According to the BIMS scoring, a score of 0-7 indicated severe mental impairment. The MDS also indicated that Resident 28 was dependent on others for personal hygiene. On 9/9/24 at 8:45 A.M., an observation was made in Resident 28's room. Resident 28 was in bed laying on foul smelling, dark brown substance. Resident 28's brief was also visibly wet. On 9/9/24 at 9:44 A.M., an interview was conducted with Certified Nursing Assistant (CNA) 33. CNA 33 stated she was the assigned CNA for Resident 28. CNA 33 stated she conducted rounds at 7:15 A.M., and noticed Resident 28 had a bowel movement and needed to be changed. CNA 33 stated .I'm not gonna lie, I saw it this morning but I had a sling under another resident who was going to take a shower . On 9/12/24 at 9:25 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated Resident 28 should have been provided with incontinent care in a timely manner. The DON stated CNA 33 .should have asked for assistance or priorized better . The DON stated delaying incontinent care placed Resident 28 at risk for skin breakdown, wounds, or infection. A review of the facility policy titled Activities of Daily Living (ADL), Supporting, revised 3/2018, indicated, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene .Appropriate care and services will be provided for residents who are unable to carry out ADLs independently .in accordance with the plan of care, including appropriate support and assistance with: hygiene ( .grooming .), .elimination (toileting) . 2. Resident 30 was admitted to the facility on [DATE] with diagnoses which included paraplegia (inability to move the lower part of the body), muscle weakness, and need for assistance with personal care, according to the Admission Record. A review of Resident 30's MDS dated [DATE] indicated Resident 30 had a BIMS score of 15, indicating cognition was intact. The MDS also indicated, Resident 30 was dependent with personal hygiene. On 9/9/24 at 9:31 A.M., a concurrent observation and interview was conducted with Resident 30. Resident 30 was laying in bed, on her back. Resident 30 had pillows under her legs and was not wearing socks. Resident 30's toenails appeared long with jagged edges. Resident 30 stated she did not want to wear socks because her toenails were .too long . Resident 30 stated she has asked staff to trim her toenails, but nobody has done it yet. Resident 30 stated I feel embarrassed about my toenails, they have never been this long before . Resident 30 stated her family members had cut her toenails for her, but they were no longer able to. On 9/9/24 at 9:44 A.M., an interview was conducted with CNA 33. CNA 33 stated nail clippers and files were available for CNAs to use, but she was not sure whether CNAs could trim residents' nails. On 9/12/24 at 9:25 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated CNA's were able to trim resident's toenails and .it depends on the resident's preference . The DON stated .I prefer a licensed nurse (cut residents' toenails) but if the resident wants it done, it should be done . The DON stated residents with untrimmed nails were prone to skin tears or infections. A review of the facility policy titled Activities of Daily Living (ADL), Supporting, revised 3/2018, indicated, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene .Appropriate care and services will be provided for residents who are unable to carry out ADLs independently .in accordance with the plan of care, including appropriate support and assistance with: hygiene ( .grooming .), .elimination (toileting) .

Based on interview and record review, the facility failed to implement non-pharmacological interventions (NPIs - ie. positioning, dark room, ice/heat, massage), as ordered by the physician, prior to the administration of PRN (as needed) pain medications for three of three residents (Residents 22, 99 and 312) reviewed for pain management. This failure had the potential for Residents 22, 99 and 312 not to receive non-prescription pain relief, prior to receiving narcotic pain medications with added side effects. Finding: 1. Resident 22 was admitted to the facility on [DATE], with diagnoses which included chronic pain syndrome (when a person experiences persistent pain that interferes with daily life), per the facility's Admission Record. On 9/11/24, Resident 22's clinical records were reviewed: According to the Minimum Data Set (MDS-a clinical assessment tool), Resident 22 had a cognitive score of 15, indicating cognition was intact. The section titled, Health Condition, indicated, Resident 22 received scheduled and as needed pain medications. According to the physician orders, dated 10/20/23, .Oxycodone (a synthetic pain relief drug) 10 milligrams (mg) by mouth every 4 hours as needed for moderate to severe pain (pain scale 4-10, [scale of 0 indicates no pain, and 10 being the worst pain]) .Tylenol 325 mg two tablets by mouth every 4 hours as needed for mild pain .Prior to administering PRN pain medication (Tylenol, Oxycodone) document any/all interventions completed by entering the number that describes action taken. Non-Pharmacological Approaches to prn pain medications, 1. Re-positioning 2. Dim light/Quiet the Environment 3. Snacks/Drinks 4. Hand holding 5. Re-Direct 6. Music 7. Massage 8. Other every 4 hours as needed . The Medication Administration Record (MAR) was reviewed from September 1, 2024, through September 11, 2024. Oxycodone was administered three times. There was no documented evidence NPIs were attempted prior to the administration of Oxycodone. According to the care plan, titled Pain, undated, interventions included, .Provide Non-Pharmacological interventions: >Turn and reposition>Dim lights/quite environment>Relaxation techniques>Music>Massage>Distraction . The facility's Pain Assessment interview, dated 8/9/24, Section C- asked: What made the pain better? Resident 22 answered Medication, turning and repositioning. 2. Resident 99 was admitted to the facility on [DATE], with diagnoses which included orthopedic aftercare following surgical amputation, per the facility's Admission record. On 9/10/24, Resident 99's clinical records were reviewed: According to the MDS, dated [DATE], Resident 99 had a cognitive score of 11, indicating cognition was moderately impaired. The section titled, Health Condition, indicated Resident 99 received scheduled and as needed pain medications. According to the physician orders, dated, 6/28/24, .Tramadol (a medication used to treat moderate to severe pain), 50 mg, by mouth every 6 hours as needed for severe pain (scale 7-10) .Acetaminophen (Tylenol), 325 mg, give 2 tablets by mouth every 4 hours as needed for mild pain 1-3/10 .Non-Pharmacological Interventions prior to PRN pain medication administration. 1. Reposition/limb elevation 2. Dim lights/quite environment/Rest periods 3. Snacks/drink 4. Therapeutic touch/Massage is not contraindicated 5. Redirect/reassurance/emotional support 6. Music 7. Guided imagery/meditation 8. Provide distraction/diversionary activities 9. Exercise/Range of Motion/ambulation/stretching 10. Deep breathing/relaxation exercises 11. Laughter/socialization 12. Other (describe) every 4 hours as needed for pain . The MAR was reviewed from September 1, 2024, through September 10, 2024. Tramadol was administered 17 times. Two of the 17 times, Resident 99 had a recorded pain level of 5 (Below the scale indicated by physician 7-10). There was no documented evidence any non-pharmacological interventions were attempted, prior to the administration of Tramadol. According to the care plan, titled Pain, interventions included, .Provide non-pharmacological measures/Non Drug interventions prior to giving pain medications . The facility's Pain Assessment Interview, dated 6/18/24, was incomplete and did not indicate what made the pain better or worse, or where the pain was located. 3. Resident 312 was admitted to the facility on [DATE], with diagnoses which included rectal cancer, per the facility's Admission Record. On 9/11/24, Resident 312's clinical records were reviewed: The Admission Minimum Data Set (MDS - an assessment tool) was, In Progress, and had not yet been completed. According to the physician orders, .Oxycodone 10 mg, give 1 tablet by mouth every 8 hours as needed for Breakthrough Pain. Administer as needed for pain scale 7-10) .Acetaminophen (Tylenol) 325 mg, give two tablets by mouth every 4 hours as needed for mild pain (1-3) non-drug interventions prior to administering PRN 1. Reposition 2. Distraction 3. Breathing techniques 4. Gentle Massage 5. Relaxation technique 6. Music 7. Other . The MAR was reviewed from September 6, 2024, through September 11, 2024. Oxycodone was administered seven times. There was no documented evidence any non-pharmacological interventions were attempted prior to the administration of Oxycodone. According to the care plan, titled Pain, undated, interventions included, .Provide non-pharmacological measures/Non Drug interventions prior to giving pain medications . The facility's Pain Assessment Interview, dated 9/6/24, was incomplete and did not indicate what made the pain better or worse, or where the pain was located. An interview was conducted with certified nursing assistant (CNA) 11 on 9/10/24 at 2:22 P.M. CNA 11 stated if a resident complained of pain she would first obtain their vital signs (blood pressure, heart rate, respirator rate) and then attempt to make them comfortable by re-positioning them, or dimming the light, until the licensed nurse (LN) could come in and assess them for pain. An interview and record review was conducted with Licensed Nurse (LN) 11 on 9/10/24 at 2:27 P.M. LN 11 stated non-pharmacological interventions (NPIs) should always be attempted before administering pain medications. LN 11 stated the NPIs may help alleviate the pain, so the narcotic might not be needed. LN 11 stated there were side effects when taking narcotics such as constipation, decreased respiratory rates, and decreased movement. LN 11 stated if the physician ordered NPIs before PRN pain medications were given, then the NPIs should be performed and documented. LN 11 reviewed Resident 99's September MAR and stated no NPIs were documented prior to the resident receiving the PRN pain medications. An interview was conducted with the Director of Staff Development (DSD) on 9/10/24 at 2:37 P.M. The DSD stated NPIs were important because it was important to attempt holistic approaches first. The DSD stated if the NPIs were helpful, the pain medications might not be required. The DSD stated if the physician ordered NPIs, then the orders needed to be followed by staff. The DSD stated if nurses were not attempting NPIs, they were not following the physician's plan of care. An interview was conducted with the Director of Nursing (DON) on 9/12/24 at 9:00 A.M. The DON stated NPIs should be attempted prior to administering pain medications, and she expected staff to document the attempted NPIs, so other staff were aware of what worked. The DON stated by not attempting NPIs, staff were unaware if the NPIs might have alleviated the pain, so the pain medication might not have been needed. The DON stated if the physician wrote an order to do NPIs prior to medicating for pain, she expected the licensed nurses to attempt the NPIs. According to the facility's policy, titled Pain Assessment and Management, dated October 2022, .Implementing Pain Management Strategies: .2. Non-pharmacological interventions may be appropriate alone or in conjunction with medications .a. Environment .b. physical .c. exercise .d. cognitive or behavioral .

Based on interviews and record reviews, the facility failed to provide sufficient staffing to meet care needs, when call lights were not answered timely for three of six confidential residents (CR 1, 2, 3) interviewed for sufficient staffing. This failure had the potential to result in residents' needs not being met, which had the potential to result in physical and psychosocial harm. Findings: On 9/9/24, a review of the offsite survey record indicated, the facility had low weekend staffing on the 3rd quarter of 2024. An interview on 9/9/24 at 8:27 A.M., with CR 2 was conducted. CR 2 stated he had a left heel wound and cannot see well. CR 2 stated he needed assistance in going to the bathroom, transfers, or going to bed. CR 2 stated staff ignored his call light when he needed help. Staff came and turned off the call light. On 9/10/24 at 10:13 A.M., a confidential meeting with the residents was conducted. Two of five residents have identified issues with call light response. 1. CR 2 stated it took a lot of time for call lights to get answered especially on the evening shift (3pm - 11pm). CR 2 stated there were only 2 CNAs in the afternoon shift, so if one CNA was giving a shower, it would take a while for his call light to get answered. CR 2 also stated, he would tell staff not to turn off his call light until they return, but staff forgot about him. CR 2 also stated The facility needed more staff in the morning and evening shift because they have a lot to do. 2. On 9/10/24 at 10:45 A.M., CR 3 stated staff would answer his call light and helped him if he needed to use the bathroom, but for other needs, staff would let him wait. A review of the Resident Council minutes for the month of June, July, and August 30, 2024, indicated call light response and insufficient staffing issues were repeatedly identified. An interview on 9/11/24 at 2:50 P.M., with licensed nurse (LN) 23 was conducted. LN 23 stated she started nine months ago and noticed the facility had call light issues. LN 23 stated we tried to keep with the residents' needs, but sometimes it was not feasible. LN 23 stated we had an in services recently regarding call lights response, but still, we have complaints from our residents. An interview on 9/12/24 at 9:16 A.M., with the Staffing Coordinator (SC) was conducted. The SC stated we tried to call staff who are off on those days, and staffing was also based on the facility's census. The SC stated LNs do CNA work when short of CNA assistance. On 9/12/24 at 3:00 P.M., an interview and review of the facility's daily shift assignments for the weekends of April, May and June 2024 was conducted with the Director of Staff Development (DSD). For the month of April 2024: On 4/7, afternoon shift (3pm - 11pm), a LN called off. No replacement. For the month of May 2024: On 5/27, afternoon shift (3pm - 11pm), a certified nursing assistant (CNA) called off. No replacement. For the month of June 2024: On 6/9, afternoon shift (3pm - 11pm), a CNA and a LN called off. No replacement. On 6/9, night shift (11pm - 7am), a CNA and a LN called off. No replacement. On 6/22, afternoon shift (3pm - 11pm), a CNA worked for two hours only from 3pm - 5pm. On 6/23, morning shift (7am - 3pm), a LN called off. No replacement On 6/30, afternoon shift (3pm - 11pm), a restorative nursing aide (RNA) only worked four hours from 3 P.M. to 7 P.M. On 9/12/24 at 3:45 P.M., an interview with the Administrator (ADM) was conducted. The ADM stated if a staff called off, the Director of Nursing (DON) tried to call for a replacement. The ADM stated we have low staffing on the weekends because everyone wanted to be off on the weekends and we have not use registry that often. An interview on 9/12/24 at 3:55 P.M., with the DON was conducted. The DON stated she was aware of the call offs especially on the weekends and the concerns from the resident council regarding repeated staffing issues and call lights. A review of the facility's patient needs waiver to title 22 indicated the facility request was approved from July 1, 2024 to June 30, 2025. The record indicated, . #2 the facility shall continue to provide a minimum of 3.5 direct care service hours per patient per day. 3# .when the facility cannot provide 2.4 cna direct care service hours per patient per day, the facility shall use licensed vocational nurses and or registered nurses. A record review of the facility's policy on staffing dated October 2017 indicated . policy interpretation #1 licensed nurses and certified nursing assistants are available 24 hours a day to provide direct resident care services. 39111 3. A confidential interview was conducted with confidential resident (CR) 1. CR 1 stated it often took over one hour to get help being changed after an incontinence episode. CR 1 stated this mostly occurred in the daytime. CR 1 stated she did not think there was enough staff to answer the call lights and provide help in a timely manner. A confidential staff interview was conducted with confidential staff (CS) 2. CS 2 stated with all the gowning up (putting on personal protective equipment such as gowns, gloves, and/or masks) for isolation precautions, added respiratory therapy tasks such as suctioning residents and providing breathing treatments, nursing staff had difficulty answering the call lights in a timely manner. CS 2 stated there needed to be more nursing staff on the subacute unit as the majority of the residents had higher acuity (more medical attention/needs) and required two or more staff to provide total care (residents cannot participate in the care due to a medical condition). CS 2 stated staff for subacute unit did not answer call lights or provide care on subskilled. On 9/11/24 at 2:26 P.M., an observation was conducted on the subacute and subskilled units. The call light went on in Room A and was accompanied by the banging sound of an object on the overbed table. Two respiratory therapists (RT) were observed engaged in conversation directly across from Room A. At 2:30 P.M., the RTs were observed walking away from Room A without answering the call light. When the RTs walked away a licensed nurse was observed putting on PPE to go into Room A to answer the resident's call light. On 9/11/24 at 2:30 P.M., an interview was conducted with RT 1. RT 1 was asked about Room A's call light and banging sounds while she and another RT were outside the room and observed not answering the resident's call light. RT 1 stated she was in the zone and did not notice the resident's call light or banging sounds. RT 1 stated everyone was responsible for answering the call light. On 9/11/24 at 2:40 P.M., an interview was conducted with certified nursing assistant (CNA) 100. CNA 100 stated she worked on the subskilled unit and that answering the call light timely could be difficult. CNA 100 stated while the subskilled unit was visible from the subacute nursing station, the subacute staff did not answer the call lights on the subskilled unit. CNA 100 stated if the staff on the subskilled were busy in resident rooms and a call light was on, they would not know until they stepped into the hallway to see the call light. CNA 100 stated the subskiled unit was under the supervision of the nurse on the Moss unit (located on the other side of the facility) and she was not sure if the charge nurse on Moss could see the call lights that were on on the subskilled unit. CNA 100 stated if they needed assistance on the subskilled unit, they would have to ask the charge nurse on the subacute unit to phone over to the Moss unit to request help. A record review of the facility 's patient needs waiver to title 22 indicated the facility request was approved from July 1, 24 to June 30, 25. The record indicated .#2 the facility shall continue to provide a minimum of 3.5 direct care service hours per patient per day. #3 .when the facility cannot provide 2.4 cna direct care service hours per patient per day, the facility shall use licensed vocational nurses and or registered nurses. A record review of the facility's policy on staffing dated October 2017 indicated . policy interpretation #1 licensed nurses and certified nursing assistants are available 24 hours a day to provide direct resident care services.

Based on interview and record review, the facility failed to ensure Preadmission Screening and Resident Review II (PASARR II - a federal requirement to help ensure that individuals with mental disorders were not inappropriately placed in nursing homes for long term care) were conducted for two of five residents (Resident 6 and Resident 99) reviewed for PASARR screening. This failure had the potential for Residents 6 and 99, to be improperly placed and not have received additional qualified services. Findings: 1. Resident 6 was admitted to the facility on [DATE], with diagnoses which included schizophrenia (a chronic mental illness that affects how a person thinks, feels, and behaves), per the facility's Admission Record. On 9/12/24, Resident 6's clinical records were reviewed: According to the Minimum Data Set (MDS-a clinical assessment tool), dated 8/1/24, Resident 6 had a cognitive score of 12, indicating cognition was intact. According to the PASARR I Screening, dated 6/10/24, Resident 6 was coded, Positive which indicated a Level II- Mental Health Evaluation was required. According to the Department of Health Care Services letter, dated 6/12/24, the State arrived at the facility and was unable to conduct the PASARR II assessment, because Resident 6 had been discharged to the hospital on 6/10/24. According to the facility's census, Resident 6 returned to the facility on [DATE] and there was no documented evidence the Department of Health Care Services was informed of the return, so the PASARR II could be re-scheduled and conducted. An interview and record review was conducted with the Minimum Data Set Nurse (MDSN) on 9/12/24 at 9:38 A.M. The MDSN stated she was responsible to re-submit the Resident Review PASARR 2 Assessment to the State after a positive PASARR I was found. The MDSN reviewed Resident 6's PASARR status and stated the PASARR II was missed when the resident went to the hospital, and it should have been conducted after he returned. The MDSN stated she missed it and never re-submitted a review to the State. The MDSN stated PASARR II's were important to ensure the facility's placement was appropriate for the resident, and to determine if additional services were needed to ensure a meaningful life. According to the facility's policy titled Admission Criteria, dated March 2019, .9. All new admissions and readmissions are screened for mental disorders (MD) .per the Medicaid Pre-Admission Screening and Resident Review (PASARR) process. a. The facility conducts a Level I PASARR screen for all potential admissions .to determine if the individual meets the criteria for a MD .b. If the level I screening indicates the individual meets the criteria for an MD .he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process . 2. Resident 99 was admitted to the facility on [DATE], with diagnoses which included unspecified psychosis not due to a substance or known physiological condition, per the facility's Admission Record. On 9/10/24, Resident 99's clinical records were reviewed: According to the Minimum Data Set (MDS-a clinical assessment tool), dated 7/5/24, a cognitive score of 11 was listed, indicating moderately impaired cognition. According to the PASARR I Screening, dated 6/28/24, Resident 99 was coded, Negative which indicated, a Level II- Mental Health Evaluation was not required. According to the physician's orders, dated 8/15/24, the physician indicated a new diagnosis of schizoaffective disorder (a rare mental illness that occurs when someone has both schizophrenia and a mood disorder at the same time), and two psychotropic medications (drugs used to treat mental health disorders), were added. There was no documented evidence Resident 99 had a PASARR I reassessment conducted after the 8/15/24, mental health diagnoses, which would have triggered a PASARR II assessment based on the schizoaffective diagnosis. An interview and record review was conducted with the Minimum Data Set Nurse (MDSN) on 9/11/24 at 8:39 A.M. The MDSN stated if a new diagnosis of schizophrenia was added, she must repeat a PASARR I, which automatically triggered a PASARR II assessment. The MDSN stated if a PASARR I was not repeated, then it would not be captured until the next quarterly assessment. The MDSN reviewed Resident 99's physician order dated 8/15/24, and the PASARR status. The MDSN stated she was usually informed of new diagnosis at the morning staff meeting, but she cannot recall if she was informed of Resident 99's schizoaffective disorder. The MDSN stated when the schizoaffective diagnosis occurred, she should have repeated a PASARR I, so the State would be informed and conduct a PASARR II. The MDSN stated since Resident 99 had not completed a PASARR II assessment, it was undetermined if he qualified for additional services or if he was correctly placed at this facility. The MDSN stated Resident 99's next quarterly MDS assessment would have been in October 2024, so any additional services would have been delayed. An interview was conducted with the Director of Nursing (DON) on 9/12/24 at 9 AM. The DON stated Resident 99 should have been reassessed for a PASARR I, after the diagnoses of schizoaffective disorder. The DON stated a PASARR II would have been triggered and the resident might have qualified for additional mental health services if it had been captured. According to the facility's policy titled Admission Criteria, dated March 2019, .9. All new admissions and readmissions are screened for mental disorders (MD) .per the Medicaid Pre-Admission Screening and Resident Review (PASARR) process. a. The facility conducts a Level I PASARR screen for all potential admissions .to determine if the individual meets the criteria for a MD .b. If the level I screening indicates the individual meets the criteria for an MD .he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process .

Based on interview and record review, the facility failed to develop a resident-centered care plan for one of six residents (Resident 6) when Resident 6's care plan did not include dementia care. This failure had the potential for Resident 6's needs to be unmet. Findings: Resident 6 was admitted to the facility on [DATE], with diagnoses which included major depressive disorder (a mood disorder that causes low interest in things that once brought joy) and anxiety disorder (feelings that results in panic attacks), according to the facility's Admission Record. A review of Resident 6's History and Physical (a medical examination that involves a patient interview, physical exam, and documentation of findings), dated 6/15/24, indicated Resident 6 has dementia (loss of cognitive function that affects thinking, remembering, and reasoning) and Resident 6 did not have the capacity to understand and make decisions. A joint interview and record review was conducted with the Director of Nursing (DON) on 9/12/24 at 10:01 A.M. The DON stated according to Resident 6's History and Physical, the resident had a diagnosis of dementia. The DON acknowledged care plan related to Resident 6's dementia was not developed to ensure the resident's care needs were addressed. According to the facility's policy titled Dementia - Clinical Protocol, revised 11/2018, the facility .will identify a resident-centered care plan to maximize remaining function and quality of life .The [interdisciplinary team (a team of staff consisting of multiple disciplines including the physician, nurse, social worker, etc.)] will identify and document the resident's condition and level of support during care planning .Resident needs will be communicated to direct care staff through care plan conferences . According to the facility's policy titled Care Plans, Comprehensive Person-Centered, revised 12/16, indicated A comprehensive, person-centered care plan .includes .objectives .to meet the resident's physical, psychosocial, and functional needs .

Based on observation, interview, and record review, the facility failed to ensure one of six residents (Resident 81's) care plan was revised when Resident 81's gastrostomy tube (G-tube, a tube surgically inserted through the belly that brings nutrition directly to the stomach) was discontinued. This failure had the potential for Resident 81's care to be miscommunicated among caregivers. Findings: Resident 81 was admitted to the facility on [DATE], with diagnoses which included traumatic subdural hemorrhage (brain bleed) according to the Admission Record. An observation was conducted on 9/9/24 at 11:55 A.M. in the resident dining hall. Resident 81 was observed feeding himself with a family member present. A review of Resident 81's physician's order, dated 8/22/24, indicated Resident 81 had a diet order for soft textured food. A review of Resident 81's care plan indicated, Resident 81 had a G-tube. Resident 81's care plan indicated check tube feeding residuals (the volume of fluid remaining in the stomach during tube feeding) every shift and to hold tube feeding if residuals was greater than 250 milliliters. An interview was conducted with the Registered Dietitian (RD) on 9/11/24 at 2:31 P.M. The RD stated Resident 81 was exclusively eating by mouth and was no longer on tube feeding. An interview was conducted with Licensed Nurse (LN) 1 on 9/11/24 at 4:02 P.M. LN 1 stated Resident 81 was no longer on tube feedings. LN 1 stated Resident 81's care plan should have been revised since Resident 81 was no longer receiving tube feeding. An interview with the Director of Nursing (DON) was conducted on 9/12/24 at 8:14 A.M. The DON stated that the care plan interventions for Resident 81 were no longer accurate, and that the care plan should have been revised. The DON stated that since Resident 81 was no longer receiving tube feeding, the care plan could cause confusion amongst the staff caring for Resident 81. A review of the facility's policy titled Care Plans, Comprehensive Person-Centered, revised 12/2016, indicated .12. Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change .

Based on observation, interview, and record review, the facility failed to ensure professional standards of practice were followed for three of eight residents (Resident 5, Resident 6, and Resident 18) when: 1. A resident (Resident 5) was newly diagnosed at the facility with schizophrenia (a chronic mental illness characterized by delusions and hallucinations), without meeting the criteria for schizophrenia as indicated by The Diagnostic and Statistical Manual of Mental Disorders (DSM, a reference manual from the American Psychiatric Association to help define and classify mental disorders). 2. A resident (Resident 6) was newly diagnosed at the facility with schizophrenia without meeting the criteria for schizophrenia as indicated by the DSM. 3. A licensed nurse (LN 32) did not obtain the heart rate of Resident 18 prior to administering two blood pressure medications. This failure had the potential for Resident 5, Resident 6, and Resident 18 to experience unnecessary medication side effects. (Cross Reference F758) Findings: 1. Resident 5 was admitted to the facility on [DATE] with diagnoses including anxiety disorder (a mental condition causing intense feelings of fear and anxiety) and major depressive disorder (a mental illness causing persistent feelings of sadness) according to the Admission Record. A review of Resident 5's physician's order, dated 1/19/24, indicated an order for Seroquel (an antipsychotic medication) for schizophrenia as evidenced by indifference to surroundings manifested by pulling at life sustaining devices. An interview was conducted on 9/11/24 at 9:16 A.M. with Certified Nursing Assistant (CNA) 1. CNA 1 stated Resident 5 had no hallucinations. A telephone interview was conducted on 9/12/24 at 8:35 A.M. with Responsible Party (RP) 1. RP 1 stated Resident 5 had no history of schizophrenia. RP 1 stated Resident 5 had a history of anxiety and thought that Seroquel was being given for Resident 5's anxiety. RP 1 stated the psychiatrist never mentioned schizophrenia, and that no one informed her Resident 5 had a diagnosis of schizophrenia. A review of Resident 5's progress note written by LN 7, dated 4/4/23 at 2:50 P.M., indicated Resident 5 was admitted with Seroquel .with no appropriate diagnosis . A joint interview and record review was conducted with the Director of Nursing (DON) and Social Worker (SW) 1 on 9/12/24 at 10:55 A.M. SW 1 stated Resident 5 received Seroquel in the hospital for pulling her tracheostomy tube (a tube surgically inserted in the neck to help someone breathe). SW 1 stated there was no diagnosis of schizophrenia from the hospital. The DON and SW 1 stated Medical Doctor (MD) 1 diagnosed Resident 5 with schizophrenia based on Resident 5's behavior of pulling tubes. The DON and SW 1 stated there was no documentation in Resident 5's medical record that indicated that the resident experienced hallucinations. The DON stated the physician's orders for Resident 5's Seroquel indicated that the medication was to be given for schizophrenia as evidenced by .indifference to surroundings manifested by pulling at life sustaining devices . The DON stated she had not seen an order for pulling life sustaining tubes as the only indication for schizophrenia and would have questioned the order if she had been aware. The DON stated she expected to see auditory hallucinations (hearing things that not there), visual hallucinations (seeing things that are not there), or delusions (a false belief, not reality) as an indication for schizophrenia. The DON further stated there were no physician's orders for non-pharmacological interventions (healthcare treatment without medications) before the use of Seroquel which was important to determine if Seroquel was needed for Resident 5. The DON stated RP 1 should have been made aware of Resident 5's schizophrenia diagnosis. The DON stated Resident 5's schizophrenia diagnosis did not follow the guidance provided in the DSM. A telephone interview was conducted on 9/12/24 at 2:21 P.M. with MD 2. MD 2 stated he did not get involved with psychiatry diagnoses. An interview was conducted on 9/12/24 at 1:20 P.M. with the Administrator (ADM). The ADM stated the DON was unable to reach MD 1 via phone to request information regarding Resident 5's schizophrenia diagnosis. On 9/12/24 at 1:34 P.M., a phone call was placed to MD 1 with no answer. A voicemail message was left with a call back number. There was no response received from MD 1. According to the DSM version 5, .Schizophrenia is characterized by delusions, hallucinations, disorganized speech and behavior .For a diagnosis, symptoms must have been present for six months . A review of the facility's policy titled Antipsychotic Medication Use, revised 12/2016, indicated .Antipsychotic medications shall generally be used for the following conditions/diagnoses .consistent with the definition(s) in the Diagnostic and Statistical Manual of Mental Disorders [DSM] .schizophrenia .Diagnoses alone do not warrant the use of antipsychotic medications .antipsychotic medications will generally only be considered if .behavioral interventions have been attempted . A review of the facility's policy titled Conformity with Laws and Professional Standards, revised 4/2017, indicated Our facility's policies, procedures, and operational practices are developed and maintained in accordance with current accepted professional standards and principles as well as current commonly accepted health standards established by national organizations, boards, and councils . 2. Resident 6 was admitted to the facility on [DATE] with diagnoses including anxiety disorder and major depressive disorder according to the Admission Record. A review of Resident 6's physician's order, dated 7/9/24, indicated an order for Seroquel for schizophrenia as evidenced by unprovoked agitation. An interview was conducted on 9/11/24 at 9:56 A.M. with Licensed Nurse (LN) 3. LN 3 stated Resident 6 was alert, oriented, and compliant with care. LN 3 stated Resident 6 was on Seroquel for schizophrenia. A joint interview with Resident 6 and CNA 2 was conducted on 9/11/24 at 12:12 P.M. in Resident 6's room. Resident 6 stated he has anxiety, but not schizophrenia. Resident 6 stated he was taking Seroquel for anxiety. CNA 2 stated Resident 6 was alert and did not have any hallucinations. A review of Resident 6's History and Physical (a medical examination that involves a patient interview, physical exam, and documentation of findings), dated 4/30/24, indicated Resident 6 had the capacity to understand and make decisions. A joint interview and record review with the DON and SW 1 was conducted on 9/12/24 at 10:21 A.M. SW 1 stated Resident 6 received Seroquel for agitation while in the hospital. SW 1 stated MD 1's progress note, dated 5/2/24, indicated Resident 6 had auditory hallucinations and paranoia (unrealistic distrust of others). The DON stated there were no nursing documentation found on Resident 6's medical record that indicated Resident 6 experienced hallucinations and paranoia. The DON stated Resident 6's Seroquel was ordered for unprovoked agitation. The DON further stated there were no physician's orders for non-pharmacological interventions before the use of Seroquel which was important to determine if Seroquel was needed for Resident 6. The DON stated Resident 6's schizophrenia diagnosis did not follow the guidance provided in the DSM. An interview was conducted on 9/12/24 at 1:20 P.M. with the Administrator (ADM). The ADM stated the DON was unable to reach MD 1 via phone to request information regarding Resident 6's schizophrenia diagnosis. On 9/12/24 at 1:34 P.M., a phone call was placed to MD 1 with no answer. A voicemail message was left with a call back number. There was no response received from MD 1. According to the DSM version 5, .Schizophrenia is characterized by delusions, hallucinations, disorganized speech and behavior .For a diagnosis, symptoms must have been present for six months . A review of the facility's policy titled Antipsychotic Medication Use, revised 12/2016, indicated .Antipsychotic medications shall generally be used for the following conditions/diagnoses .consistent with the definition(s) in the Diagnostic and Statistical Manual of Mental Disorders [DSM] .schizophrenia .Diagnoses alone do not warrant the use of antipsychotic medications .antipsychotic medications will generally only be considered if .behavioral interventions have been attempted . A review of the facility's policy titled Conformity with Laws and Professional Standards, revised 4/2017, indicated .Our facility's policies, procedures, and operational practices are developed and maintained in accordance with current accepted professional standards and principles as well as current commonly accepted health standards established by national organizations, boards, and councils . 49330 3. Resident 18 was admitted to the facility on [DATE] with diagnoses that included hypertension (high blood pressure) and atrial fibrillation (an irregular heartbeat) according to the Admission Record. On 9/11/24 at 8:40 A.M., an observation of a medication pass was conducted with Licensed Nurse (LN) 23. LN 23 was observed taking Resident 18's blood pressure. LN 23 stated Resident 18 had a blood pressure reading of 119/70. LN 23 was observed giving Resident 18 lisinopril 10 milligrams (mg) and diltiazem 240 mg, two medications that work by lowering blood pressure. On 9/11/24 at 8:48 A.M., a concurrent interview and record review was conducted with LN 23. LN 23 was observed documenting in Resident 18's electronic Medication Administration Record (eMAR). LN 23 stated the instructions for Resident 18's blood pressure medications were .Hold if SBP (the top number of the blood pressure reading) is less than 110 .and/or HR (heart rate) is less than 60 BPM (beats per minute) . LN 23 stated .I may have made a mistake .I completely skipped checking the pulse [heart rate] . LN 23 stated it was important to check Resident 18's heart rate prior to giving the blood pressure medications because .We don't want her pulse to go lower than 60 .she can have a change of condition . On 9/12/24 at 9:25 A.M. an interview was conducted with the DON. The DON stated her expectation was for the licensed nurses to obtain all pertinent vital signs prior to administering any medication. The DON stated Resident 18 was at risk for fainting because she was given blood pressure medications without having her pulse checked. A review of the facility policy titled Administering Medications, revised April 2019 indicated, .The following information is checked/verified for each resident prior to administering medications .Vital signs, if necessary . A review of the facility's policy titled Conformity with Laws and Professional Standards, revised 4/2017, indicated .Our facility's policies, procedures, and operational practices are developed and maintained in accordance with current accepted professional standards and principles as well as current commonly accepted health standards established by national organizations, boards, and councils .

Based on interview and record review, the facility failed to implement a comprehensive systematic approach to ensure effective monitoring and systems to maintain acceptable parameters of nutritional status for 2 of 24 sampled residents (115, 36) and 6 of 6 extended sampled residents (40, 41, 55, 59, 62, 91). Resident 115 had an unidentified and unplanned significant weight loss while receiving nutrition via a tube feeding. The facility failed to ensure that the qualified registered dietitian (RD) participated in a care plan conference for a nutritionally compromised resident that pertained to tube feeding, and weaning from a ventilator (breathing machine able to inflate the lungs via breathing tube), versus a dietary services supervisor (Resident 115). The facility failed to identify and address unplanned slow gradual progressive weight loss prior to becoming an unplanned significant weight loss. In addition, the facility failed to identify and notify the physician of the unplanned significant weight loss (Resident 91). Lack of timely notification to the physician in regard to an unplanned significant weight loss that had the potential for delayed nutrition intervention to address the weight loss (Resident 40). DSS was not knowledgeable on facility expectations as it pertained to quarterly, dietary monitoring reviews of nutrition related concerns that would require a referral to the RD (Resident 40). The facility failed to identify an accumulated significant weight gain for a 3 month period per the facility's criteria for Resident 55. The facility did not have an effective system in place to ensure the facility's interdisciplinary nutrition plan of care were effective at attaining the identified nutritional and weight goals; nutrition plan of care lacked monitoring parameters as it related to measurable objectives, and lacked root cause analysis to determine underlying causes for the unplanned weight changes as it related to the nutrition care plan for Resident 41, 36, 59, 62, 55. As a result, the facility's system was not effective at capturing slow insidious, weight loss or weight gain prior to significant unplanned weight loss or weight gain. The staff were not consistent in identifying unplanned significant weight changes per the facility criteria in order to ensure timely notification to the physician. The facility had not ensured that the RD was consistently aware of residents' overall goals as it pertained to nutrition assessments. The facility failed to ensure the IDT (interdisciplinary team) care plans were developed and monitored to attain the identified nutritional goals for multiple residents. The above cited systems failures had a potential to negatively impact and compromise the medical status of all residents residing in the facility. Elderly patients with unintentional weight loss are at higher risk for infection, depression and death. (American Family Physician, February 15, 2002/Volume 65, Number 4) Findings: 1. On 3/5/14 at 10:17 A.M., Resident 115's medical record was reviewed. Resident 115 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. the Record of Admission. During an interview with the Registered Dietitian (RD 1) on 3/5/14, at 10:15 A.M., RD 1 reviewed the initial nutrition assessment, dated 4/15/13 and said, "I used 20-25 kcal/kg (kilocalories per kilogram) based on 52.3 kg (115 pounds) to assess daily calorie needs because he was on a vent." RD 1 said, "I assessed Resident 115's calorie needs to be from 1,050 - 1, 300 calories a day in which the tube feeding order Glucerna 1.2 at 60 cc/hr (cubic centimeters per hour) x 20 hours (hrs) provided 1,440 calories per day which was more than assessed needs." RD 1 acknowledged the area on the form for "UBW" (usual body weight) was blank. RD 1 said she had not known Resident 115's UBW, and had not attempted to obtain the UBW. The same nutrition assessment completed on 4/15/13 indicated, "Res on ventilator; kcal needs are lowered. Current TF (tube feeding) adequate to meet needs. Res tolerating TF well. Skin with [MEDICAL CONDITION] ...Goal 1) Cont (continue) to tolerate TF well, 2) maintain wt (weight) or gradual wt gain 1-2 #/wk. Plan 1) Cont with current TF order, 2) cont with flush (water flush), 3) Will monitor monthly or PRN (as needed)." According to the Weekly Weight Record, Resident 115's weight on 4/21/13 was 107 pounds. On the weight record, the facility noted that Resident 115 had an 8 pound weight loss in one week and notified the physician and the RD. On 4/21/13 a care plan to address Resident 115's "actual Weight loss" indicated under Resident Goals, "Will have no further weight loss within the next wk , Will minimize the risk for significant weight loss of 5% in 1 months, 7.5% in 3 months, 10% in 6 months ..." The care plan lacked documentation of root cause analysis for determining underlying causes for the unplanned significant weight loss. On 4/22/13, RD 1 completed a follow up nutrition assessment. RD 1 noted, "Res with 7% or 8# decrease in one week. Wt hx: 4/21/13 107#, 4/13/13 115#. admitted with [MEDICAL CONDITION]; wt fluctuations likely. Wt gain is desired. Will recommend increase TF TO 62 ml/hr x 20 hours = ...1,488 kcalories..." Resident 115's primary care physician (MD 5) completed a history and physical (H & P) for Resident 115 on 4/11/13, the day of his re-admission to the facility. According to the H & P, zero [MEDICAL CONDITION] was noted. According to the Nursing Admission Assessment form completed on 4/11/13, there was a check mark next to [MEDICAL CONDITION] (the extent of the [MEDICAL CONDITION] as noted by 1+, 2+, 3+ 4+ or generalized were all left blank), and a notation that indicated "head/[MEDICAL CONDITION] due to surgery." During an interview with RD 1 on 3/5/14 at 12:37 P.M., RD 1 said the above recommendation would increase calories by about 50 calories per day. RD 1 said she was aware of the 8 lb weight loss but thought the [MEDICAL CONDITION] could have been a contributing factor, and had not wanted to increase the calories too much per kg because Resident 115 was "on a vent", and "because I was still recommending more calories than the assessed needs of 1,050 -1,300 calories a day." The initial assessed needs were based on the 115 pound admission weight when he was assessed by RD 1 to be "85% deviation from DBW (desirable body weight)." There was no documentation that RD 1 had conducted a comprehensive nutrition re-assessment after there was a significant change in condition; weight loss. On 5/6/13, RD 1 conducted a follow up visit and noted, "Res (resident) being followed weekly as well. Res with 8 # (pound) or 7% (loss of body weight) in 3 weeks, however Res had this wt loss last week and TF rate was increased. Now Res wt has been stable. Wt hx: 5/5 107#, 4/27 106#, 4/12 115#. Will cont with POC and monitor." During an interview with RD 1 on 3/5/14 at 12:37 P.M., RD 1 was asked if the above nutrition assessment was promoting weight gain as she had noted "wt gain is desired" in the nutrition assessment completed on 4/15/13 (at weight 115 lbs), and 4/22/13 (at weight 107 lbs). RD 1 said, "His weight was stable, and I did not want to recommend an increase in calories because he is on a vent." During the same interview, RD 1 said the nutrition care plan that was developed for Resident 115 indicated, "Resident will maintain weight at 115 lb." On 5/15/13 RD 1's note indicated that Resident 115 was on the same formula, and " ...5/11- 107#...wt continues to be stable. Res tolerating TF well ...zero [MEDICAL CONDITION] ...cont with POC, will cont to monitor." RD 1 said that she had not made recommendations to increase the calories that Resident 115 would receive per day because "his weight was stable at 107 lbs." RD 1 added, " He was already receiving 30 kcal/kg at that time and he was on a vent." On 7/15/13, RD 1's note indicated Resident 115 weighed "106#" on "7/2013." According to the Weekly Weight Record, Resident 115 weighed 104# on 7/13/13. RD note included "will recommend CMP (comprehensive metabolic panel; blood tests which serves as an initial broad medical screening tool). Will cont (continue) to monitor." On 8/15/13, RD 1's nutrition note indicated that Resident 115 weighed "107 # on 8/2013 ... alb 3.6 ([MEDICATION NAME]; the body's major plasma protein), H/H decreased (hematocrit and hemoglobin, red blood cells that carry oxygen) cont with POC (plan of care)..." On 8/22/13, RD 1's nutrition note indicated Resident 115 was on ventilator, weighed 107 lbs as of 8/2013 .."cont with POC ..." On 9/27/13, RD 1's nutrition note indicated Resident 115 weighed 106 # on 9/2013 ...tolerating TF well. "Cont with POC, will cont to monitor." On 10/5/13, the facility's Weekly Weight Record indicated that Resident 115 weighed 103 pounds. This showed a three pound weight loss from the previous weight that was taken on 9/8/13 when he weighed 106 pounds. On 10/23/13, 17 days after the facility had identified the resident had experienced further unplanned weight loss, RD 1 conducted a nutrition follow up. RD 1's nutrition note indicated Resident 115 was on ventilator, continued on the same TF formula that had provided 1,488 calories per day, wt 106# 9/2013 and now weighed 103 pounds as of "10/2013." The note indicated various labs which included "10/11/12 H/H decreased ...tolerating TF well. Skin with zero major issues. Cont with POC, will cont to monitor." RD 1's note above had not indicated any acknowledgement or concern of a 10.4% unplanned significant weight loss since the re-admission date of [DATE] to 10/5/13. RD 1's note had not indicated nutrition recommendations to address the significant unplanned weight loss, and did not indicate that RD 1 planned to call the physician to discuss Resident 115's nutritional status after continued unplanned weight loss. RD 1's note had not included a comprehensive nutrition re-assessment after a significant change in condition occurred, and had not conducted a root cause analysis for continued weight loss for a tube fed resident. Resident 115's weight of 103 lbs. on 10/5/13 was 12 pounds less than the facility's nutrition care plan goal of maintaining 115 lbs. On 3/5/14 at 11:55 A.M., the charge nurse was asked to review Resident 115's Weekly Weight Record to check if the physician should have been notified about the weight loss. The charge nurse said the physician was notified of the initial 8 lb weight loss on 4/21/13. She said the additional weight loss after 4/21/13 had not met facility criteria to notify the physician about the weight loss as the weight loss was not "a 3 lb loss in a week, or 5 lb loss in a month." During the same interview, the same charge nurse was asked to check the percentage of weight loss from 4/11/13 to 10/5/13 and compare the percentage to the directions located at the top of the Weekly Weight Record. The charge nurse said, "I forgot how to calculate the percentage of weight loss. I just look for 3 lb weight loss in a week, or 5 lb weight loss in a month." On 3/5/14 at 12:00 P.M., the Director of Nursing (DON) was asked to review Resident 115 's Weekly Weight Record. The DON was asked if a change in condition (SBAR) should have been completed for Resident 115 due to weight loss. The DON said yes, an SBAR should have been completed since Resident 115 weighed 115 lbs on 4/11/13, and now weighed 103 lbs on 10/15/14 which was a 10.4% unplanned significant weight loss in 6 months. At that time, the DON pointed to the directions that was located at the top of the Weekly Weight Record log that indicated, "Notify Physician & Family For: Residents who lose 5% of body weight in 1 month; Residents who lose 7.5% of body weight in 3 months; Residents who lose 10% of body weight in 6 months ... " The DON said it was the charge nurse's responsibility to have completed the change of condition for the 10.4 % unplanned significant weight loss in 6 months that occurred. The DON reviewed Resident 115's medical record and said that the facility had not notified the physician when 10.4% unplanned significant weight loss had occurred. The DON was present for the above interview with the charge nurse and verified that a charge nurse should have known how to calculate percentage of weight loss in order to implement the directions on the Weekly Weight Record. Per the facility's Weekly Weight Record, the facility recorded additional weight loss for Resident 115. Weights on 12/1/13 showed 101 lbs. and on 11/2/13, 103 lbs. On 12/13/13, 11 days after the facility had recorded additional weight loss for Resident 115 and after Resident 115 had already experienced unplanned significant weight loss, RD 1 conducted a nutrition follow up. Per RD 1's nutrition note on 12/13/13, Resident 115 was on the same tube feeding order that had provided 1,488 calories per day ..., "on ventilator. Wts: 12/2013 101#, 11/2013 103#, 9/2013 106#, 7/2013 106#; 5# or 4.7% loss x 6 months which isn't significant. Tolerating TF well. Skin with zero major issues. Zero new labs to assess. Will increase TF to 65 ml/hr x 20 hours (Glucerna 1.2 at 65 ml/hr x 20 hours) = ...1,560 kcal ...as wt loss not desired. Cont with current flush. Will cont to monitor." On 2/21/14, RD 1 noted, " ...continues on ventilator. Wts; 2/2014 102#, 1/2014 103#, 12/2013 101#, 10/2013 103#, 9/2013 106#; wt stable x 4 months. Tolerating TF well. Admit wt at 115# 4/11/13; 13# or 11% loss x 10 months which isn't significant but is undesirable. Zero major skin issues ...will increase TF to 68 ml/hr x 20= ... 1,632 kcal ...will cont to monitor." During an interview with RD 1 on 3/5/14 at 12:15 P.M., RD 1 was asked if she knew what the overall prognosis and/or medical goal was for Resident 115, and she said, "That is something that gets discussed at the care plan conferences. I don't attend the care plan conferences, the DSS (dietary services supervisor) does. I get 20-22 hours a week here, and care plan conferences go on when I'm not here." RD 1 was asked if she had reviewed the care plan conference notes from the medical record prior to conducting a nutrition follow up for Resident 115, and she said, "No." RD 1 was asked if the facility had an interdisciplinary team that she was part of to discuss the root cause analysis for Resident 115's continued weight loss. RD 1 said the previous Administrator had told her that concerns with tube feedings would not be addressed in an IDT weight management committee meeting. RD 1 added that the new Administration after July 2013, told her to bring TF concerns to IDT weight management committee meetings. RD 1 was asked if the concern with Resident 115's continued weight loss while being tube fed was brought to an IDT meeting to help determine the underlying reasons for continued weight loss, she said, "No, because his weight loss was not significant and had not triggered to be part of an IDT meeting." RD 1 explained his weight had been stable and had not reached 3 pound weight loss in a week, or 5 lb weight loss or 5% weight loss in a month. RD 1 stated she recommended small increments of change to the tube feeding rate "because he is on a vent." RD 1 stated when a resident is on the vent they do not need the usual amount of calories since they do not burn enough calories. RD 1 stated that since Resident 115 was on the ventilator she was cautious in recommending an increase in calories per kilogram of body weight. According to an "Interdisciplinary Assessment and Progress Notes," dated 1/13/14, the DSS attended the meeting, and not the RD, along with other health care team members. The above note indicated previous weight: 101 lb as of 12-1-13, and current weight was 103 lbs as of 1-2-14, and there was a check mark next to "Weight is currently stable or has recently stabilized." The form contained an area that indicated "Recent significant weight loss" which was blank, and "If Significant Weight Variance Identified, Evaluate" that was blank. On 3/5/14 at 3:50 P.M., an interview was conducted with RT 1 (Respiratory Therapist) regarding Resident 115's respiratory status. RT 1 said that the overall goal of the facility for Resident 115 is to "eventually get him off the vent. He is on a weaning stage right now ..." The RT said the weaning off the ventilator prcess began around August 19, 2013. The RT said the resident was off the ventilator in the day, and was placed back on the vent at about 8 PM each night. On 3/5/14 at 4:07 P.M., the interview with RT 1 was shared with RD 1. RD 1 was informed of what RT 1 had said regarding Resident 115 who had been in the weaning stage from the vent since August 19, 2013, and was off the vent during the day and was placed back on the ventilator at 8 PM each night. RD 1 stated, "I thought it was strange that he is receiving 35.5 kcal/kg and still losing weight." RD 1 verified that Resident 115 had not received 35.5 kcal/kg until the formula rate was increased to Glucerna 1.2 at 68 cc/hr x 20 hours at which time weight loss had already become unplanned significant weight loss from 115 lbs to 102 lbs before the 35.5 kcal/kg was provided. During the same interview, RD 1 said, "The rate and calories required would change if a resident was off the vent." RD 1 verified she was unaware Resident 115 was in the weaning stage in regard to his ventilator status, and said, "That would have changed my nutrition plan of care had I known that. They should have referred to me (nursing should have let her know). I would have discussed the nutrition plan of care with the physician (if she had known that Resident 115 was off the ventilator during the day)." On 3/6/14 at 9:57 A.M., a telephone interview was conducted with the primary care physician (MD 5) for Resident 115, in the presence of the DON. MD 5 was asked if she would be concerned if Resident 115 had weight loss, and she said, "Yes, of course, I am very concerned about weight loss." MD 5 was asked if weaning from the vent could impact nutritional energy requirements, and she said, "Yes, partial weaning could impact nutritional needs." MD 5 was asked if she was aware that the facility's RD had not attended the care plan conferences for Resident 115 and had not known that Resident 115 had been partially weaned off the vent seven months earlier when she would conduct nutrition assessments for Resident 115, and she said, "In my opinion, I would need to verify that with the RD." According to standards of practice,"Specific Medical Conditions Pocket Resource for Nutrition Assessment DHCC (Dietetics in Health Care Communities) 2009, RD 1 said she had used to guide her during her nutrition assessments, "Successful feeding of the mechanically ventilated patient must mirror the physiologic status of the patient as well as the stage they currently occupy in the mechanical ventilation timeline. This timeline begins with the acute initiation phase when the patient is first placed on the ventilator and ends when the postweaning phase marks the complete independence of the patient from ventilator. Ventilator Dependency Feeding Stages: 1. Acute repletion: replenish muscle glycogen stores (a source of energy for the body's cells stored in the muscle) and reverse catabolism (breakdown of muscle protein), 2. Pre-weaning: maintain positive nitrogen balance (a determination made about the body's ability to meet its protein needs), improve visceral protein stores (the amount of protein that is contained in the internal organs) and promote weight gain., 3. Weaning: provide extra energy substances to meet the increased metabolic requirements of both primary and accessory respiratory musculature and attempt to minimize increased CO2 (carbon [MEDICATION NAME]) production avoiding large carbohydrate components in the patient dietary intake., 4. Postweaning: maintain nutrient needs despite anorexia (loss of appetite) or dysphagia (difficulty swallowing); support anabolism (to build up muscle mass). Carefully evaluate daily caloric needs, and readjust them as the patient's rehabilitation becomes more and more intense and energy demanding. A planned feeding strategy should be initiated as soon as the patient's condition is stable enough to support effective nutritional intervention. The postweaning nutritional planning must begin as soon as the patient is placed on the ventilator ..." The same document as above indicated, " ... Nutrient Requirements; Calories: Caloric needs may be estimated several ways. When determining calories, total calories must be taken into consideration (i.e., protein, fat and carbohydrate) ...some of the various methods for calculating energy needs are: Maintenance: ....25-35 kCal/kg/day, Anabolism; ...35-45 kCal/kg/day ..." Per RD 1's interview on 3/5/14 at 12:15 P.M., Resident 115 s weight loss had not met facility criteria to be referred to an IDT weight management meeting. On 3/5/14 at 12:00 P.M., the DON verified the facility failed to identify that Resident 115 had accumulated a 10.4% significant weight loss within a 6 month period of time, and the facility policy and procedure had not been followed to notify the physician. Resident 115's progressive weight loss was slower than what the facility was focused on as being a concern when the weight loss had not reached 3 lbs in a week, or 5 lbs in a month although it was continued weight loss, as documentation and staff interviews would indicate Resident 115's weight "was stable." Resident 115's progressive weight loss accumulated to 10.4% unplanned significant weight loss in 6 months, which the facility failed to identify. The facility had not conducted a comprehensive root cause analysis for Resident 115's unplanned significant weight loss of a 10.4% that occurred between 4/13 - 10/13. The facility had not conducted a thorough root cause analysis for continued gradual weight loss as the facility had not ensured that the contracted registered dietitian was aware that Resident 115 had begun weaning from the vent 7 months earlier. On 3/6/14 at 9:57 A.M., Resident 115's physician verified that partial weaning from a vent could impact nutritional needs. On 3/6/14 (time of RD note entry was not documented in the medical record), RD 1 conducted a nutrition follow up and noted, " ...Res nutritional needs based on latest wt 3/2014 101# or 46 kg: 1610-2070 kcal (35-45 kcal/kg for anabolism(to build up muscle mass)) ...,spoke with DON and RT, vent is being weaned; okay to increase TF to allow for wt gain. Res tolerating TF well ...,spoke with family Res UBW 128# back in [DATE] ' before surgeries began ' . Will recommend TF increase to 40 kcal/kg; modify formula to glucerna 1.5 62 ml/hr x 20 hour = 1, 860 kcal ...,will modify to weekly wts x 4 weeks ..." On 3/11/14 at 3:45 P.M., RD 2 said the tube feeding was increased on 3/6/14 "because he was losing weight. " Per the above note, RD 1 noted Resident 115 weighed 101 # and "vent is being weaned ...will recommend TF increase to 40 kcal/kg (35-45 kcal/kg for anabolism) ... " Resident 115 weighed 101 lbs and had same status of "vent is being weaned ", three months earlier on 12/1/13. The facility's policy and procedure titled, "Nutritional Care Management Nutritional Assessment and Care Plan,(Undated Policy No. 430)," contained direction to facility staff that indicated, "Provides nutritional care and services to each resident, consistent with the resident 's comprehensive assessment ..., Recognizes, evaluates, and addresses the needs of every resident, including but not limited to, the resident at risk or already experiencing impaired nutrition ..., the interdisciplinary team clarifies nutritional issues, needs, and goals in the context of the resident ' s overall condition ...Pertinent sources of such information may include interview of the resident or resident representative ...the assessment will identify usual body weight ..., The in-depth nutritional assessment may also include the following information: ...goals and prognosis ..., medical ...problems affecting nutritional care ...,DSS can make notations of diet changes, resident ' s acceptance of the prescribed diet, and other relevant contacts with the resident. Registered Dietitian can note progress of nutritional problems or resolution - monitoring and evaluation ...The Nutritional Progress Record may be used as the quarterly screening tool by the DSS or RD. The DSS should refer the resident to the RD if resident has had a significant or insidious change in weight or is not meeting care plan goals ..., When a dietary problem is identified, it is added to this care plan in the following format: 1) State problem, including the cause of the problem if known ..., The Consultant Dietitian is available to attend the resident care plan conference as needed." The facility's policy and procedure titled, "Weight Management Committee (Policy & Procedure Manual September 2004)," indicated, "Policy; It is the policy of this facility to provide residents nutrition to maintain acceptable parameters of nutrition. Residents with nutritional concerns will be assessed in a timely manner by the interdisciplinary team. Purpose: To identify residents with nutritional changes or residents at significant risk and have them reviewed as indicated to maintain acceptable nutritional parameters as their clinical condition will support. Procedure: 1. The weight management committee will meet weekly. The committee should meet within one week of the reporting of the monthly weights. 2. The weight management committee will consist of members of the interdisciplinary team. 3. Resident's with nutritional and/or weight concerns are included in the meetings. The criteria for a resident to be reviewed may, but is not limited to: A. Residents who have a sudden change in nutritional intake and are at risk or significant weight loss or exhibit gradual weight loss/gain ... B. Residents who have lost or gained 5 lbs. since the last recorded weight., C. Residents who have lost or gained >5% of their body weight in the last month, D. Residents who have lost or gained >7.5% of their body weight in the last 3 months, E. Residents who have lost or gained greater 10% of their body weight in the last 6 months ..., G. Residents with progressive weight loss requiring close observation ..." According to accepted standards of practice, "Among older people, weight loss is associated with frailty, functional impairments, immune disorders, pressure ulcers, [MEDICAL CONDITION], cognitive impairment, low quality of life, and increased mortality. Research indicates it is critical that any weight loss in older adults be prevented." (Source: "Position of the American Dietetic Association: Liberalization of the Diet Prescription Improves Quality of Life for Older Adults in Long-Term Care", Journal of the American Dietetic Association, December 2005). "Involuntary weight loss can lead to muscle wasting, decreased immunocompetence, depression and an increased rate of disease complications. Various studies have demonstrated a strong correlation between weight loss and morbidity and mortality. One study showed that nursing home patients had a significantly higher mortality rate in the six months after losing 10 percent of their body weight, irrespective of [DIAGNOSES REDACTED]." (FEBRUARY 15, 2002 / VOLUME 65, NUMBER 4 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN) 2. On 3/11/14 at 10:00 A.M., Resident 91's medical record was reviewed. Resident 91 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Record of Admission. Per the initial nutrition assessment, dated 8/26/13, Resident 91 was 4'10" and weighed 120 lbs at the time of admission. The area on the form for "UBW (usual body weight)" was left blank. On 8/28/13, there was an RD note that indicated, "Received word from nursing that Res has c/o hunger. Will increase TF to 55 ml/hr x 20 hours = ...1320kcal ...will cont to monitor." On 9/27/13 and noted the following, " ...On ventilator.., wts 9/14 116#, 9/8 -118#, 8/31 119#, 8/21 120#. Tolerating TF well. Skin intact. Cont with POC, will continue to monitor." Per the Weekly Weight Record, there was another weight obtained for Resident 91 on 9/21/13, of 114 lbs, that was recorded on the Weekly Weight Record prior to RD 1's nutrition assessment above. Resident 91 weighed 120 lbs on 8/21/13, and weighed 114 lbs on 9/21/13, one month later. The change in weight from 120 lbs to 114 lbs that occurred within one month was a 5% unplanned significant weight loss. On 3/11/14 at 10:30 A.M., the Director of Nursing (DON) reviewed Resident 91's Weekly Weight Record and was asked if the physician should have been notified with regards to the significant weight loss. The DON calculated the weight loss and he started calculating from 9/8/13 to 9/28/13. The DON said that the weight loss had not met the facility's criteria of 5% weight loss in a month, therefore, the physician was not notified about the weight loss. That was the reason why Resident 91 was not discussed in the weight variance committee meeting. The DON said he chose to look at the above time frames because "that was community standard." On 3/11/14 at 11:52 A.M., LN 16 reviewed Resident 91's Weekly Weight Record and said, "The licensed nurse should have called the physician because there was 5 lbs weight loss in 1 month." On 3/11/14 at 4:17 P.M., the DON was asked to review Resident 91's weight loss from 8/21/13 at 120 lbs to 9/21/13 at 114 lbs, and he said, "Since there was weight loss of 6lbs in a month the MD should have been notified." The DON said that the facility's charge nurse was responsible for notifying the MD. The DON reviewed 91's medical record and verified that the MD had not been notified when a 5% unplanned significant weight loss had occurred. Furthermore, RD 1 had not identified the 5% unplanned significant weight loss in the 9/27/13, nutrition follow up assessment. RD 1 had not conducted a root cause analysis with the interdisciplinary team of the facility including the physician to analyze the cause for the weight loss, and had not planned a nutrition intervention to address the unplanned significant weight loss and to prevent further weight loss. Per the Weekly Weight Record the following weights were documented for Resident 91: 8/21/13 - 120 lbs 8/31/13 - 119 lbs 9/8/13 - 118 lbs 9/14/13 - 116 lbs 9/21/13 - 114 lbs 9/28/13 - 114 lbs 10/5/13 - 116 lbs 10/12/13 -115 lbs 10/19/13 - 113 lbs 10/25/13 - 114 lbs 11/2/13 - 112 lbs 11/10/13 - 111 lbs 11/16/13 - 111 lbs On 3/5/14 at 11:20 A.M., RN 2 was asked what the facility criteria was for the facility to monitor and report weight loss in a resident to the physician and RD. RN 2 said, "If there is a weight variance of 3 lbs in a week, or 5 lbs in a month the physician would be notified. It would be up to the physician to consult the RD." RN 2 said if the physician had been notified about weight loss it would be documented under the column "Physician notified date/sign" on the Weekly Weight Record. According to the Weekly Weight Record Resident 91 weighed 120 lbs on 8/21/13 and weighed 111 lbs on 11/16/13, three months later. That constituted a body weight loss of 7.5% in three months. There was no documentation on the Weekly Weight Record that the physician had been notified when there was continued weight

Based on observation, interview, and record review, the facility failed to ensure that 1 of 24 sampled resident's (83) bowel incontinence care needs were met; instead, they were unnecessarily delayed which resulted in the resident becoming tearful. Findings: 1. On 3/5/14 at 2:50 P.M., Resident 83 was observed in bed, with a [MEDICAL CONDITION] (artificial surgical airway opening for assistance with breathing) which was connected to a ventilator (a machine which assists with breathing). On 3/5/14 at 2:50 P.M., Resident 83 was interviewed. Resident 83 stated she wanted to speak to her nurse because she had told her nurse she had diarrhea and the nurse never came back. Immediately after the interview with Resident 83, an interview was conducted with a medical records staff person (MR), who located (LN) 3, to respond to Resident 83's care needs. LN 3 was observed to enter Resident 83's room after being informed of Resident 83's needs. On 3/5/14 at 4:12 P.M., an interview was conducted with Resident 83. Resident 83 was observed to have tears in both eyes, and stated, "I still have diarrhea and no one has helped me." No one had attended to the resident. An interview with LN 3 was attempted after the interview with Resident 83, however, LN 3 could not be located. On 3/5/14 at 4:25 P.M., an interview was conducted with LN 20. LN 20 stated he was currently responsible for the care of Resident 83 during his P.M. shift. LN 20 stated that he had not assessed Resident 83 and was not aware that she had episodes of diarrhea. LN 20 stated that Resident 83's condition was not communicated to him from any of the nurses who worked the day shift. On 3/5/14 at 4:28 P.M., an interview was conducted with MR regarding LN 3 who responded to Resident 83's request for help after the Department notified her. The MR confirmed that LN 3's shift had ended and she had left for the day. On 3/6/14 at 8:30 A.M., Resident 83's medical record was reviewed with LN 3. Resident 83 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The physician's History and Physical (H&P) dated 2/27/14, indicated that Resident 83 had a history of [REDACTED]. The H&P indicated, "this resident has the capacity to understand and make decisions." Resident 83's Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. A nursing note dated 3/5/14, during the 4:00 P.M. shift, indicated "Resident (83) complained of loose bowel movement, yellowish-green mucoid, foul odor, endorsed (reported) nurse." During a record review on 3/6/14 at 8:30 A.M., a change of condition -SBAR ( situation, background, assessment, recommendation) GI(gastrointestinal) symptoms, indicated Resident 83 had diarrhea that started on 3/5/14. According to the SBAR, the physician was notified on 3/5/14 at 8:00 P.M., and ordered Immodium 2mg (milligrams) as needed after every loose stool. The MAR indicated [REDACTED].M. related to an additional loose stool episode. An interview with LN 3 was conducted on 3/6/14 at 8:35 A.M. LN 3 stated she was aware Resident 83 had diarrhea yesterday, but did not clean the resident when she went into the resident's room. LN 3 stated the resident was not assigned to her and that she endorsed the resident's needs to LN 5. LN 3 stated that she should have attended to cleaning Resident 83, who was unable to assist herself, rather than informing another nurse. On 3/6/14 at 9:04 A.M., an interview was conducted with LN 5, the nurse assigned to Resident 83 on 3/5/14, for the day shift. LN 5 stated Resident 83's diarrhea was not communicated to her by LN 3 or any other staff. LN 5 was asked if she, as a licensed nurse, did rounds and checked on Resident 83 to ensure that the resident's needs had been met before giving report to the oncoming nurse. LN 5 stated she did not do rounds before the end of her shift to ensure the resident's needs were met. On 3/6/14 at 9:30 A.M., a joint interview was conducted with LN 3 and LN 5. Both LN's stated that the facility's policy for a resident's change of condition included using the SBAR. Both acknowledged that Resident 83's bowel needs were neglected which resulted in the resident becoming tearful. On 3/6/14 at 10:37 A.M., an interview was conducted with Resident 83. Resident 83 stated she was upset because no one had listened to her.